3
Health History and Physical
Examination
Courtney Reinisch
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Clinical Judgment Communication
Collaboration
LEARNING OUTCOMES
1. Explain the purpose, components, and techniques of a 3. Select appropriate techniques of inspection, palpation,
patient’s health history and physical examination. percussion, and auscultation for the physical examination.
2. Obtain a nursing history using a functional health pattern 4. Distinguish among emergency, comprehensive, and
format. focused assessments in terms of indications, purposes, and
components.
KEY TERMS
auscultation objective data
database palpation
functional health patterns percussion
inspection subjective data
nursing history
During an assessment, you will obtain a patient’s health history medical history and physical examination, and (3) laboratory
and perform a physical examination. This is part of the interpro- and diagnostic test results. A nurse and health care provider
fessional team’s patient evaluation. The interprofessional team, (HCP) perform a history and physical assessment using formats
also known as an interdisciplinary or multidisciplinary team, and data based on each discipline’s focus.
is made up of health care professionals who provide care to a
patient. The findings of your nursing assessment (1) contribute Medical Focus
to a database that identifies the patient’s current and past health A medical history is used primarily by the HCP to determine
status and (2) provide a baseline against which we evaluate future risk for disease and diagnose medical conditions. The medical
changes. The purpose of the nursing assessment is to enable you history is usually collected by a member of the health care team,
to make clinical judgments about your patient’s health status.1 such as a physician, advanced practice nurse (APN), resident,
Assessment is the first step of the nursing process. It is performed physician’s assistant, or medical student. The HCP’s physical
continually throughout the nursing process to evaluate nursing examination and diagnostic tests aid in establishing medical
interventions and progress toward patient outcomes. diagnoses and implementing and monitoring the medical treat-
Assessment as a term is complex, with many meanings. In ment plan. The information collected and reported by the HCP
this text, assessment describes a hands-on data collection process. is used by nurses and other health care team members (e.g.,
Database identifies a specific list of information (data) to collect. pharmacist, physical therapist, dietitian, social worker) based
on the focus of their care. For example, the abnormal results of a
neurologic examination by an APN may help diagnose a stroke.
DATA COLLECTION You use the same results to identify fall risk in a patient. A phys-
The database is all the health information about a patient. It ical therapist uses this information to plan therapy involving
includes (1) nursing history and physical examination, (2) the range-of-motion exercises.
36
, CHAPTER 3 Health History and Physical Examination 37
TABLE 3.1 NURSING MANAGEMENT
Assessment and Data Collection
• On admission, complete a comprehensive admission assessment (see
Table 3.5).
• Obtain patient’s health history by interviewing patient and/or caregiver..
• Perform physical examination using inspection, palpation, percussion, and
auscultation as appropriate.
• Record findings from the health history and physical examination in the
patient’s record.
• Organize patient data into functional health patterns (see Table 3.3).
• Develop and prioritize nursing problems for the patient.
•
Throughout hospitalization, perform focused assessments based on
patient’s history or clinical manifestations (see Table 3.8).
• Refer patients to the appropriate community-based services.
• Supervise aspects of data collection by AP:
• Vital signs, including oxygen saturation Fig. 3.1 Conducting a nursing focused interview. (Courtesy Linda
• Height and weight, oral intake, and output Bucher, RN, PhD, CEN, CNE, Staff Nurse, Virtua Memorial Hospital, Mt.
• Per agency policy, point-of-care testing, such as blood glucose Holly, NJ.)
nonjudgmental approach. You communicate through spoken lan-
Nursing Focus guage and actions, including your manner of dress, gestures, and
Nursing care is the diagnosis and treatment of human responses body language. Culture influences the words, gestures, and postures
to actual or potential health problems or life processes. The one uses and the information we share with others (see Chapter 2).
information obtained from the nursing history and physical In addition to understanding the principles of effective com-
examination is used to determine the patient’s strengths and munication, you will develop a personal style of relating to
responses to a health problem. For example, a patient with a patients. One style of communication does not fit all. The word-
diagnosis of diabetes may respond with anxiety or lack of knowl- ing of questions can increase the likelihood of obtaining the
edge about managing the condition. This patient may have the needed information. The ease of asking questions, particularly
physical response of the abnormal fluid loss caused by hyper- those related to sensitive areas such as sexual function, comes
glycemia. These human responses to the condition of diabetes with training and experience.
are diagnosed and treated by nurses. During the nursing history The amount of time you need to complete a nursing history
interview and physical examination, you will obtain and record varies with the format used and your experience. The nursing
the data to support decisions about nursing care (Table 3.1). history may be completed in 1 or several sessions, depending on
the setting and patient. For example, an older adult patient with
Types of Data a low energy level may need a few brief interviews to allow time
The database includes subjective and objective data. Subjective to give the needed information. You must judge the amount
data, or symptoms, are collected by interviewing the patient of information to collect on initial contact with the patient. In
and/or caregiver during the nursing history. This type of data interviews with patients with chronic disease, patients in pain,
includes information that can be described or verified only by and patients in emergency situations, ask only those questions
the patient or caregiver. It is what the person tells you, either that are pertinent to a specific problem. You can complete the
spontaneously or in response to a direct question. health history interview at a more appropriate time.
