HEALTH HISTORY• A health history is the collection of subjective datathat provides a detailed profile of the patient healthstatus.• Therapeutic communication skill and interviewtechnique used to gather health history.• It helps to identify actual and potential healthproblem.
Physical examination is an integral part of healthexamination and it includes head to toe examinationof the patient to rule out any deviation from thenormal.PHYSICAL EXAMINATION
PURPOSE•To gather baseline data.•To confirm the alterations, disease or inability toperform the activities of daily living.•To supplement data obtained in the nursing history.•To make nursing diagnosis.•To make clinical judgments about the client’schanging health status and management.•To evaluate the effectiveness of health care.•.
INSTRUMENTSSUPPLIES PURPOSEFlash light orpenlightTo assist viewing of the pharynxand cervix or to determine thereactions of the pupils of the eyeNasal speculum to visualization of the lower andmiddle turbinatesOpthalmoscope To visualize the interior of the eyeOtoscope To visualized the ear drum andexternal auditory canalKnee hammer To test reflex
INSTRUMENTSSUPPLIES PURPOSETuning fork To test hearing acuity and vibratorysense.Vaginal speculum To assess cervix and vaginaCotton applicator To obtain specimensGloves To prevent contaminationLubricant To ease insertion of instrumentsTongue depressors To depress the tongueStethoscope To auscultate heart, lung, abdomen andcardiovascular sound.Thermometer To check the temperature
POSITIONS OF PATIENT2. PRONE POSITION:1. SUPINE POSITION:
METHODS OF EXAMINING:1. Inspection:A method of systematic observation. Inspectionshould begin with general observation of the patientprogressing to specific body areas.
2. Palpation:Process of examining patients by application of thehands.Used to determine:• Consistency of tissue.• Alignment and intactnessof structures.• Symmetry of body parts.• Areas of warmth andtenderness.
Parts of hands used for variouspalpation:Part of hand Type of palpationFinger tips To assess texture, shape,size, consistency andpalpationDorsum of hand andfingersTo assess temperaturePalm of hand To assess vibrationPinching of fingers To assess turgor,consistency and position
For light palpation, press the skin gently with the tips oftwo or three fingers held close together.
3. Percussion:Tapping of the body lightly but sharply to determineconsistency of tissues and/or organs through vibration`& areas of tenderness.
PERCUSSIONThe sounds may be:• Resonance: a low pitched and loud soundheard over the normal lung tissues.• Hyper resonance: very loud , very lowpitched sound longer than resonancesignifies emphysema.• Tympany : a drum like sound heard overthe air filled tissues such as gastric airbubble.• Dull: A medium pitched sound with amedium duration without resonance heardover solid tissues such as heart , liver.
Percussion sound with examples:PercussionsoundsIntensity Pitch PercussionexampleDullness Medium Moderate LiverResonance Loud Low Normal lungHyperresonanceVery loud Lower EmphysematouslungTympany Loud Higher Puffed out cheek, gastric airbubble
4. Auscultation:Process of listening for sounds over body cavities todetermine presence and quality of heart, lung, andbowel sounds.
TYPES OF AUSCULTATIONDirect auscultation: useofunaided earIndirect auscultation:use ofstethoscope
PROCESS OF HEALTHASSESSMENT:I. GENERAL APPEARANCE & BEHAVIOR:i) Gender and race: Certain illnesses are more likely toaffect the specific gender and race. Eg. Risk of havingskin cancer is 20% higher in whites than in blacks.
ii) Age: Age influences the normal physicalcharacteristics.iii) Signs of distress: There may be obvious signs andsymptoms indicating pain, difficulty in breathing oranxiety.
iv) Body type: Trim, muscular, obese or excessively thin.
v) Posture: Observe whether the client has a slumped,erect or bent posture.
vi) Gait: Observe the walking pattern of the client. Notwhether the movements are coordinated oruncoordinated.
vii) Body movements: Note for any tremors involving theextremities.viii) Hygiene and grooming: Note the appearance of hair,skin and finger nails. Also observe for the clothing.ix) Affect and mood: Affect is a person’s feelings as theyappear to others.x) Speech: An abnormal pace may be caused by emotionsand neurological impairments.xi) Substance abuse: Check for the history of substanceabuse.
