Physical Assessment
Shahzad BashirLecturer NMC,ION
Health Assessment (HA)History taking & physical examination19/9/20112Discussion/Case studyDemonstrationPeer group activity Class Agenda9/9/2011Lets Review what we know!Differentiate between health, illness, disease and wellness
Can a diabetic client be called healthy?
What is the difference between an illness and sickness
39/9/2011AnswersHealth: A state of complete physical, mental & social wellbeing, not merely the absence of disease. (WHO def) Wellness: Level of wellbeing, a person perceives of being healthyDisease: Alteration of structure and function of body. ( Dis ease)Illness: A response a person has to a disease49/9/2011ContThe new definition, considers health as a dynamic state of well being with different levels of functional abilities at different point in time. So a diabetic patient no doubt has a disease, but there are times when the client feels well and can be called healthy.Illness is a response to a disease and sickness is the individual perception of its illness. Thus it is possible that a person has a disease DM, has hypoglycemia sometimes, but still feels that he is normal so thus does not feel sick.
59/9/2011 ScenarioA 55years old man comes to the clinic with complain of persistent dry cough. GP takes history and performs physical examination. Patient is hypertensive, non-smoker, has no history of chest infection, fever, weakness or body ache. Chest is clear. Allergy is not known. Physician suspects him of having allergy and prescribes anti-allergic for 2 days. But cough does not relieve, patient comes again with persistent cough on next morning. GP refers him to a consultant for specialized consultancy. The consultant takes history and examined the patient. He finds nothing wrong with patient but a lapse in taking complete history by the GP. What was the component of history which was let pass and patient was missed-diagnosed?69/9/2011 Health history ,techniques to examine, systems PE, identifying abnormalities and documenting findings Systemic approach based on detail and critical thinking to gather information about health status and to analyze these information to find ways to manage health problem.
7Health Assessment9/9/2011Components of Health Assessment89/9/2011 Importance of HAAccurate diagnosis rests firmly upon the foundation of a thoughtful and inclusive history and a competently performed physical examination.
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Purposes of Health Assessment
Nurses use health assessment skills to:Develop (obtain baseline data) and expand the data base from which subsequent phases of the nursing process can evolveTo identify and manage a variety of patient problems (actual and potential)Evaluate the effectiveness of nursing careEnhance the nurse-patient relationshipMake clinical judgments109/9/2011Assessment tool/format119/9/2011 HA vs AHA HATo identify and manage a variety of patient problems (actual and potential)obtain baseline data and expand the data base from which subsequent phases of the nursing process can evolveEvaluate the effectiveness of nursing care
AHAObtain detailed data base to help and justify diagnostic procedures.Integration data obtained by PE and History taking into broader aspect of nursing diagnosis, medical diagnosis, nursing as well as medical manage.129/9/2011Data collection and data clusteringWhat is a data??Information, clue, observation, finding, sign and symptom. Data - complete and accurate.Type - Subjective and objectiveSource Primary or secondary Which one is data here:pulse, Doppler machine, Diarrhea, temperature, 90% oxygen saturation, fever, SOB, abdominal girth, weakness, cough.
What is data clustering?Processing data by organizing prioritizing, comparing the norms, hypothesizing, analyzing and concluding it as significant data. It requires clinical reasoning skill.What is this data telling you: Pulse 98/min, fever, SOB, cough and weakness
139/9/2011A systemic approach of using five senses applying different techniques to gather data base to identify and manage health problem 14Physical Examination9/9/201115
9/9/2011Principles of PESet the stageEnvironmentBrief explanation in startHead to toe approach Standing on right sideLess threatening to invasiveExternal then internalNormal to affected areaBody symmetry from both sides
169/9/2011Self preparationAnxietyOrganizationMannerismsSafetyGentlenessCompetence
179/9/2011Equipment preparationWithin reach and readyArranged as per needExtra supplies / equipmentsClean & warm equipment
189/9/2011Patient preparationExplain when, where and why the assessment will take placeKeep appointmentProperly coveredComfortHelp the client prepare: Empty bladder Change clothesChange into gownProperly covered
199/9/2011Environment preparationPrivacyNoise ControlDrapesAdequate lightRoom temperatureClient position
209/9/2011ContEasy access to a restroom.A door or curtain that ensure privacy.Adequate warmth for client comfort.A padded, adjustable table or bed.A lined receptacle for soiled articles.Sufficient room for moving to either side of the client.A clean counter for placing examination equipment.
