describe how take appropriate nursing history and good physical examination

1. Nursing History taking & physical
examination
Awad Fadlalla
RN, BNS, MSN,
Shaqra University- 2021

2.  What is History taking? It is a process by which
information is gained by a physician by asking
specific questions to the patient with the aim of
obtaining information useful in formulating a
diagnosis and providing medical care to the patient

3. Importance of History Taking?
 Obtaining an accurate history is the critical first step in
determining the etiology of a patient's illness.
 Diagnosis in medicine is based on :
 Clinical history
 Physical Examination
 Investigations

4. Approach to history taking
 Your look is important Your dressing
 Introduce your self and create a rapport Approach to
history taking
 Be alert and pay full attention
 Ensure consent has been gained.
 Maintain privacy and dignity.
 Ensure the patient is as comfortable as possible
 Summarize each stage of the history taking process.
 Involve the patient in the history taking process Approach
to history taking

5. Components of History taking
1. Identifying or Demographic data :
2. Chief complain
3. History of present illness(HPI)
4. Past Medical history(PMH)
5. Family History
6. Drugs & Allergies history
7. Socioeconomic history .
8. Review of Systems (ROS):
9. Physical examination
10. investigation

6. Demographic data :
1. Date and Time
2. Patient's name
3. Age
4. Sex
5. Religion
6. Address
7. Occupation
8. Marital status
9. Educational level
10. referring physician.

7.  Chief Compliant:
─ The main reason for which the patient is trying to seek
medical help by visiting the physician. Usually a single
symptoms, occasionally more than one complaints eg: fever,
headache, pain, etc .
─ The patient describe the problem in their own words. It
should be recorded in patients own words.
─ The complain should be recorded with their onset duration

8. History of Present Illness (HPI):
 Elaborate on the chief complaint in detail Ask relevant associated
symptoms . Gain as much information you can about the specific
complaint.
 The onset of (when did it start? .
 location : where is it?
 duration : how long does it last ?
 character of pain (constant, intermittent, stabbing,
 Radiation :
 aggravated by ( eating , drinking , activity
 Reliving factor by : medications , change position ).
 associated with : defecation, urination, eating )
 Lead the conversation by asking questions. Always start with an
open ended question and take the time to listen to the patient’s
‘story’. Once the patient has completed their narrative then closed
questions can be asked to clarify . Leading question are to be
avoided.

9. Past Medical History (PMH):
 Ask History of :
 Any history of similar complaint in the past
 Any chronic disease present like hypertension, diabetes
 Past hospitalizations and past surgeries
 Medications if any taken in the past (dosage and duration)
 Pediatric: Birth history, Developmental Milestones, Immunizations
 Gyane/Obstetric history if female

10. Drug History :
─ Allergies History : Penicillin, iodine.
─ Chronic medication : Aspirin, anticoagulants
─ Drug using now

11. Family History:
 It is important to establish whether there are any
genetically transmitted diseases within families
 Any illness run in the family?
 Similar history in the family,
 Parents and siblings suffering with any chronic illness,
 Parents if died, how old and what they died of
 You should be able to collect relevant family history
depending upon the present illness.
 Example, Patient has come due anemia , Try to rule out
sickle cell, thalassemia/ G6PD deficiency

12.  Socioeconomic history :
 Smoking history - amount, duration and type.
 Drinking history - amount, duration and type
 Any drug addiction
 Sexual history if suspected STI.

13. Review of Systems (ROS):
 General:
─ level of consciousness
─ Weight gain or loss
─ nutritional state
─ posture, gait, and movement
─ personal hygiene.
 Respiratory:
─ Cough
─ Hemoptysis
─ Dyspnea

14.  Cardiovascular:
─ Chest pain
─ orthopnea
─ extremity edema.
 Gastrointestinal:
─ Dysphagia
─ vomiting
─ Hematemesis
─ constipation.
─ Others

15. Review of Systems (ROS) continue
 Skin:
─ Easy bruising, bleeding tendencies.
 Genitourinary:
₋ Dysuria
₋ hematuria
₋ Others
 Gynecological:
₋ Last menstrual period
₋ gravida , para , Abortions
₋ length of regular cycle and periods
 Neurological:
─ Headaches, seizures , weakness , coma .

16. physical examination

17. Physical Examination
 Purpose:
1. To collect objective data from the client
2. To detect the abnormalities .
3. To diagnose diseases
4. To determine the status of present health and refer the client for
consultation if needed.

18. Principle of physical examination
 Ensure patient's : comfortable , privacy , confidentiality
 Explain the procedure to patient
 Hand washing and should be warm .
 Stand on the right side of the Patient
 Follow systematic approach ( from head to toe) to
avoiding any duplication or omission.
 Always compare the right- and left-hand sides of the body
for symmetry.
 Ask the patient to empty bladder before physical
examination .
 document the procedure at the end

19. Techniques of Physical Examination:
 There are four methods of physical examination
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
 In abdominal examination the technics order
(Inspection- Auscultation- Palpation- Percussion)

20. Eqiupments of physical examination :
1. Disposable gloves
2. Examination table
3. Record form
4. Torch light
5. Reflex hammer
6. Sphygmomanometer
7. Stethoscope
8. Thermometer
9. Ophthalmoscope eye
10. Otoscope

21. EQUIPMENT continue
11- Tongue blade
12- Watch with a seconds hand
13- Measuring tape
14- Cotton swabs and cotton gauze pad
15- Ballpoint pen, pencils
16- Tuning fork – tests auditory .
17- screens for distant vision

22. Implementation
1. Explain procedure to client .
2. Instruct the patient to void if possible .
3. provide privacy by Closing the doors and put screen
4. Wash hands .
5. measure and record height, weight, and vital signs
6. Assist the patient onto the examination table if possible.
7. To examine the head, neck, chest patient should sit on edge of
examination table or bed.
8. Abdomen and CVS- patient lie in a supine position
9. Perform a physical examination (Performing a head-to-toe
assessment)

23. physical examination includes
 Measure Vital Signs : TPR &BP
 Record Height & weight
 General appearance (general survey )
 Skin ( through proceeding each system )
 Head (hair, scalp , eyes , ears , nose , mouth )
 neck (Thyroid, Carotid arteries, lymph nodes,
 Chest – respiratory
 Chest – CVS -peripheral circulation
 Abdomen
 Lower limbs (Extremities )

24.  general survey (General appearance )
 A general survey is an overall review or first
impression a nurse has of a person’s well being.
 General surveying is visual observation the following.
General appearance :
1. Observe the client’s: race, sex ,
2. Level of consciousness (awake or comatose )
3. Orientation:( person, time, and place )
4. Signs of pain , facial expression , mood
5. Nutritional state
6. Posture, gait, and movement
7. Personal hygiene and Restlessness

25. Skin Assessment
 Assessment of Skin & nail
─ While proceeding from head to toe, examine the skin through each body system
by :
 Inspect of skin :
─ skin color, pigmentation, lesions , jaundice, cyanosis, scars, superficial vascularity,
hydration, edema, color of mucous membranes, hair distribution, nails.
 Palpation of skin :
─ Examine skin for temperature, texture, elasticity, turgor.

26.  Capillary Refill:
 Press down firmly on the patient's finger or toe nail so it blanches.
 Release the pressure and observe how long it takes the nail bed to "pink" up.
 Capillary refill times greater than 2 to 3 seconds suggest peripheral vascular disease,
arterial blockage, heart failure, or shock.

27. Thank you