The document discusses a seminar presentation about history collection and physical assessment. It covers key terminology, the importance and components of collecting a patient history, and the definition, principles, preparation, techniques, and components involved in performing a physical assessment. The presentation provides an overview of best practices for nurses to obtain comprehensive information about a patient's health status through thorough history collection and physical examination.

1. SEMINAR PRESENTATION
History Collection And Physical Assessment
Rakhi Das
Iyr MSc Nursing
Jubilee Mission College of Nursing, Thrissur

2. INTRODUCTION
 Health is a state of complete physical, mental
and social well being and not merely the
absence of disease and infirmity – WHO
definition of health
 Nurses play a vital role in the continuity of
care of a client through a keen and thorough
history collection and physical Examination.

3. TERMINOLOGIES
 Client
 History
 Physical Assessment
 Observation/ inspection
 Palpation
 Percussion
 Auscultation

4. TERMINOLOGIES CONT…
 Health
 Illness
 Disease
 Cheyne stokes respiration
 Bradycardia
 Tachycardia
 Bradypnea
 Tachypnea

5. TERMINOLOGIES CONT…
 S1 S2
 Systole
 Diastole
 Pulse pressure
 Thrill
 Pallor
 Cyanosis
 Jaundice

6. TERMINOLOGIES CONT…
 Erythema
 Clubbing
 Alopecia
 Edema
 Cerumen
 Reflex
 Tremor
 Visual field

7. HISTORY COLLECTION

8. HISTORY COLLECTION
DEFINITION
It is a systematic collection of information or
data obtained from the patient and other
relevant sources concerning the patient’s
physical status as well as his/her
psychological, social and sexual functions.

9. TYPES OF HISTORY
o Health history
o Medical history
o Nursing history
STRUCTURE OF HEALTH HISTORY
 Comprehensive health history
 Focused health history

10. .
COMPREHENSIVE HEALTH HISTORY FOCUSED HEALTH HISTORY
• Is appropriate for new patient in
office or hospital
• Provide fundamental and
personalized knowledge about
the patient
• Clinician – patient relationship
strengthens
• Helps identify or rule out physical
causes related to patient concern
• Provides baseline for future
assessment
• Creates platform for health
promotion
• Develops proficiency in skills for
physical assessment
• Appropriate for established
patient especially during
urgent or routine visits
• Assess symptoms
restricted to concerned
parts
• Address focused concerns
or symptoms
• Applies examination
methods relevant to
concerned problem

11. IMPORTANCE/ PURPOSE OF HISTORY
COLLECTION
 Helps to understand the patient’s health
status
 Open channel for communication and further
care
 Gives a baseline information about personal
and social life
 Seeks approval from family members for
participation in comprehensive care
 Gives the client a sense of trust development

12. CONT…
 Helps to rule out possible relations with past
and present medical & surgical history
 Helps to early diagnosis of risk for any
hereditary diseases
 Keeps informed track of medications in use
 Help family members who may be in risk for
disease
 It helps to plan effective nursing care

13. COMPONENTS OF HISTORY COLLECTION
 Initial information
 Chief complaints
 Present illness
 Medications
 Past history
 Family history
 Personal and social history

14. CONT…
 Review of systems
 General
 Skin
 Head, Eyes, Ears, Nose, Throat (HEENT)
 Neck
 Breasts
 Respiratory
 Cardiovascular

15. REVIEW OF SYSTEM CONT…
 Gastrointestinal system
 Urinary system
 Genital
 Male
 Female
 Peripheral vascular
 Musculoskeletal
 Psychiatric

16. CONT…
 Psychiatric
 Neurologic
 Hematologic
 Endocrine
INVESTIGATION HISTORY

17. LIMITATIONS IN HISTORY TAKING
 Clients psychological state
 Cultural beliefs and barriers
 Mis- communication or wrong interpretations
 Physiological barriers
 Environmental factors
 Reluctance in self disclosure

18. OVERCOMING LIMITATIONS
 Mannerism and respect
 Introduction
 Respect cultural values and beliefs
 comfortable environment
 casual tone, conversation
 Allow client to ventilate
 listen attentively, give response and feedback
 Consider confidential matters

19. PHYSICAL ASSESSMENT

20. DEFINITION
A Physical Assessment is a systemic collection
of objective information. It should be
conducted in an organized and
knowledgeable manner
It is a non- invasive general physical
examination of the physical parameters of a
client admitted in a care facility by using four
elementary methods viz. Inspection,
Percussion, Palpation and Auscultation

21. TYPES OF PHYSICAL ASSESSMENT
A complete assessment
Assessment of a body
system
Assessment of body part

22. ACCORDING TO JEAN FORET GIDDENS
Shift assessment
Comprehensive assessment
Episodic / follow up assessment
Screening assessment
Problem Based Assessment

23. PURPOSE OF PHYSICAL ASSESSMENT
 To obtain a baseline data about the client’s
functional abilities
 To supplement, confirm or refute data obtained
in nursing history
 To obtain data that will help the nurse to
establish nursing diagnosis and plan client’s
care
 To evaluate the physiologic outcomes of health
care and thus the progress of a client’s health
problem

24. PURPOSE CONT…
 To make clinical judgements on a client’s health
status
 To detect disease in early stage
 To contribute to nursing research
 To safeguard the patient and relatives from early
signs of communicable disease
 To determine cause and extend of disease
 To strengthen therapeutic communication and
establish rapport

25. PRINCIPLES OF PHYSICAL ASSESSMENT
 Cephalo-caudal Approach
 Be aware of Physiologic changes that occur
with age
 maintain privacy
 Permit ample time for the client to answer
questions and assume desired position
 be aware of cultural differences

26. PRINCIPLES CONT…
 Arrange for a interpreter if needed
 Address the client in professional manner
 Adapt assessment techniques to any
sensory impairement
 Continue therapeutic communication rather
than being silent

27. PREPARATION FOR PHYSICAL ASSESSMENT
A
• Preparation of the Client
B
• Preparation of the
Setting/Environment
C
• Preparation of Articles/
Equipments

28. ARTICLES NEEDED

29. POSITIONS USED FOR PHYSICAL ASSESSMENT
POSITION AREAS ASSESSED CAUTIONS
Dorsal
Recumbent
Head and neck, axillae,
anterior thorax, lungs, breasts,
heart, extremities,
vagina, peripheral pulses,
vital signs
May be contraindicated for patients
with cardio pulmonary problems. Not
used for abdominal assessment
because of the increased tension of
the abdominal muscle
Supine
(horizontal
recumbent)
Head and neck, axillae,
anterior thorax, lungs, breasts,
heart, extremities,
peripheral pulses, abdomen
Tolerated poorly with clients with
cardiovascular and respiratory
problems
Sitting Head and neck, axillae,
posterior and anterior thorax,
lungs, breasts, heart, upper and
lower extremities,
reflexes,
vital signs
Elderly and weak clients may need
support

30. POSITIONS CONT…
Lithotomy Female genitals, rectum,
female reproductive tract
May be uncomfortable for
elderly, often embarrassing
Genupectoral(knee chest) Rectum Uncomfortable position
tolerated poorly by clients
with respiratory problems,
tiring and embarrassing
Sims’ Rectum, vagina Difficult for elderly with
limited joint movements
Prone Posterior thorax,
hip joint movements
Often not tolerated by
elderly and client with
with cardio vascular and
respiratory problem

31. TECHNIQUES OR STEPS OF PHYSICAL
EXAMINATION
Inspection
Palpation - Light (superficial)
- Deep palpation
Percussion - Direct/immediate
- Indirect/mediate
Auscultation - Direct auscultation
- Indirect auscultation

32. COMPONENTS OF PHYSICAL ASSESSMENT

33. COMPONENTS OF PHYSICAL ASSESSMENT
 General survey
 Intugument
 Head and neck
 Thorax and lungs
 Cardiovascular
 Peripheral vascular
 Abdomen

34. CONTD…
 Male genetalia
 Female genetalia
 Anus, rectum, prostate
 Musculoskeletal
 Neurologic

35. DOCUMENTATION
 Write down and record the data and findings
as soon as possible
 Write in the appropriate sequence
 Underline or highlight major findings
 Communicate and countersign

36. CURRENT INNOVATIONS:
Source: Malarvizhi M. Glimpses of current
affairs in child health. TNNMC-JPN. Jan –
Jun 2018. 6(1)
Pacifier thermometer

37. D- EYE DIGITAL OPTHALMOSCOPE

38. CLINICLOUD THERMOMETER AND
STETHOSCOPE

39. SUMMARY AND CONCLUSION
Assignment for Self study and discussion:
Discuss about Physical assessment of
abdomen specifying techniques and
landmarks/abdominal regions used to identify
abdominal areas

40. JOURNAL ABSTRACT
 Kuhn JK & McGovern M. Peripheral vascular
assessment of the elderly client. Journal of
Gerontological nursing. December 1992. 19(1), 35-38
The atherosclerotic process often takes its toll on the
blood vessels of elderly clients, causing disabling and
painful problems. These authors state that a
thourough assessment of an elderly person’s
peripheral vascular system, combined with
appropriate health teaching, can prevent or delay
such problems as ischemic pain, skin ulcerations,
gangrene or amputation. The assessment includes
client interview, inspection, palpation, auscultation
and special techniques to employ if arterial or venous
insufficiency is suspected

41. JOURNAL ABSTRACT
 Powell KE et al. Physical activity and public health: updated
recommendations for adults. AHA circulation 116(9), 1081-1093
Study and recommendations on Types and amount of physical
activity needed by healthy adults to improve and maintain health.
Development of this document was by and expert panel of
scientists, including physicians, epidemiologists, exercise
scientists, and public health specialists. This panel reviewed
advances in pertinent physiologic, epidemiologic, and clinical
scientific data, including primary research articles and reviews
published since the original recommendation was issued in 1995.
Issues considered by the panel included new scientific evidence
relating physical activity to health, physical activity
recommendations by various organizations in the interim, and
communications issues. Key points related to updating the
physical activity recommendation were outlined and writing
groups were formed.

42. JOURNAL ABSTRACT
 Muhrer, Jill C. The importance of History and physical assessment in Nursing.
The nurse Practitioner. 2014 April 13. 39(4), 30-35
This article supports the importance of using the patient history and physical
assessment as a basis for selecting relevant diagnostic testing, which leads to a
timely and accurate diagnosis. This process protects patients from the risks of
unnecessary testing and is cost-effective. As patient volume increases and
encounter times become shorter, it is critical for clinicians to establish a working
diagnosis in a timely manner. With the advent of advanced technological
equipment and rising healthcare costs, it is even more important to be selective
about the use of these tools and to base testing decisions on the specific
findings noted in the patient's clinical evaluation. Therefore, the clinical history
and physical exam are critical to the diagnostic process and often provide more
information than can be gained by broad testing strategies. An old adage claims
that if you listen to patients, they will eventually tell you what is wrong. However,
most patients come in for appointments with multiple concerns, which can make
it even more challenging to focus the encounter without losing important
information regarding the patient's healthcare issues

43. REFERENCE
1. Kaur L, Kaur MA. Textbook of nursing foundations.
Fifth edition. Jalandhar: S.Vikas and company
medical publications INDIA; 2010
2. Bickley LN, Szilagyi PG. Bate’s Guide to physical
examination and History taking. Ninth edition.
Philadelphia: Lippincott Williams & Wilkins
3. Barker AM. Advance Practice Nursing Essential
knowledge for the profession. New Delhi: Jones and
Bartlet India Pvt Ltd; 2010
4. Veerabhadrappa GM. Clinical record book for
Pediatric child health nursing. Jalandhar: S.Vikas
and company medical publications INDIA

44. REFERENCE
5. Dugas BW. Introduction to Patient care a
Comprehensive approach to Nursing. Fourth
edition. New Delhi Harcourt India Pvt Ltd;
2002
6. Basheer SP, Khan SY. A Concise textbook of
Advanced Nursing Practice. Banglore:
EMMESS Medical publishers; 2013
7. Soni S. Textbook of Advanced Nursing
Practice. New Delhi: Jaypee brothers
medical publishers; 2013

45. REFERENCE
8. Potter PA ,Perry AG. Fundamentals of
Nursing. Fifth edition. Vol 1. New Delhi:
Elsevier; 2004
9. Taylor C et al. Fundamentals of Nursing- the
art and science of Nursing Care. Sixth
edition. New Delhi: Wolters Kluwer Pvt Ltd;
2008
10. Kozier B, Erbs G, Berman A, Snyder SJ.
Fundamental of Nursing- concepts process
and practice. First Edition. Saunders
Publication. 2008

46. JOURNAL REFERENCE
 Malarvizhi M. Glimpses of current affairs in Child
health. TNNMC- JPN 6(1) 2018 Jan-Jun
 Muhrer, Jill C. The importance of History and physical
assessment in Nursing. The nurse Practitioner. 2014
April 13. 39(4), 30-35
 Kuhn JK & McGovern M. Peripheral vascular
assessment of the elderly client. Journal of
Gerontological nursing. December 1992. 19(1), 35-38
 Powell KE et al. Physical activity and public health:
updated recommendations for adults. AHA circulation
116(9), 1081-1093

47. INTERNET REFERENCE
 https://scholar.google.co.in/
 https://www.thesaurus.com/
 https://www.online-medical-dictionary.org/