VITAL SIGNS:Equipment Needed:• A Stethoscope• A Blood Pressure Cuff• A Watch Displaying Seconds• A Thermometer
1. Temperature:Temperature can be measured is several different ways:• Oral• Axillary• Aural• Rectal.2. Respiration:In adults, normal restingrespiratory rate is between16-24 breaths/minute.
3. Pulse:A normal adult heart rate is between 60 and 100 beatsper minute. A pulse greater than 100 beats/minute isdefined to be tachycardia. Pulse less than 60beats/minute is defined to be bradycardia.4. Blood Pressure:Record the blood pressure assystolic over diastolic(Eg. "120/70" ).
HEIGHT, WEIGHT ANDCIRCUMFERENCE:• A person’s general level of health can be reflected inthe ratio of height to weight.• Weight is a routine measure during health visits.• A client’s weight will normally vary daily because offluid loss or retention.• Progressive weight gain is` expected during pregnancy.• Head, chest and abdominalcircumference should beassessed in case of infants.
Look(Inspection)Listen(auscultation)Feel(palpation)Tap (percussion)Smell(olfaction)SKILLS OF PHYSICALEXAMINATION
HEAD TO TOE ASSESSMENTA. THE INTEGUMENT:The integument includes skin, hair and nails. Theexamination begins with a generalized inspection using agood source of lighting.1. SKIN: Assessment of the skin involves inspection andpalpation.• Pallor/Jaundice• Cyanosis• Erythema• Edema
2. HAIR: Inspect the hairs for colour, alopecia (hair loss)and the cleanliness of the scalp.3. NAILS: Nails are inspected for nail plate shape, anglebetween the nail and the nail bed, nail texture, nail bedcolour and the intactness of the tissues around the nails.Clubbing is a condition in whichthe angle between the nail andnail bed is 180 degree or greater.It may be caused by long termlack of oxygen.
NORMAL NAIL SHAPE• Technique: view the index finger note the angle ofthe nail base it should be above 160 degree.
• ABNORMAL NAIL SHAPESEarly clubbingLate clubbing
B. HEAD:a. Eyes: Examine the conjunctiva,sclera. Test pupils for irregularity,accommodation, and reaction.Evaluate visual fields and visualacuity.
VisionVisual activity(ability to seesmall detail): by snellens chart.Peripheral vision:
b. Ears: Examine the pinna and peri-auricular tissues. Testauditory acuity, perform Weber and Rinne tests.
EARSExamination of ears: Pull the ears backward andupward.Instrument used: Auto scope• External ears: Crusts, discharges, lesions etc.• Tympanic membrane: Normally it is shiny,translucent, with a pearl grey color. See for anyperforation, lesions, bulging.• Hearing: There are 3 ways for testing the hearing.
Webers testIt is used to assess the conductivehearing loss.Technique: Place a vibrating tuningfork in the midline of the personsskull and ask if he can hear thesounds same in both the ears or betterin one ear.Result :The person should hear the toneproduced by bone conduction equallyin both ears, is the positive test result
Rinne testThis is a test to compare the air conduction and thebone conduction sounds.Technique:Place the stem of the vibrating tuning fork onpersons mastoid process and ask him or her to signalwhen the sound disappears note the time inseconds. Invert the tuning fork so the vibrating end isnear the ear canal he should hear the sound.Note the time in seconds.Results : AC : BC = 2 : 1
c. Nose: Connect the nasal speculum to the otoscope and examine the nares,noting the condition of the mucosa, septum and turbinates.d. Mouth: Examine the oral mucosa, thetongue and teeth. Evaluate thefunction of cranial nerves IX, X,and XII.e. Face: Evaluation of symmetry, smile, frown, and jaw movement will provideinformation about motor divisions of cranial nerves V and VII.
