The History Directs the Focus of the Physical Exam

Health Assessment

B/S bv Chapter 5

The Value of History Taking

•  The history directs the focus of the physical exam

•  The history often is the basis for forming the diagnosis

•  Keys to obtaining a history successfully

–  Develop a atmosphere of trust

–  Learn to ask the right questions

–  Gain skill in interpreting the responses

–  Know what to do next

–  Care begins simultaneously during the history

When Taking the H&P:

- The nursing process is utilized: Assess, Nrsg. Dx., Plan, Implement,

Evaluate

- The information is critical for identifying physical & psychological

problems the patient is experiencing

- Health history & physical assessment are performed by the nurse (RN)

- Performed under various settings: clinics, acute care, outpatient office, long-

term care, school, home

- Explain to patient purpose of health hx & PE, how this information will be

used.

-  So I can determine and plan the course of your care

-  So that I can plan your educational program

First Impressions are important

•  A positive first impression is necessary to start the “trusting relationship”, between you and the pt.

•  This begins with the initial contact

–  Appearance should be clean, neat, professional

–  Approach with confidence

–  Demeanor

–  Body language- yours and theirs

•  Shake hands- provides opportunity for making initial observation

Establishing the Patient Relationship

–  Polite introduction

–  Is the pt. made to feel like an invited guest or an unwanted pest?

–  Be respectful of person, space, property & family

–  Determine how the pt. wants to be addressed; Desired name

–  Avoid disrespectful terms & voice tone (consider age & culture)

Patient Relationship (cont’)

–  Location and Position of the interview is important

–  Quiet & Private location, if possible

–  Is it possible to make the pt more comfortable?

–  Make eye contact and keep position should be at eye level

–  Appropriate distance and position promotes

–  Safety

–  Respect of Personal zone

Elements of the Comprehensive History

Include:

•  First Impressions and the environment

•  Identifying data

•  Chief complaint or concerns

•  History of present illness

•  Current health status and medical care

•  Significant past history

•  Family history

•  Systems review

–  Patient info

–  Look at the pt’s. records: labs, med. HX, diagnostic tests, medical/nurse’s notes

–  What was said in nursing report (SBAR)

–  What is the “reported” chief complaint(s)?

–  The Patient’s environment

–  What is the setting?

–  Are medical documents available or on file? Are they assessable?

–  What is the setting like?

–  Is the patient undergoing medical therapy or under medication at the time of interview?

Identifying Data (Biographical data)

•Name, age, DOB, Sex

•Race/ cultural factors/ religious practices

•Current care provides

•Language preferences

–  / cultural factors

•Current care provides – address parents of children in order to establish trust

–  The Chief complaint

What is the single most critical concern to the pt.?

–  “What seems to be the problem today?”

–  “What can I help you with today?”

–  Which system (origin) do you believe to be affected by the Chief Complaint?

–  Do you clearly understand the pts. chief complaint or complaints?

–  Are there multiple complaints?

“if I could make one thing better for you, which would you want it to be?”

–  Are the multiple complaints likely related?

–  Will you need to address multiple issues?

–  Could some of these be chronic issues?

Tips for effective history taking

–  Ask open-ended questions:

•  “What seems to be bothering you today?” - Opens them up to talk

–  Closed- ended questions

•  “Is your chest pain sharp or dull?” – having to answer yes or no.

–  You may ask Multiple choice questions

–  Listen actively!!!

•  Act as if you are listening, learn forward towards the patient, eye contact.

•  Repeat the pt’s. statements

•  Clarify answers if needed

•  Take notes if you have to, but write briefly. Don’t bury yourself looking down on paperwork

•  Display your concern

•  Confront with caution

Hx. Of present illness

–  Explore the CC in more detail

–  Explore other complaints

–  Are they associated?

–  do they involve different body systems?

Current Health status & medical care

–  what medical therapies or treatment are they undergoing?

–  What medications are they taking? Get Name, dose, route, frequency if possible

–  Who is the regular physician? Are there specialists who are seeing them?

–  Allergies, what kind of reaction do they experiece?

–  Home situation, daily life, family life

–  Are there any recent changes to diet? Recent wt. gains/loss – was it intentional?

