Physical Assessment - Chapter 1 History and Physical Examination
Performing an accurate physical assessment and being able to differentiate normal from abnormal findings is one of the most important roles for today’s health care practitioner. If an accurate physical assessment cannot be performed, whether for baseline data or when the patient’s condition changes, then the patient is not receiving the level of competent care that should be given. The purpose of this home study presentation is to provide the reader with the information to enhance existing assessment skills and learn new information which can be applied to the clinical setting. You will work through the physical assessment on the basis of body systems and also include a psychosocial assessment. This program will cover the following systems in this order:
General Guidelines For Health History and Physical Assessment
Review Available Data
Quickly review the chart prior to performing your assessment. Note the patient’s name, age, address, race, occupation, and religion. This will provide you with an idea of the patient’s lifestyle and will avoid asking repetitive questions.
Always greet the patient in a friendly, non-threatening manner. Use “Mr.”, “Mrs.”, or similar titles unless the patient is a child or adolescent. Explain your relationship to the patient’s care. During introductions many patients are often trying to figure out what they believe the examiner thinks of them. If the impression is good, the patient is more likely to be satisfied and cooperate with the examination.
An example of an introductory statement in relation to health assessment performance is, “I will be taking a health history and performing a physical assessment to help meet your health care needs. The assessment will also provide a baseline picture of your health status so that we can notice any changes in your condition.”
If in a semi-private room, ensure maximum privacy by drawing the divider curtain. This is a time to excuse the family, if possible, so the patient can provide candid responses to sensitive issues of which the family may not be aware. Hostile or intoxicated people or persons who have been abusing chemical substances may feel trapped in a small room. For this reason, and also for the examiner’s safety, leave the door open. Also, this type of patient may feel more relaxed if coffee or juice can be offered.
The patient should be wearing comfortable, loose fitting pajamas or a gown. During the rapport establishing phase of the relationship, the examiner should stay at least three feet away from the patient to avoid invading personal space. As the assessment progresses there will be a need to move closer than three feet, but the personal space should still be maintained when just conversing with the patient.
Follow a Systematic Assessment Flow
Although the patient’s condition often dictates what area is covered first in the assessment, one should still observe some type of systematic progression to avoid excluding important assessment areas.
Techniques Of Physical Assessment
A method of systematic observation. Inspection should begin with general observation of the patient progressing to specific body areas. Inspection is a physical assessment technique that is often used but seldom thought about.
Process of examining patients by application of the hands. Used to determine:
- The consistency of tissue directly or indirectly with the palms of the hands or finger pads.
- Alignment and intactness of structures (such as the nasal septum or extremities).
- Presence of thrills. Thrills are fine vibrations and can sometimes be felt over aneurysms or Grade IV or stronger heart murmurs.
- Symmetry of body parts and movement.
- Transmission of sound through vibration (known as tactile fremitus).
- Areas of warmth and tenderness.
For light palpation, press the skin gently with the tips of two or three fingers held close together. Note tenderness or warmth (although the backs of the examiner’s hands are most sensitive to skin temperature) as well as the size and position of structures and the existence of masses. For deep palpation, place one hand on top of the other and press down with the fingertips of both hands. For example, deep palpation of the right upper quadrant lets you estimate the size of the liver.
Tapping of the body lightly but sharply to determine consistency of tissues and/or organs through vibration and areas of tenderness. Sounds that will be heard include:
- Resonance – Loud, long low-pitched sound heard over hollow structures such as the lungs and abdomen.
- Hyperresonance – Loud, very long sound, lower pitched than resonance, heard over areas such as overaerated lung tissue found in COPD. Hyperresonance sound lies between tympani and resonance.
- Tympany – High-pitched, loud sound of medium duration heard over the stomach or gastric bubble.
- Dullness – Medium-pitched, slightly louder than a flat sound heard over solid organs such as the heart, liver, or a distended bladder.
- Flatness – Soft, high-pitched, short sound heard over bone and muscle.
The technique of percussion involves putting the middle finger of the nondominant hand on the patient’s body and tapping it briskly with the middle finger of the dominant hand. If the examiner’s hands are small, the technique may not make a sound loud enough to be heard. In this case, try striking the finger with the side of the thumb instead.
Process of listening for sounds over body cavities to determine presence and quality of heart, lung, and bowel sounds. High-pitched tones are best heard with the diaphragm of the stethoscope while low-pitched tones are best heard with the stethoscope’s bell (“bell-low” is an easy way to remember). Hold the diaphragm firmly against the skin to block out extraneous noise. The bell should be place more lightly on the skin.
Chapter 1: Health History/Physical Assessment By Systems
General Health History/Assessment
Provides information about possible health risks and psychosocial information
Current occupations may be different than what a person normally does (for example the produce worker in the market may bea coal miner who is temporarily unable to perform his/her usual occupation).
Allows the examiner to assess if the patient has been exposed to atypical substances such as Agent Orange or out-of-country microorganisms. Also can provide psychosocial information.
People oftentimes bring more home more than just souvenirs from out of country trips. Unexplained skin conditions and gastrointestinal problems may have originated from exposure to unfamiliar microorganisms. Note the location of the travel and the length of time since returning home.
Expressed Health Concern
Patients should be asked their reason for seeking medical help. It is important to get the expressed health concern or chief complaint in the patient’s own words. If the illness is chronic, they should be questioned as to what changes in their condition prompted them to seek help or when they last felt well. Basic Medical History
If appropriate, ask questions about the person’s history of varicella, polio, measles, mumps, and rubella. Also ask about the person’s DPT status and last immunization for tetanus.
Much information about a person’s past health can be ascertained by asking the person, “What is the sickest you have ever been?”
Reasons for hospitalizations, years of occurrence, and outcome of illnesses should be assessed.
The patient should be questioned as to food, drug, and airborne allergies. Reactions to allergens should be established. Assess past and current treatment for allergic reactions.
Past history of serious injuries and fractures should be established. Patients can be asked if they have ever been in a serious automobile or industrial accident.
Name, dosage, and frequency of medications should be listed; include over-the-counter and folk medicines.
Habits include the use of alcohol, street drugs, caffeine, and tobacco use (include smokeless). These questions may be saved until the end of the examination when a better rapport has been established and the likelihood of honest responses are greater. Instead of asking “How much do you drink?”, the examiner should ask questions such as, “Have you ever thought you drank too much?” or “Have your family or friends ever complained about the amount you drink?”
Family Medical History Include questions about the health status of the patient’s siblings, parents, grandparents, spouse, and children. Ask whether they are living and well or the cause of death if they are deceased. Specifically ask questions relating to cardiovascular problems and race specific illnesses such as sickle cell anemia.
- Build (thin, obese, emaciated, etc.)
- Radial Pulse
- Blood Pressure (sitting, standing, and lying if related to current illness or over age 50)
- Speech (descriptive terms include: fast, slurred, thick, articulate, speaks no English, absence of speech)
- Emotion (descriptive terms include slightly nervous, comatose, calm, etc.)
- Stated Aged Versus Apparent Age (documentation would read “appears chronological age” or “stated age 40, looks 50”)