C. Neck:Palpate the neck with emphasis on the salivary glands,lymph nodes, and thyroid. Look for tracheal deviation.Identify the carotid arteries and auscultate for bruits.
• Lymph nodes are assessed by palpating with the pad of thefinger for enlargement , tenderness and mobility .• Normally nodes are not palpable. If palpable they should besmall, mobile, smooth and non tender.LYMPH NODES
Thyroid : palpation for size , symmetry ,tenderness and nodules.
Trachea: Palpation for alignment and position:unequal space between trachea and sterno-cleidomastoid muscle on each side is abnormal, indicativeof trachea displacement.
CAROTIDARTERY :Palpate one carotidartery at a time justbelow the upperborder of the thyroidcartilage.
Funnel chest (Pectus excavatumdescribes an abnormal formation ofthe rib cage that gives the chest acaved-in or sunken appearance.)Pigeon chest (Pectus carinatum,is a deformity of the chestcharacterized by a protrusion ofthe sternum and ribs.)
D. CHEST AND LUNGS:i) Inspection:• Observe the rate, rhythm, depth, and effort of breathing.• Listen for abnormal sounds such as wheezes.• Observe for retractions.ii) Palpation:• Identify any areas of tenderness.• Assess expansion and symmetryof the chest.• Check for tactile fremitus.
iii) Percussion:Percuss from side to side and top to bottom .Categorize what you hear as normal, dull, or hyperresonant.INTERPRETATION:Percussion Notes and TheirMeaning:Flat or Dull Pleural Effusion or LobarPneumoniaNormal Healthy Lung or BronchitisHyper resonant Emphysema or Pneumothorax
iv) Auscultation:Use the diaphragm of the stethoscope to auscultatebreath sounds. Note the location and quality of thesounds you hear.
ABNORMAL BREATH SOUNDS :Crepts : fine, short interrupted sound heard during inspirationand expiration. Example : Respiratory distress.Rhonchi : low pitched continuous musical sound heard duringexpiration and clears with coughing. Example : Pneumonia.Wheeze : high pitched continuous musical sound heard duringinspiration or expiration and does not clear with coughing.Example : Pneumonia .Pleural friction Rub : grating type of sound heard duringinspiration and does not clear with coughing, example :Empyema .
CARDIACASSESSMENT:• Inspection of the HeartThe chest wall and epigastrium isinspected while the client is insupine position. Observe forpulsation and heaves or lifts.Normal Findings:• There should be no lift or heaves.
PALPATION OF THE HEARTThe entire pre-cordium (anterior surface of the body covering theheart and lower thorax) is palpated methodically using thepalms and the fingers, beginning at the apex, moving to the leftsternal border , and then to the base of the heart.NORMAL FINDINGS:• No, palpable pulsation over theaortic, pulmonary, and mitral valves.• Apical pulsation can be felt onpalpation.• There should be no noted abnormalheaves, and thrills felt over the apex.
Percussion of the Heart• The technique of percussion is oflimited value in cardiac assessment. Itcan be used to determine borders ofcardiac dullness.Auscultation of the Heart• Aortic valve – Right 2nd intercostalspace (ICS) sternal border.• Pulmonary Valve – Left 2nd ICS sternalborder.• Mitral Valve – Left 5th ICSmidclavicular line.• Tricuspid Valve – Left 5th ICS sternalborder
AV Valves- Tricuspid and Mitral Semilunar valves- Pulmonicand aortic
Auscultating the heart– Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid andmitral.– Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure ofsemi-lunar valve).– Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.– Count heart rate at the apical pulse for one full minute.Normal Findings:• S1 & S2 can be heard at all anatomic site.• No abnormal heart sounds is heard (e.g. Murmurs, S3 &S4).• Cardiac rate ranges from 60 – 100 beats per min.
E. ABDOMINALASSESSMENT:Abdomen is divided into 4 main quadrants:• Right Upper Quadrant (RUQ)• Right Lower Quadrant (RLQ)• Left Upper Quadrant (LUQ)• Left Lower Quadrant (LLQ)
i) Inspection:• Look for scars, striae, hernias, vascular changes, lesions, orrashes, movement associated with peristalsis or pulsations.• Note the abdominal contour. Is it flat, scaphoid, orprotuberant?ii) Auscultation:• Place the diaphragm lightly on theabdomen, listen for bowel sounds.• Listen for bruits over the renalarteries, iliac arteries, and aorta.
iii) Percussion:• Percuss in all four quadrants using proper technique.• Categorize what you hear as tympanitic or dull.Tympany is normally present over most of theabdomen in the supine position. Unusual dullness maybe a clue to an underlying abdominal mass.
Liver Span• Percuss downward from the chest in the right mid-clavicularline until you detect the top edge of liver dullness.• Percuss upward from the abdomenin the same line until you detect thebottom edge of liver dullness.• Measure the liver span between thesetwo points. This measurement shouldbe 6-12 cm in a normal adult.
Splenic Dullness• Percuss the lowest costal interspacein the left anterior axillary line.This area is normally tympanitic.• Ask the patient to take a deepbreath and percuss this area again.Dullness in this area is a sign ofsplenic enlargement.
vi) Palpation:Palpation of the Livera. Standard Method:• Place your fingers just below theright costal margin and press firmly.• Ask the patient to take a deep breath.• You may feel the edge of the liver press against yourfingers. Or it may slide under your hand as the patientexhales. A normal liver is not tender.
b. Alternate Method:• This method is useful when the patient is obese or whenthe examiner is small compared to the patient.• Stand by the patients chest.• "Hook" your fingers just belowthe costal margin and pressfirmly.• Ask the patient to take a deep breath.• You may feel the edge of the liver press against yourfingers.
GENITALIAAND RECTUM:Providing privacyNot prolonging the examinationWarming instruments i.e. vaginal speculumUsing lubricants to minimize discomfortWear gloves during genital & rectal examinationEmpty the bladder before examination
Male genitals• Inspect the skin of glance penis. Observe for anylesions, color, discharge or inflammation.• Assess secondary sex characteristics , observe thepenis and testes for size and shape, color, texture ofscrotal skin symmetry and the distribution of pubichair , position of meatus and circumcision.• Palpate the penis using your thumb and first twofingers. Note any tenderness or nodules. Normally,testes feel firm and not hard with similar consistency.
Female genitalia• Female genitalia is examined by inspection andpalpation.• Inspect the external genitalia. Separate the labia andinspect the labia minora, clitoris, urethral orifice andvaginal opening.• Observe for inflammation, discharge, ulceration,varicose veins, swelling and nodules.• In internal inspection, observe cervix for color,position, bleeding.
EXTREMITIES:Upper and lower Extremities are assessed for size andsymmetry , various patterns , colour and texture of skinand nail beds , hair distribution on hands , lower legs ,feet and toes . Observe for pigmentation , rashes , scars, ulcers and edema.
HOMAN’S SIGN• Test for homan’s sign, an indicator of phlebitis in whichpain and soreness are present in the calf area when thefoot is dorsiflexed .The person’s dorsiflexed leg issupported from calf with your non dominant hand . Noteany pain or soreness in the calf area. If present this wouldbe a positive homan’s sign ,indicating the possibility ofphlebitis .
MOTOR SYSTEM:Inspect the voluntary muscles for atrophy,fasciculation (uncontrollable twitching)andinvoluntary movements. In addition assess gait ,Rombergs sign for muscle strength and coordination.Gait : is a person’s style of walking. To assess gait,instruct the person to walk across the room, turn andwalk back towards you . Observe the persons balanceand posture . Ataxia is an uncoordinated gait thatresult from cerebellar disease or intoxication.
Rombergs test : Rombergs test is a test of sensory equilibrium.Instruct the person to stand with the feet together and eyesopen . Note the persons balance .Then have the person closethe eyes. Normally you will observe only minimal swaying . Apositive test will suggest cerebellar ataxia.
