HAND-OUT #1

Fundamentals of Health Assessment

Health History

All assessments involve collecting two kinds of data:

1.Objective data- are observed; are verifiable.
2.Subjective data- provided by the patient; verifiable only by the patient.

The success of your patient interview depends on effective communication.

Techniques to ensure effective communication:

Select a quiet private setting.

Choose terms carefully and avoid using medical jargon.
Speak slowly and clearly.
Use effective communication techniques, such as silence facilitation, confirmation,
reflection, and clarification.
Use appropriate body language.
Confirm patient statements to avoid misunderstanding.
Summarize and conclude with Is there anything else?

Component Of Clinical History

I. General Data: Name, age, sex, Nationality, Religion, Address and Number of times
admitted in the institution.
II. Chief Complaint - is the reason why the patient sought consult.
e.g. vomiting, headache, chest pain

III. History of Present Illness

Symptom Analysis
O nset
L ocation
D uration
C haracteristics / Clients Perception
A ggravating Factors and Associated manifestations
R elieving Factors
T iming
S etting and severity

IV. Past Medical History - previous hospitalization, medical conditions, surgery; childhood
diseases;
maintenance medications.
V. Family History: Heredofamilial conditions e.g. cancer/malignancy; asthma; HTN; DM
 V. Personal and Social History: work history; allergies to certain foods or drugs; vices;
water source

Purpose of General Physical Examination

To confirm an overall state of health
Baseline values for vital signs
To diagnose a medical problem
Usually focuses on organ system based on patients chief complaint
Clinical diagnosis
Based on signs and symptoms of a disease
Sign objective information that can be detected
Symptom subjective information from the patient
Laboratory and diagnostic tests
Confirm clinical diagnosis
Aid in forming differential diagnosis
Aid in developing a prognosis
Formulate a treatment plan and/or drug therapy
Safety Precautions
Hand washing
Before and after each patient contact
Before and after each procedure
Wear gloves if there is probability of contact with
Blood Non-intact skin
Body fluids Moist surfaces
Wear a mask if there is any possibility of exposure to an infectious disease transmitted
by airborne droplets
Isolation precautions
Personal protective equipment
Keep patients with possible infections separated from other patients
Discard all disposable equipment and supplies appropriately
Clean and disinfect the exam
room after each patient
Sanitize, disinfect, and sterilize
equipment appropriately

Assessment Techniques
The order of techniques is as follows
Inspect Palpation Percussion Auscultation
Except for the abdomen which is
Inspect Auscultation Percuss Palpate
A. Inspection critical observation *always first*
1. Take time to observe with eyes, ears, nose (all senses)
2. Use good lighting
3. Look at color, shape, symmetry, position
4. Observe for odors from skin, breath, wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with other assessment techniques

B.Palpation light and deep touch

1. Back of hand (dorsal aspect) to assess skin temperature
2. Fingers to assess texture, moisture, areas of tenderness
3. Assess size, shape, and consistency of lesions and organs
4. Deep = 5-8 cm (2-3) deep; Light = 1 cm deep

Palpation requires you to touch the patient with different parts of your hand using
varying degrees of
pressure.
Because your hands are your tools:
1. Keep your fingernails short and your hands warm.
2. Wear gloves in palpating mucous membranes or areas in contact with body fluids.
3. Palpate tender areas last.

Light Palpation Deep Palpation

C. Percussion sounds produced by striking body surface

1. Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)
2. Used to determine size and shape of underlying structures by establishing their borders and
indicates if tissue is air-filled, fluid-filled, or solid
3. Action is performed in the wrist.
Types of Percussion
1. Direct Percussion
This technique reveals tenderness; it is commonly used to assess an adult patients
sinuses.
a. Using one or two fingers, tap directly on the body part.
b. Ask the patient to tell you which areas are painful, and watch his face for signs of
discomfort
2. Indirect Percussion
This technique elicits sounds that give clues to the make-up of the underlying tissue.
Press the distal part of the middle finger of your non dominant hand firmly on the body
part.
Keep the rest of your hand off the body surface.
Flex the wrist of your dominant hand, tap quickly and directly over the point where your
other middle finger touches the patients skin.
Listen to the sounds produced.

