HEALTH HISTORY AND PHYSICAL

EXAMINATIONSASHA RARANG, MSN, CCM, RN

Health History and Physical Examination

• Obtaining a patient’s health history and performing a physical examination are activities by the nurse during the assessment phase of the nursing process

• The purpose- to make a clinical judgmnet or Dx about the pt’s health status

Data Collection

Data Collection

Data Collection Nursing Focus Types of Data

Subjective=symptomsObjective=signs

Interview ConsiderationsSubjective data, pt interview, Health portability and Accountability Act HIPAA for pt’s privacy rule, pt can

get a copy of their health records. Symptom Investigation

Location, quality(what does it feel like?), quantity(how often), Chronology(When was the first time it occurred?), aggravating or alleviating factors(what makes it better or worse?) etc…

Data OrganizationGordon's 11 functional health pattern NANDA developed Taxonomy II with 13 domainsSee the table in your textbook

Nursing History:Subjective Data

Important Health Information– Past health history–Medications– Surgery or other treatments

Nursing History:Subjective Data

Functional Health Patterns– Health perception–health management

pattern – Nutritional-metabolic – Elimination pattern– Activity-exercise pattern– Sleep-rest pattern – Cognitive-perceptual pattern

Nursing History:Subjective Data

Functional Health Patterns, continued– Self-perception–self-concept pattern– Role-relationship pattern – Sexuality-reproductive pattern – Coping–stress tolerance pattern– Value-belief pattern

Physical Examination:Objective Data

General SurveyPhysical Examination– Techniques• Inspection: Visual exam• Palpation: use of touch• Percussion: the production of sounds by

rapid strike• Auscultation: listening to sounds by

stethoscope

Abdominal Palpation

Auscultation

Percussion

Physical Examination:Objective Data