The Nursing History and Physical Assessment

Guidance of Care
What does the health history provide for the nurse and doctor?
Health History
What includes subjective and objective data when providing guidance of care?
Health Assessment
What is it called when you look at physical, mental, spiritual, socioeconomic, and cultural status of the patient or community we're examining?
Nursing Health History
What is the biographical info, present illness or health concerns, family hx (genogram), psycholsocial hx, review of systems, client expectations, health hx, environmental hx, spiritual hx, medication hx, surgeries, past tx, functional health patterns, and the documentation of findings?
Nursing Health History
Cognition/Perception (one of the functional health patterns) includes sensory perception (hearing/vision deficits) and how the pt obtains information or sees things. What is this part of?
During the physical assessment
When do we gather objective data about the patient, focus on functional abilities and responses to illness/stressors, and establish baseline data?
Purpose of the Physical Assessment
-Identify nursing diagnoses and collaborative problems
(What's the problem and what are some interventions of that weakness?)
-Monitor the status of an identified problem (Know when there was a change or see if what's been working or not)
-Screen for health problems
-Evaluate nursing care
Comprehensive Physical Assessment
A physical assessment that includes an interview and head to toe exam. It's detailed and completed upon admission or onset of care with a provider. Provides the complete care of the patient on paper.
Ongoing Physical Assessment
As needed assessment that occurs with every patient interaction. Attention to small things that have changed over the course of the day
Ex: ICU q 2 hour assessments
Good ways to prepare for the assessment
-Develop rapport (introduction and how is your day?)
-Explain the procedure (what you're doing)
-Respect cultural differences
-Use proper positioning and draping (don't leave them exposed or unsafe)
-Promote comfort and Provide privacy
-Limit noise (to hear heart and lung sounds)
-Enable visualization with good lighting
-Have supplies readily available (watch, stethoscope, chart, swabs, pen, light, BP cuff, gloves, etc.)
Integration of Assessment
Performing routine tasks while assessing (checking skin during bed bath, checking LOC while introducing yourself).
Bell of stethescope is used for low pitched sounds
During auscultation, which part of the stethescope would you use to hear a heart murmer?
During auscultation, which part of the stethescope would you use to hear high-pitched sounds like S1 and S2 heart sounds (lg part)
Assessment Parameters for Older Adults
Basic ADLs (activities of daily living), IADLS (instrumental activities of daily living) and focus on vision and hearing changes.
Aspects of a General Survey
-Affect: happy or sad, tone of voice
-Body type/posture
-Vital signs