REFLEXES OF MUSCLES:Tests of muscle strength andassessment of common reflexes
Type Procedure NormalreflexDeeptendonreflexesBiceps Flex the client’s arm at elbow withpalms down. Place your thumb inantecubital fossa at the base of bicepstendon . Strike the thumb with thereflex hammer .Flexion ofarm atelbow.Triceps Flex the client’s elbow , holding armacross the chest , or hold the upperarm horizontally and allow the lowerarm to go limp. Strike triceps tendonjust above the elbow .Extensionat elbow.Patellar Make the client sit with legs hangingfreely over the side of the bed orchair or have the client lie supine andsupport knee in a flexed position .Briskly tap patellar tendon just belowExtensionof lower legat knee.
Procedures NormalreflexAchillesMake the client assume the sameposition as for patellar reflex. Slightlydorsiflex the client’s ankle by graspingtoes in the palm of your hand . Strikeachilles tendon just above the heel.Plantarflexion offoot .Babinski’sHave the client lie supine with legsstraight and feet relaxed . Take thehandle end of the reflex hammer andstroke lateral aspect of the sole from theheel to the ball of the foot , curvingacross the ball of the foot toward thebig toe.Bending oftoedownwards.
Maneuvers to assess muscle strength:Muscle group ManeuverNeck Place your hand firmly against the client’s upper jaw .ask theclient to turn head laterally against resistance.Shoulder Place your hand over the midline of the client’s shoulder ,exerting firm pressure . Have the client raise shoulder againstresistance.Elbow,Biceps,Triceps.Pull down the forearm as the client attempts to flex the arm. Asthe client’s arm is flexed ,apply pressure against the forearm .askthe client to straighten his/her arm.Hip ,QuadricepsWhen the client is sitting apply downward pressure to thigh . Askthe client to raise his leg up from the table.The client sits, holding shin of the flexed leg . Ask him tostraighten his leg against the resistance.
MUSCLE STRENGTHTo grade or quantify muscle strength, assess the patient asfollow:Grade Description0/5 No muscle movement1/5 Visible muscle movement, but no movement at the joint2/5 Movement at the joint, but not against gravity3/5 Movement against gravity, but not against added resistance4/5 Movement against resistance, but less than normal5/5 Normal strength
SENSORY SYSTEM:• Light touch/ superficial pain: Using a wisp of cottonand a safety pin alternatively , touch the distal andproximal portions of the upper and lower extremities.• The temperature test can be done by asking thepatient to touch and identify the hot and cold test tubefilled with hot and cold water respectively.• Vibration is assessed by tapping a tuning fork andplacing it firmly on a person’s inter-phallengial jointof the finger and great toe. Ask the patient to describethe sensation and to identify when the sensation ends.
• Two point discrimination: When assessing two pointdiscrimination , touch the person alternatively withone or two safety pins on a particular body part, suchas the finger pads . ask the patient if one or twosensations are felt.• Point localization is assessed by touching variousparts of the person’s body with a wisp of cotton. Theperson is instructed to open the eyes after having feltthe touch and point to the area.
CONSCIOUSNESSAssessment of consciousness begins with notingwhether the client is awake and alert . If the person hasaltered the level of consciousness , assess whether theperson is demonstrating stupor or coma . Glasgowcoma scale to be maintained for the patient withaltered sensorium and in that three points are observed:eye open response, verbal response and motorresponse .
AFTER CARE:When the physical examination is over, remove thedrape & help the person to put on cloths. Be sure thepatient is safe and comfortable.DISMANTLING OF ARTICLES:Articles should be sent for sterilization. Disposablearticles should be immediately disposed off andreplacement of all the articles should be done to thearea specified.
POINTS TO BE REMEMBER:• Ensure that adequate privacy is provided during theobservation.• Always take help in case of pediatric /unconsciouspatient / uncooperative patient .• Ensure adequate light.• Inform the patient / relatives beforeand after the physical examination .• Record all the observations andpreserve in safe custody .• Inform any abnormal findingsto senior nurse/doctor.