Health hist ory

All assessments involve collecting two kinds of data: objective and subjective.
The health history gathers subjective data about the patient.

Objective data Subjective data

■ Are obseNed ■ Provided by the patient , or ·subiecr
■ Are verifiable ■ Venf1ed only by the patient
■ Include findings such as a red , ■ Include statements such as "My
swollen arm in a patient with arm pain head hurts·· or "I have trouble sleeping"

Interviewing tips
The success
To make the most of your patient interview, create an environment in
of your patient
interview
which the patient feels comfortable. Also, use the following tech-
depends on niques to ensure effective communication.
effective
communication.
Components of a complete health history
Biograph ical data
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Name and phone numbers of two people to call If necessary:
---------- R ELATIONSHIP P HONE #
Address - : - : - - - - - - - -_ N AME
Date of birth _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Advance directive explained: O Yes O No

Living will on chart: 0 Yes O No
Chief complai nt Obstetric history (females)
Last menstrual period _ _ __ Ask about the
History of present Illness
Gravida _ _ _ _ Para patient's feehngs of safety
to help identify physical,
Menopaus e O Yes O No psycholog ical, emotional .
Current medicat ions Paychoeocllll history and sexual abuse issues.
Coping strategies
• I 1e • FREQUENCY LAST DOSE

Feelings of safety

Medical histo~ ~ - Social history

Allergies ■
D Drug:_ _ __ _
· •· -~~
-~-;;;;11::;1111::1::1:::,zn
□ Food : _ _ _ _
D Environmental:
□ Blood reaction:
D Other: _ _ _ __
Childhood illnesses
Previous hospitaliz ations
(Illness, accident or injury, surgery, blood transfusion)
.:
Be sure to include prescriptio n
drugs, over-the-c ounter drugs,
herbal preparations, and vitamins
and supplemen ts.
D ATE
D ATE
Smoker O No
Alcohol O No
D Yes (# packs/ day _ _ # years _ _ )
O Yes (type_ _ _ amount/d ay _ __ )
llllcJt drug use O No O Yes (type _ _ _ _ )
Rellgloua and cultural observan ces
Activities of dally llvlng
Diet and exercise regimen _ __
Ask about the
Elimination patterns _ _ _ _ __
Sleep patterns _ _ _ _ _ _ __ patient's family
medical history,
Work and leisure activities _ _ __
including history
Use of safety measures
of diabetes or
(seat belt, bike helmet, sunscreen)
heart disease.
Health maintena nce history

Colonosco py
Yes No io-n- - - ----.i1~- - - - - - - - -
Dental examin-a-:-t:-
Health problems
Arthritis . D D Eye examinatio n - - - ~, -- - - - - - - - - - -
Blood problem (anemia, sickie cell, clotting, bleeding) . D D Immunizat ions _ _ _ __,__ _ _ _ _ _ _ _ _ _ __
Mammogr aphy
Cancer D D
Diabetes mellitus . .□ D
Eye problem (cataracts, glaucoma) D D Family medical history
Heart disease (heart failure, Mi, valve disease) D □ Health problem Who (parent, grandparent,
D D Yes No
Hiatal hernia sibling)
HIV/AIDS D D Arthritis D D
Hypertension D D Cancer D D
Kidney problem D D Diabetes mellitus D D
Liver problem D D Heart disease (heart
Lung problem (asthma, bronchitis, emphysema, failure, Ml, valve disease) D D
pneumonia, TB, shortness of breath) D D Hypertens ion D D
Stroke □ D Stroke D D
Thyroid problem D D
Ulcers (duodenal, peptic) D D
Psycholog ical disorder D D
Review of structures and systems
- - - - -- General health
Neurologic system
Head - - -- - - - -
Eyes, ears, and nose
Psychological status
Mouth and throat
Neck
Endocrine system - - - - -~ Skin, hair, and nails

Cardiovascular system
Breasts and axillae
Respiratory system

Gastrointestinal During the final

system - - - - ~~-:::!...~ Hematologic part of the health
system history, ask about
each body structure
Urinary system and system to make
sure that important
Reproductive symptoms weren't
system missed. Star t at the
top of the head and
work your way down to
Musculoskeletal the toes.
system
 Your patient is vague in describing
his chief complaint. Using your Health history
interviewing skills, you discover his
problem is related to abdominal
distention. Now what? This flowchart
will walk you through what to do next.

My
stomach
gets
bloated.

Ask the patient to 1dent1fy the

symptom t hat's bother,ng h,rr

Form a fi rst impression.

Does the patient's condition alert you to an emergency? For example, does he say the btoat,nq developed suddenly?
Does he mention that other signs or symptoms occur with it, such as sweating and light-headedness?
(Indicators of hypovolemia)

Do you have
any other signs or Talce a thoroug h history. Note GI
symptoms? disorders that can lead to abdominal
distention.
Take a brief history.

Thoroughly examine the patient. O~rve

for abdominal asymmetry. Inspect the
skin. auscultate for bowel sounds.
Perform a focused physical examination percuss and palpate the abdomen, and
to quickly determine the severity of the measure abdominal girt.h.
patient's condition.

Evaluate your findings. Are emergency signs or symptoms present, such as abdominal rigidity
and abnormal bowel sounds?

Intervene appropriately to stabilize the Review your findings to consider

patient, and notify the doctor possible causes, such as cancer, bladder
immediately. distention, cirrhosis, heart failure, and
gastric dilation.

After the patient's condition stabilizes,

review your findings to consider possible Deviee an appropriate care plan.
causes, such as trauma, large-bowel Position the patient comfortably,
obstruction, mesenteric artery administer analgesics, and prepare the
occlusion, and peritonitis. patient for diagnostic te~~.
Physical assessment
Assemble the necessary tools for the physical assess- best picture
ment. Then perlom1 a general survey to form your
initial impression of the patient.
Obtain baseline data, including
Measuring blood
height, weight, and vital signs. Got your tools? pressure
This information will direct Good.
Let's get to work! ■ Position your patient with his upper arm at
the rest of your assessmen t. heart level and his palm turned up.
■ Apply the cuff snugly, 1" (2.5 cm) above the
brachia! pulse.
■ Position the manometer at your eye level.
■ Cotton balls ■ Palpate the
■ Gloves brachia! or radial
■ Metric ruler (clear) pulse with your fin -
■ Near-vision and visual acuity charts gertips while inflating
■ Ophthalmoscope the cuff.
■ Otoscope ■ Inflate the cuff to
■ Penlight 30 mm Hg above the
■ Percussion hammer point where the pulse
■ Safety pins disappears.
■ Scale with height measurement ■ Place the bell of
■ Skin calipers your stethoscope over the point where you felt the pulse, as
■ Specula (nasal and vaginal)
shown in the photo. (Using the bell will help you better hear
■ Sphygmomanometer
Korotkoff's sounds, which indicate pulse.)
■ Stethoscope
■ Release the valve slowly and note the point at which
■ Tape measure (cloth or paper)
Korotkoff's sounds reappear. The start of the pulse sound
■ Thermometer
indicates the systolic pressure.
■ Tuning fork
■ The sounds will become muffled and then disappear. The
■ WOOden tongue blade
last Korotkoff's sound you hear is the diastolic pressure.

Tips for interpreting vital signs

■ Analyze vital signs at the same time. Two or more abnormal values may provide
clues to the patient's problem. For example. a rapid, thready pulse along wi th low
blood pressure may signal shock. __
■ If you obtain an abnormal value, take the vital sign again to make sure it's iJCCli

rate.
. ' le. teniper
■ Remember that normal readings vary with the patients age. For exarnP
ature decreases with age, and respiratory rate can increase with age. f 11 ,
■ Remember that an abnormal value for one patient may be a norrna I value or·
other. which is why baseline values are so important.
Physical assessment techniques Because pa lpation
When you perfonn the physical assessment, you'll use four techniques: and percussion can
in-.1 '( t :on. palpation, percussion, and ausc·ultation. Use these alt er bowel sounds,
techniques in this sequence except when you perform an the sequence for
abdominal assessment. assessi ng the
abdomen is
in:;:)pection,
auscultation,
percussion, and
Inspection palpation.

