General Guidelines For Health History and Physical Assessment

Introduction

Performing an accurate physical assessment and being able to differentiate normal from abnormal findings is one of the most important roles for today’s health care practitioner. If an accurate physical assessment cannot be performed, whether for baseline data or when the patient’s condition changes, then the patient is not receiving the level of competent care that should be given.You will work through the physical assessment on the basis of body systems and also include a psychosocial assessment.

General Guidelines For Health History and Physical Assessment:

Review Available Data: Quickly review the chart prior to performing your assessment. Note the patient’s name, age, address, race, occupation, and religion. This will provide you with an idea of the patient’s lifestyle and will avoid asking repetitive questions.

Establish Rapport: Always greet the patient in a friendly, non-threatening manner. Use “Mr.”, “Mrs.”, or similar titles unless the patient is a child or adolescent. Explain your relationship to the patient’s care. During introductions many patients are often trying to figure out what they believe the examiner thinks of them. If the impression is good, the patient is more likely to be satisfied and cooperate with the examination. An example of an introductory statement in relation to health assessment performance is, “I will be taking a health history and performing a physical assessment to help meet your health care needs. The assessment will also provide a baseline picture of your health status so that we can notice any changes in your condition.”

Control Environment: If in a semi-private room, ensure maximum privacy by drawing the divider curtain. This is a time to excuse the family, if possible, so the patient can provide candid responses to sensitive issues of which the family may not be aware. Hostile or intoxicated people or persons who have been abusing chemical substances may feel trapped in a small room. For this reason, and also for the examiner’s safety, leave the door open. Also, this type of patient may feel more relaxed if coffee or juice can be offered.

Position Patient: The patient should be wearing comfortable, loose fitting pajamas or a gown. During the rapport establishing phase of the relationship, the examiner should stay at least three feet away from the patient to avoid invading personal space. As the assessment progresses there will be a need to move closer than three feet, but the personal space should still be maintained when just conversing with the patient.

Follow a Systematic Assessment Flow: Although the patient’s condition often dictates what area is covered first in the assessment, one should still observe some type of systematic progression to avoid excluding important assessment areas.

Techniques Of Physical Assessment:
Inspection
A method of systematic observation. Inspection should begin with general observation of the patient progressing to specific body areas. Inspection is a physical assessment technique that is often used but seldom thought about.

Palpation:
Process of examining patients by application of the hands. Used to determine:

• The consistency of tissue directly or indirectly with the palms of the hands or finger pads.
• Alignment and intactness of structures (such as the nasal septum or extremities).
• Presence of thrills. Thrills are fine vibrations and can sometimes be felt over aneurysms or Grade IV or stronger heart murmurs.
• Symmetry of body parts and movement.
• Transmission of sound through vibration (known as tactile fremitus).
• Areas of warmth and tenderness.

For light palpation, press the skin gently with the tips of two or three fingers held close together. Note tenderness or warmth (although the backs of the examiner’s hands are most sensitive to skin temperature) as well as the size and position of structures and the existence of masses. For deep palpation, place one hand on top of the other and press down with the fingertips of both hands. For example, deep palpation of the right upper quadrant lets you estimate the size of the liver.

Percussion:
Tapping of the body lightly but sharply to determine consistency of tissues and/or organs through vibration and areas of tenderness. Sounds that will be heard include:

• Resonance – Loud, long low-pitched sound heard over hollow structures such as the lungs and abdomen.
• Hyperresonance – Loud, very long sound, lower pitched than resonance, heard over areas such as overaerated lung tissue found in COPD. Hyperresonance sound lies between tympani and resonance.
• Tympany – High-pitched, loud sound of medium duration heard over the stomach or gastric bubble.
• Dullness – Medium-pitched, slightly louder than a flat sound heard over solid organs such as the heart, liver, or a distended bladder.
• Flatness – Soft, high-pitched, short sound heard over bone and muscle.

The technique of percussion involves putting the middle finger of the nondominant hand on the patient’s body and tapping it briskly with the middle finger of the dominant hand. If the examiner’s hands are small, the technique may not make a sound loud enough to be heard. In this case, try striking the finger with the side of the thumb instead.

Auscultation:
Process of listening for sounds over body cavities to determine presence and quality of heart, lung, and bowel sounds. High-pitched tones are best heard with the diaphragm of the stethoscope while low-pitched tones are best heard with the stethoscope’s bell (“bell-low” is an easy way to remember). Hold the diaphragm firmly against the skin to block out extraneous noise. The bell should be place more lightly on the skin.

References:

ArcMesa Educators. (n.d.). Retrieved from http://nursinglink.monster.com/training/articles/298-physical-assessment---chapter-1-history-andphysical-examination

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