–  Any recent changes in sleep pattern? What do they do to help themselves sleep?

–  Tobacco, alcohol, substance abuse – how much (on a daily or weekly basis)

–  Type of occupation

–  Immunizations, flu shots, pneumonia vaccines, - when was the last time

Significant Past history

–  What is the general state of health as per the pt. (subjective)

–  Significant adult or childhood illnesses or injuries

–  Psychiatric illnesses

–  Past hospitalizations, surgeries, or long-term treatments – why?

Family History

–  Relative risk factors

–  DM, HTN, Renal dis., heart dis.’

–  early acute MI, early sclerotic coronary disease, stroke,

–  Asthma, allergies, cardiac dysrrhythmias,

–  Cancer, osteoporosis, mental illness

Review of Systems

R.O.S. – is an overview of the pt’s general health - usually subjective

–  System reviews is usually focused by the chief complaint

-  questions are asked about each major body systems in terms of past or

-  present symptoms.

–  “Are you having any problems with your bladder?” (nocturia,)

–  You want to Act on the chief complaint by

–  Directing immediate care as appropriate

–  Hx taking may need to be temporarily deferred (ex: respiratory distress)

–  Interpret the feedback and Act

–  What do I think of these responses the patient is making?

–  Do they make sense?

–  Am I missing something?

–  Do I need clarification?

–  Use your knowledge of A&P and pathophysiology to assess and ask questions

–  Why is the pt. experiencing these signs and symptoms?

–  Create a picture of what is happened to this pt. today

Sensitive Topics

Topics such as: abuse, rape, personal issues

Is it the right location or place to talk privately with the patient

–  Does anyone present make the pt. feel uncomfortable

Can you gain their trust?

Choosing appropriate words to show sensitivity

Understand the pts. feelings related to the sensitive nature

Be very professional

The silent patient

–  Short periods of silence may be normal

–  Allow them time to collect their thoughts

–  Provide reassurance and encouragement

–  Consider:

–  That the patient may be frightened; or perhaps you frightened them

–  Are you dominating the discussion?

–  Have you offended the pt.?

–  Is there is a physical or mental disorder? Or a lack of understanding?

The overly talkative pt.

–  Allow the pt. to speak

–  If necessary, politely interrupt and focus the discussion

–  Focus on more critical issues

–  Ask specific, closed-ended questions

–  Summarize the pt’s. story and move on

–  Don’t display your impatience

The anxious frightened patient

–  Look for signs of anxiety or fear

–  Try to alleviate concerns and develop trust

–  Do not give false reassurance

–  “Everything is going to be fine”

–  Identify the source of anxiety/fear

–  Try to understand the pts. Feelings – “I don’t know why you are so anxious, would you like to talk about it?”

The Angry Hostile Patient.

–  These are common feelings associated with stress or fear

–  Understand the source of these feelings

–  Respond in a professional & caring manner.

–  Personal safety is a primary concern!!!

–  Distance

–  Assistance

–  Firm but let your verbal and body language show that you care

The intoxicated Patient

–  Irrational

–  Altered sense of right and wrong

–  May become violent

–  If the pt. is shouting,

–  Increased potential for violent behavior

–  Listen

–  Don’t respond back with shouting

The Depressed or Suicidal pt.

–  Know the warning signs

–  Explore the specific feelings of the pt.

–  Be direct and specific

–  Question regarding thoughts of suicide or personal harm

–  Talk openly and specifically about suicide plans

The Patient with a Confusing

History or Behavior

–  The entire story does not add up

–  Assess mental status

–  Consider possible dementia or delirium

–  Identify cause if possible

–  Consider specific causes based upon behavior

The Patient with a Language Barrier

–  Extremely difficult to assess

–  Enlist friends or family to act as interpreter

–  Use pre-established questions in the pts. Language

–  Language lines

Intelligence and Literacy

–  Does the pt. really understand your question?

–  History may be inaccurate

–  Enlist caregiver or family

–  Can the pt. actually read?

Patients with Sensory Deficits

–  Hearing impaired

–  Does the pt. read lips?

– Face the pt when talking to them

– Stand close to the good ear

– Talk slowly and distinctly

– Use a Sign language interpreter

– Place a sign to alert others of pt. needs

– Don’t yell – does the patient wear hearing aids? Where are they?