Objective data, or signs, are data that we can observe or mea- Judge the reliability of the patient as a historian. An older
sure. You obtain objective data using inspection, palpation, per- adult may give a false impression about their mental status
cussion, and auscultation. Objective data are also obtained by because of a prolonged response time or vision and hearing
diagnostic testing. Patients often provide subjective data while problems. The complexity and duration of health problems
you are performing their assessment. You will observe objective may make it hard for an older adult or a chronically ill younger
signs while interviewing the patient. All the findings related to a patient to be an accurate historian.
specific problem, whether subjective or objective, are known as It is important for you to determine the patient’s priority con-
clinical manifestations of that problem. cerns and expectations, since your priorities may be different from
the patient’s. For example, your priority may be to complete the
Interview Considerations health history, while the patient is interested only in relief from
The purpose of the patient interview is to obtain a health history symptoms. Until the patient’s priority need is met, you will prob-
(i.e., subjective data) about the patient’s past and present health ably be unsuccessful in obtaining complete and accurate data.
state (Fig. 3.1). Effective communication is used in the interview
process. Creating a climate of trust and respect is critical to estab- Symptom Investigation
lishing a therapeutic relationship.2 You need to communicate At any time during the assessment, the patient may report a
acceptance of the patient as a person by using an open, responsive, symptom such as pain, fatigue, or weakness. Because we do not
Health History and Physical
Examination
Courtney Reinisch
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Clinical Judgment Communication
Collaboration
LEARNING OUTCOMES
1. Explain the purpose, components, and techniques of a 3. Select appropriate techniques of inspection, palpation,
patient’s health history and physical examination. percussion, and auscultation for the physical examination.
2. Obtain a nursing history using a functional health pattern 4. Distinguish among emergency, comprehensive, and
format. focused assessments in terms of indications, purposes, and
components.
KEY TERMS
auscultation objective data
database palpation
functional health patterns percussion
inspection subjective data
nursing history
During an assessment, you will obtain a patient’s health history medical history and physical examination, and (3) laboratory
and perform a physical examination. This is part of the interpro- and diagnostic test results. A nurse and health care provider
fessional team’s patient evaluation. The interprofessional team, (HCP) perform a history and physical assessment using formats
also known as an interdisciplinary or multidisciplinary team, and data based on each discipline’s focus.
is made up of health care professionals who provide care to a
patient. The findings of your nursing assessment (1) contribute Medical Focus
to a database that identifies the patient’s current and past health A medical history is used primarily by the HCP to determine
status and (2) provide a baseline against which we evaluate future risk for disease and diagnose medical conditions. The medical
changes. The purpose of the nursing assessment is to enable you history is usually collected by a member of the health care team,
to make clinical judgments about your patient’s health status.1 such as a physician, advanced practice nurse (APN), resident,
Assessment is the first step of the nursing process. It is performed physician’s assistant, or medical student. The HCP’s physical
continually throughout the nursing process to evaluate nursing examination and diagnostic tests aid in establishing medical
interventions and progress toward patient outcomes. diagnoses and implementing and monitoring the medical treat-
Assessment as a term is complex, with many meanings. In ment plan. The information collected and reported by the HCP
this text, assessment describes a hands-on data collection process. is used by nurses and other health care team members (e.g.,
Database identifies a specific list of information (data) to collect. pharmacist, physical therapist, dietitian, social worker) based
on the focus of their care. For example, the abnormal results of a
neurologic examination by an APN may help diagnose a stroke.
DATA COLLECTION You use the same results to identify fall risk in a patient. A phys-
The database is all the health information about a patient. It ical therapist uses this information to plan therapy involving
includes (1) nursing history and physical examination, (2) the range-of-motion exercises.
36
, CHAPTER 3 Health History and Physical Examination 37
TABLE 3.1 NURSING MANAGEMENT
Assessment and Data Collection
• On admission, complete a comprehensive admission assessment (see
Table 3.5).
• