health history and physical examination.pptx

health history and physical examination

1. ASSESSMENT

2. INTRODUCTION HEALTH : Health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity. (WHO, 1947) ASSESSMENT : Assessment is defined as a systematic, dynamic process by which the nurse through interaction with client, significant others and health care providers, collects and analyze data about the client. (ANA)

3. PROCESS/COMPONENTS OF ASSESSMENT PHYSICAL EXAMINATION HEALTH HISTORY

4. HEALTH HISTORY

5. HEALTH HISTORY A health history is a collection of subjective data that provides a detailed profile of the client’s health status.

6. HEALTH HISTORY Health history can also be referred as ‘ History taking ’. During the interview, obtain information about the client’s health history and family health history.

7. HISTORY TAKING INCLUDES THE FOLLOWING : Biographic data Chief complaints History of present illness/Present medical history Past medical history Present surgical illness Past surgical illness Family history Lifestyle/high risk behaviour Obstetrical history

8. 1. BIOGRAPHIC DATA NAME ADDRESS GENDER AGE MARITAL STATUS EDUCATIONAL QUALIFICATION OCCUPATION RELIGION HEALTH CARE FINANCING PRIMARY HEALTH CARE PROVIDER FAMILY INCOME/MONTH OR YEAR ETC.

9. 2. CHIEF COMPLAINTS These are the complaints of the client which should be documented in client’s own words. Eg. Mr. Rohan claim that previously he was well until one week prior to admission. Then he started to have fever. he had fever one week back which is on and off there is no episode of seizure or convulsion He took paracetamol tablet, fever subside but reoccur afterwards. And he also had headache and body-ache since one week.

10. 3. HISTORY OF PRESENT ILLNESS Onset Signs and symptoms Treatment if any Other complaints such as Loss of appetite, Insomnia, Disorders of stomach etc. should also be found out. Find out the client’s health habits like eating, sleeping etc .

11. Example of present medical history Presently Mr. Rohan has fever, headache, body-ache and difficulty in sleeping.

12. 4. PAST MEDICAL HISTORY Any childhood illness like Mumps, Measles and so on. Allergies Mental diseases Accidents Injuries Blood transfusions Use of over the counter products Herbal or dietary supplements etc.

13. Example of past medical history Mr. Rohan do not have any past history of hospitalization. He is not a known case of any hereditary, communicable and metabolic diseases.

14. 5. PRESENT SURGICAL HITORY Type of surgery Date of surgery Which type of anaesthesia? etc. E.g. The patient has undergone Exploratory laparotomy on 23/01/2021 for intestinal obstruction under general anaesthesia .

15. 6. PAST SURGICAL HITORY Any surgery before the hospitalization? Any surgery during childhood? Which type of surgery? etc. E.g. The patient has a history of appendectomy 5 years back. Or if there is no history (the patient does not have any significant surgical history).

16. 7. FAMILY HITORY Information about all family members (father, mother, grandparents, brothers and sisters etc.) living or dead, cause of death (if dead), condition of their health (if living), family history of any illness , e.g., Diabetes mellitus, Cancer, Heart diseases etc.

17. 7. FAMILY HITORY CONTD… Sl. no. Name Age Sex Relation with patient Occupation Education Remark 1. Master Badal 10yrs Male patient Studying 6 th standard unhealthy 2. Mr.Phool chand 36yrs Male Father Farmer Illiterate Healthy 3. Mrs. Ranjita 34yr Female Mother Houswife Illiterate Healthy 4. Master Rakesh 8yrs Male Brother Studying 4 th standard Healthy 5. Master Rohit 6 yrs Male Brother Studying 1 st standard Healthy 6. Baby Naveena 5 yrs Female Sister Studying Nursery Healthy FAMILY COMPOSITION:

18. 7. FAMILY HITORY CONTD ( F AMILY TREE IS ALSO KNOWN AS PEDIGREE CHART)

19. 8. LIFESTYLE/HIGH RISK BEHAVIOUR Smoking, alcoholism, substance abuse. If yes, how much and since when? Food habits, likes and dislikes, pattern of sleep, exercise pattern, health care facility available etc.

20. 9. OBSTETRICAL HISTORY Menstrual history History of pregnancy History of labour and puerperium Complications during pregnancy or labour if any History of children, alive or dead etc.