Inspect each body system using vision, smell,

and hearing to assess normal conditions and
deviations. Observe for color, size, location,
movement, texture, symmetry, odors, and
sounds as you assess each body system.

Palpation
Palpation requires you to
touch the patient with dif-
ferent parts of your hands,
using varying degrees of Light palpation Deep palpation
pressure. Because your ■ Use this technique to feel for surface ■ Use this technique to feel internal or-
hands are your tools, keep abnormalities. gans and masses for size, shape, tender-
your fingernails short and ■ Depress the skin ½" to %" (1.5 to 2 cm) ness, symmetry, and mobility.
your hands warm. Wear with your finger pads, using the lightest ■ Depress the skin 1112" to 2" (4 to 5 c m)
touch possible. with firm, deep pressure.
gloves when palpating
■ Assess for texture, tenderness, tem- ■ Use one hand on top of the other to
mucous membranes or perature, moisture. elasticity. pulsations, exert firmer pressure, if needed.
areas in contact with body superficial organs. and masses.
fluids. Palpate tender
areas last.
Percussion
Percussion involves tapping your fingers or hands quickly and
sharply against parts of the patient's body to help you locate organ
borders, identify organ shape and position, and determine if an or-
gan is solid or filled with fluid or gas.
.
.• I.'~
Direct percussion
This technique reveals tender-
ness; it's commonly used to as-
sess an adult patient's sinuses.
Here's how to do it:
■ Using one or two fingers, tap
directly on the body part.
■ Ask the patient to tell you
which areas are painful, and
watch his face for signs of dis-
comfort.
II
n Getting ready
Indirect percussion
This technique elicits sounds that
give clues to the makeup of the
underlying tissue. Here's how to
doit:
•
■ Press the distal part of the
middle finger of your nondominant
hand firmly on the body part.
■ Keep the rest of your hand off
the body surface.
■ Flex the wrist of your dominant
hand.
■ Using the middle finger of your
dominant hand. tap quickly and
directly over the point where your
other middle finger touches the
patient's skin .
■ Listen to the sounds produced .
Auscultation
Auscultation involves listen-
ing for various breath, heart,
and bowel sounds with a
stethoscope .
■ Provide a quiet enviror,
ment.
• Make s~re the area to L, •
auscultated is exposed. (A1,
cultating over a gown or be .
._.liner:is can interfere with
!' S~H"l9~L-
i~
►
llll~Warm.
., --:· ~ • t
the ~tethoscope ,,.,
t.-t,fruyour hand.
!.' . '.c~ • . : :, • •',.' ~ ,·
i_' ■-ifi~~;i~~ eyes to help t
rE cus_your·attention.
~1f.iow~
..... ·. :·to·1 auscultate
:
~-.•· .
f1 ■ · · us~·the· diaphragm to p1,,
.. 'u p_.}1g_~~P . il~~.ed
sounds. $UC'
as\firpt tSi) and second (S ,!
. '·•°'tr. ➔' ·....;J.~,:-.. ~
[ heart sounds:-Hold the d1a-
' , phra,gm fim:ily against the
' ,v..! .. , ' f
:,· patier:,t,'~ •~k!n, enough to lea\·
~ a-~H~~Jrjn,g' on the skin after ·
t ward.-:· · .·
:; ■ ·u~e the bell to pick up le:.
'i pitch~d sounds, such as th 11u
~ (S3) and :f<?urth (S4) heart
. sounds. Hold the bell lightly
against the patient's skin. 1us:
enough to form a seal. Holdi:'r,
the bell too firmly causes th P
skin to act as a diaphragrn
obliterating low-pitched
sounds.
■ Listen to and try to ider,'., ·
the characteristics 01 one
sound at a time.