- Blindness: your voice and touch are critical at this point to Establish a trusting relationship

Common pitfalls

Using a tone of voice that sends the wrong message

–  “What is your problem today, Mr. Jones?”

–  Why did you push the call bell?

(Patients impression)

–  He thinks I call for every little problem

–  I must have called and was not supposed to

–  I think I’m bothering these nice people

–  Lack of respect for cultural, religious or ethnic differences

–  “Why do you people use these home herbal remedies?”

–  “You have enough kids. You should consider birth control”

(Patients Impression)

This person thinks I am a fool

She laughs at the traditions of my culture

He does not respect my personal decisions

Poor choice of words or using technical terms

–  How many years has your husband been using these ace inhibitors

–  Your wife is experiencing congestive heart failure

–  Have you voided?

(Patients impression)

–  What the heck is he talking about?

–  My wife’s heart is failing?!?! Has her heart stopped yet?

–  Son, could you speak English?

Summary

–  Obtaining the history guides the physical exam

–  History taking is accomplished along with the physical exam and therapies

Role of Nurse

•  Nurse obtains health history

–  Biographical data – age, wt./ht., culture, religious practices,

–  Past health history

–  Family history – genogram (family tree diagram of identifying family illnesses)

–  Review of systems (subjective)

–  Patient profile

Genogram

•  Used to record history of family members

•  Includes: age, cause of death or if living; their current health status

•  Subjective data - what the patient tells you

•  Objective data- perceptible to other persons; able to be analyzed, counted or measured.

Physical Examination – (Objective)

•  A complete physical examination includes:

–  Skin-

–  Head & neck

–  Thorax and lungs

–  *Breasts

–  Cardiovascular

–  *Rectum

–  *Genitalia

–  Neurological system

–  Musculoskeletal system

*may be deferred depending on reason for admission

–  PE is done after the health history is obtained,

wash your hands before and after the exam

–  Provide a well lighted, and warm area

warm your stethoscope in your hand

–  Have pt. change into a gown if not already in so

–  Respect the pts. Privacy at all times. Close doors, pull curtains, keep body parts covered. Be aware of the other people that may be in the room (pt roommate, family members, ancillary staff, etc.)

–  Explain what you are going to do before you do it.

–  Wear gloves when you may be exposed to blood and body fluids

–  Use a organized and systematic approach to encourage cooperation and trust

** A complete exam is not done on q.d. on every pt. in the hospital for extended periods.

**Proficiency at physical exams requires repetition and reinforcement in the hospital setting.

Physical exam (cont.’)

•  Basic tools for physical exams requires use of your senses of vision, hearing, smell as well as special tools :

–  Stethoscope

–  Bp cuff

–  Tongue blade

–  Flashlight

–  Reflex hammer

–  Pulse oximetry

4 Approaches used in obtaining a Physical Assessment

·  Inspection

·  Auscultation

·  Percussion

·  Palpation

Inspection- observation/ general inspection

•  Old, young, do they appear to be the stated age?

•  Are they thin, obese, anxious, depressed?

- Posture- the posture that a pt. assumes may be indicative of illness. Posture and stature are usually addressed on admission.

- Pts. With breathing difficulties may prefer to sit or they may lie perfectly still if having abdomen pain.

- The pt. may prefer to pace if anxious or having renal colic

- Patients with meningitis may c/o head and neck pain upon flexing the neck

- Body movements- Tremors may be due to Parkinson’s or other causes.

- Asymmetrical movements may occur as a result of CNS disorders or CVA.

There may be drooping of one side of the face, weakness or paralysis of one

extremity or foot dragging.

- Spasticity may be present in Multiple Sclerosis. or dystonia in Parkinson’s

- Nutrition- obesity may be generalized or specifically localized in the trunk in those with endocrine disorders (Cushing’s syndrome), have they been taking corticosteroids for an extended period of time?

- Weight loss may be due to inadequate calorie intake over a long period of time; or in diseases that produce muscle wasting (like in disorders that affect protein synthesis – bulimia, liver disease).

- Speech patterns- voice slurred due to CNS disorders or damage to the

cranial nerves. Recurrent damage to the laryngeal nerve will produce