21. PHYSICAL EXAMINATION

22. P HYSICAL EXAMINATION It is the systemic collection of objective information that is directly observed or is elicited through examination techniques.

23. P HYSICAL EXAMINATION CONTD.. It is the thorough inspection or a detailed study of the entire body or some parts of the body to determine the general physical or mental conditions of the body.

24. PURPOSES OF PHYSICAL EXAMINATION To understand the physical and mental well-being of the clients. To detect diseases in its early stage. To determine the cause and the extent of disease. To understand any changes in the condition of diseases, any improvement or regression.

25. PURPOSES OF PHYSICAL EXAMINATION CONTD… To determine the nature of the treatment or nursing care needed for the client. To safeguard the client and his family by noting the early signs especially in case of a communicable disease. To contribute to the medical research . To find out whether the person is medically fit or not for a particular task.

26. METHODS/TECHNIQUES OF PHYSICAL EXAMINATION INSPECTION PALPATION AUSCULTATION PERCUSSION OLFACTION METHODS OF PHYSICAL EXAMINATION

27. INSPECTION It is a systematic visual examination of the client. It involves observation of the colour , shape, size, symmetry, position and movements. It also use the sense of smell to detect odor, and sense of hearing to detect sounds.

28. INSPECTION CONTD… Inspection begins with the initial contact with the client and continues through the entire assessment. The optimal conditions for effective inspection are full exposure of the area and adequate lighting.

29. PALPATION It is use of hands and fingers to gather information through touch. It is the assessment technique which uses sense of touch. It is feeling the body or a part with hands to note the size and position of the organs.

30. PALPATION The hands and fingers are sensitive tools and can assess temperature, texture(appearance), moisture, vibrations, size, position, masses, fluid etc. The dorsum(back) surfaces of the hand and fingers are used to measure temperature. The palmar(front) surfaces of the fingers and finger pads are used to assess texture, shape, fluid, size, consistency(healthy) and pulsation. Vibration is palpated best with the palm of the hand .

31. ROLE OF A NURSE IN PALPATION The nurse’s hands should be warm and fingernails should be short. The touch should be gentle and respectful. She should palpate the area of tenderness at last. She should used light, moderate, or deep palpation. The purpose of deep palpation is to locate organs, determine their size and to detect abnormal masses.

32. PERCUSSION It is the examination by tapping the fingers on the body to determine the condition of the internal organs by the sounds that are produced.

33. PERCUSSION CONTD… The sound waves produced by the striking action over body tissues are known as percussion tones or percussion notes .

34. PERCUSSION CONTD… Resonance : The degree to which sound propagates(generate) is called resonance. Tones of percussion: Percussion provides five characteristics tones – TYMPANIC HYPER-RESONANT RESONANT DULL FLAT

35. PERCUSSION CONTD… TYMPANIC: Tympanic sounds  are hollow, high, drumlike sounds.. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax. RESONANT: Resonant sounds  are low pitched, hollow sounds heard over normal lung tissue. HYPER-RESONANT: Hyperresonant sounds  that are louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack.

36. PERCUSSION CONTD… DULL: Dull or thudlike sounds  are normally heard over dense areas such as the heart or liver. FLAT: Flat or extremely dull sounds  are normally heard over solid areas such as bones.

37. TYPES OF PERCUSSION DIRECT INDIRECT

38. DIRECT PERCUSSION Direct percussion is accompanied by tapping an area directly with the finger tip of the middle finger or thumb.

39. INDIRECT PERCUSSION Indirect percussion involves two hands. The hand is placed on the area to be percussed and the finger creating vibrations that allows discrimination among five different tones.

40. AUSCULTATION It is the process of listening to sounds that are generated within the body. Auscultation is usually done with the help of a stethoscope .

41. AUSCULTATION CONTD… The heart and blood vessels are auscultated for circulation of blood . The lungs are auscultated for moving air (breath sounds) . The abdomen is auscultated for movement of gastro-intestinal contents( bowel sounds ). When auscultating a part, that area should be exposed, and should be quiet.

42. AUSCULTATION CONTD… FOUR CHARACTERISTICS OF SOUND ARE ASSESSED BY AUSCULTATION : Pitch (ranging from high to low). Loudness (ranging from soft to loud). Quality (gurgling or swishing). Duration (short, medium or long).

43. OLFACTION