Direct percussion Indirect percussion

Percussion : Proper Technique

1. Hyperextend the middle finger of one hand and place the distal interphalangeal joint
firmly against the patient's chest.
2. With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist
to strike first finger.
3. Categorize what you hear as normal, dull, or hyper resonant.
4. Practice your technique until you can consistently produce a "normal" percussion
note on your (presumably normal) partner before you work with patients.
Percussion of the Chest
Anterior Chest
1. Percuss from side to side and top to bottom using the pattern shown in the
illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you hear

Posterior Chest
1. Percuss from side to side and top to bottom using the pattern shown in the
illustration. Omit the areas covered by the scapulae.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you hear.
4. Find the level of the diaphragmatic dullness on both sides.
PERCUSSION NOTES AND THEIR CHARACTERISTICS

Relative intensity Example Pathologic Examples

Location

Flatness Soft Thigh Large Pleural effusion

Dullness Medium Liver Lobar pneumonia

Resonance Loud Normal Lung Simple chronic

bronchitis

Hyperesonance Very loud None normally Emphysema,

pneumothorax

Tympany Loud Gastric air Large pneumothorax

bubbles

Percussion of the Chest

Percussion of the Abdomen

Percuss in all four quadrants (clockwise) using proper technique
 Categorize what you hear as tympanic or dull.
Tympany is normally present over most of the abdomen in the supine position.
Unusual dullness may be a clue to an underlying abdominal mass or full bladder.

D. Auscultation

Auscultation involves listening for various breath, heart and bowel sounds with a
stethoscope.

Your stethoscope should have :

a snug-fitting ear tips, which youll position toward your nose.
should have tubing no longer than 15 (38.1 cm.) with an internal diameter not greater
than 0.3 cm.
Should have both diaphragm and bell.
1. Direct auscultation sounds are audible without stethoscope
2. Indirect auscultation uses stethoscope
Know how to use stethoscope properly [practice skill]
Fine-tune your ears to pick up subtle changes [practice skill]
Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice
skill]
Flat diaphragm picks up high-pitched respiratory sounds best.
Bell picks up low pitched sounds such as heart murmurs.
Practice using BOTH diaphragms
Auscultation of the Chest
Use the diaphragm of the stethoscope to auscultate breath sounds.
Posterior Chest
1. Auscultate from side to side and top to bottom using the pattern shown in the illustration.
Omit the areas covered by the scapulae.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear

Anterior Chest
1. Auscultate from side to side and top to bottom using the pattern shown in the illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.

Auscultation of the Chest

Auscultation of the Heart
1. Always examine from the patient's right side. A quiet room is essential.
2. Listen with the diaphragm at the right 2nd interspace near the sternum (aortic area).
3. Listen with the diaphragm at the left 2nd interspace near the sternum (pulmonic area).
4. Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces near the sternum
(tricuspid area).
5. Listen with the diaphragm at the apex (PMI) (mitral area).
6. Listen with the bell at the apex.
7. Listen with the bell at the left 4th and 5th interspace near the sternum

Auscultation of the Abdomen

Place the diaphragm of your stethoscope lightly on the abdomen.

Listen for bowel sounds.
Are they normal, increased, decreased, or absent? Borborygmus = growling
Auscultation notes the character, location and frequency of bowel sounds.
Assess bowel sounds in all four quadrants using the diaphragm of the stethoscope (high
pitched and gurgling sounds)
- Bowel sounds (Borborygmi sound)
NORMAL Sounds heard every 5-20
seconds
HYPOACTIVE 1-2 sounds in 2 minutes
HYPERACTIVE 5-6 sounds heard in less
than 30 seconds
ABSENT no sound in 3-5 minutes