219/9/201122Equipment Required for PE9/9/2011
239/9/201124Position of Patient During PE9/9/2011PositioningPositions used during nursing assessment, medical examinations, and during diagnostic procedures:Dorsal recumbentSupineSimsProneLithotomyGenupectoral259/9/2011
269/9/2011Inspection PalpationPercussionAuscultation
27 Techniques of PE9/9/2011 Inspection Critical observationTake time to observe with eyes, ears, noseUse good lightingLook at color, shape, symmetry, positionOdors from skin, breath, woundDevelop and use nursing instinctsInspection is done alone and in combination with other assessment techniques289/9/2011General SurveyGeneral appearance, gait, nutrition status, state of dress, body build, obvious disability, speech patterns, affect (mood), hygiene, body odor, posture, race, gender, height, weight, vital signsHeight up to age 2 is recumbentAdd head circumference if child is less than 2 years old299/9/2011PalpationTouch with different parts of hands Dorsum / finger / ball of handsWith different degree of pressureLight: 1-2 cmDeep: 4-5 cmBimanual: using both hands to trap organTo identify size, shape, texture, mobility, mass, quality of pulses, joints & bones condition, tenderness, temperature, moisture, fluid & edema, & chest wall vibrations
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9/9/2011PercussionStriking the body surface sharply to create sound wavesSound produced determines the feature of underlying organUseful to identify organ position, size and densityUseful to detect fluid or air in a cavityTypes of percussionMediate Immediate FistPercussion notes:FlatnessDullnessResonanceHyper resonanceTympany
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9/9/2011 AuscultationListening to sounds produced by the bodyDirect auscultation sounds are audible without stethoscopeIndirect auscultation uses stethoscopeKnow how to use stethoscope properly (practice)Fine-tune your ears to pick up subtle changes (practice)Describe sound characteristics (frequency, pitch intensity, duration, quality) (practice)Flat diaphragm picks up high-pitched respiratory sounds bestBell picks up low pitched sounds such as heart murmurs, bruits, aortic aneurysm Practice using BOTH diaphragm
369/9/2011Bronchovesicular normal breath soundWheezing Narrowing/spasm of bronchioles Asthma, COPDCrackles fluid accumulation > PE, PneumoniaFriction rub inflammation of pleura > pleuritis, pneumonia
37Breath sounds9/9/2011Problem Oriented Recording (PORType of format for documentation where a data base leads to a problem list and plan for some interventions i.e. diagnostic, therapeutic, educational.S SubjectiveOObjectiveAAssumption / DiagnosisPPlanningIInterventionEEvaluationRRevision
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9/9/2011Documentation of PE findingsSpecific avoid vague terms Concise use short simple wordsComplete entry with date & signDescribe observation clearlyUse standard abbreviations onlyRecord exact size, position of lesionsUse illustrationUse black pen
399/9/2011General survey documentationElderly women, oriented to person and place only, appears weak, unable to stand, guarding abdomen, skin flushed, pt is shivering.
A 45 years old male, looks younger than his age, skinny, alert, oriented to x3. appears healthy and in no acute distress, well groomed, respond appropriately and cooperative. No gross abnormalities apparent.
Young lady of 25 years old seated on wheel chair, constantly shifting position and picking at the paper on the table. Disoriented to time, place and person (require frequent orientation to the examination process). Is thin and unkempt. Eye contact minimal. Talked throughout the examination.
409/9/2011Is a collection of subjective data Provided by the client and compiled by the nurseIt provides information about clients present and past health status, practices, perceptions, knowledge, and attitudes about their health.Approach of health history is taking interview
41Health History 9/9/2011InterviewIt is goal directed purposeful interaction between two people.Purpose:Gather information to base nursing careEstablish a helping relationship Identifying health status, concerns, & problemsScreening purposeeducation
429/9/2011Phases of InterviewIntroductory Phase;Orientation, time/comfortPurposeInterview EnvironmentPsychological (Non Judgmental & Respectful)Physical (Privacy, Noise, seating, light, temp)Working Phase;Build trust & rapportPatient readiness (less sensitive topics first)Use of therapeutic self (comm. techniques)Goal in mind.
439/9/2011ContTermination Phase;Closure/summarizePlan for futureGoal achieved/not
449/9/2011Questioning TechniquesDirective: Formal & structured to collect wide range of informationUsually content focused In-Directive: Informal, & focused on specific area of concernfreedom, open ended
Balance between them.
459/9/2011Verbal Techniques Keep Tone neutral Facilitate with go on and what elseParaphrase Clarify Respecting Use open ended questions/ broad opening statementsProceed from general to specificSummarize/ review the discussion
469/9/2011Nonverbal Techniques Eye contactSupportive gesturesDistance Keep an open mindSupportive facial expression
479/9/2011Don'ts of Interview Leading / biased questionsJudgmental / stereotyped responses Asking Why questionsAsking two question at a timeChanging topicFalse reassuranceAgreeing, disagreeing, approving & disapprovingInterrupting the client
489/9/2011Barriers in InterviewingPatients Assumptions / Expectations / FearsAge GenderConfusionCultural and social barriersCommunication DifficultiesLanguage DifficultiesPhysicalCultural Problems affecting social interactione.g claustrophobia, agoraphobia. =>Adapt methods of history taking and examination accordingly
499/9/2011Guidelines for InterviewingThe interview starts with a self-introduction Use body language and words that promote trust and good willBefore questioning starts, the client should know the kinds of information you are interested in, the use of this information and how much of the client's time you plan to takeThe environment and time selected are conducive to sharing information
509/9/2011ContUse restatement to clarify the client's responses when neededHonor the client's request to omit a questionPace of the questioning is unhurried, and comfortable for the client.Use appropriately placed, brief periods of silence so the client can gather her/ his thoughts.Responses to client statements show that you have been listening
519/9/2011ContInvite your client to expand on selected statements.At the end of the discussion, briefly review the areas covered since the start of the interviewExpress satisfaction with the process the two of you have completed.Thank the client.Ask to either set up the next meeting or plan for the possibility of a future meeting if you need this to complete your plan
529/9/2011Health History Comprises of Demographic DataPresenting ComplaintHistory of Presenting ComplaintPast medical history (PMH)Drug HistoryAllergies / ImmunisationsSocial / Occupational historyFamily HistorySystemic enquiry /Review of system (ROS)
539/9/2011Componet-1-History of Present Illness (HPI)HPI is a chronological story of what has been happeningMust get details of the problem, therefore must be systematicOLFQQAAT: onset, location, frequency, quality, quantity, aggravating factors, alleviating factors, associated symptoms, treatments tried (include all treatments - Rx, OTC, herbal, folk)COLDERRALots of systems find one that works, and use it549/9/2011Use whatever system works for you, but use a system (OLFQQAAT, PQRST, pain intensity scales, etc)Pain, quality/quantity, radiation, setting, timingRate pain from 1 to 10Use age appropriate tools (faces)Culturally appropriate care
Componet-1-History of Present Illness559/9/2011
569/9/2011Component-2Past Medical HistoryDrug HistoryAllergiesTetanus and immunisation for childrenFamily History where relevant . GENOGRAMSocial HistoryOccupation, hobbies, hand dominance, drugsCONSIDER Systemic Enquiry necessary ?Clarification with patient / third party may be necessary to ensure correct information
579/9/2011Components 3 Review of System (ROS)GIT Gastrointestinal TractResp Respiratory SystemCVS Cardiovascular SystemUro Urological SystemNeuro Neurological SystemLoco Locomotor System
589/9/2011In the following examples which data is Subjective and which one is Objective?Example 1: Mrs. G is an older white female, de-conditioned, pleasant, and cooperative. BP 160/80, HR 96 and regular, respiratory rate 24, afebrile.
Example2: Mrs. G is a 54-year-old ,hairdresser who reports pressure over her left chest like an elephant sitting there, which goes into her left neck and arm.
599/9/2011 Genogram Peer Group Activity609/9/2011Documentation Documentation forms as per agency
Use of standardized nursing admission assessment formsCombines health history and physical assessment
619/9/2011Principles of documentationWrite notes.Attention to detail Information Not Recorded = Information LostBe relevantApply StructureApply chronological order of eventsAbbreviationsWhen a mistake is madeCross it out with a single line, initial and date
629/9/2011 Method of DocumentationDate and identifying data - name, age, sex, race, place of birth (if pertinent), marital status, occupation, religionSource and reliability of historyChief complaint = reason for visit (succinct)HPI - the long version of the CC (OLFQQAAT)PMH - general health, childhood illness, adult illnesses, psychiatric illnesses, injuries, hospitalizations, surgery, immunizations, habits, allergies639/9/2011 ContFH - age and health of parents and siblings or cause of death (genogram); HTN, DM, CVD, Ca, HA, arthritis, addictionsROS (subjective head-to-toe review) General - recent wt. change, fatigue, feverSkin - rashes, lesions, changes, dryness, itching, color change, hair loss, change in hair or nailsEyes - change in vision, floaters, glasses, HA, pain 649/9/2011 Documentation of ROSEars - pain, loss of hearing, vertigo, ringing, discharge, infectionsNose and sinuses - frequent colds, congestion, HA, nosebleedMouth and throat - condition of teeth and gums, last dental visit, hoarseness, frequent sore throatsNeck - lumps, stiffness, goiterBreasts - lumps, pain, discharge, BSE659/9/2011 ContRespiratory - cough, sputum, wheezing, asthma, COPD, last PPD, last CXR, smoking history (can do here, or with habits)Cardiac - heart trouble, chest pain, SOB, murmur, h/o rheumatic fever, past EKG, FH of heart disease
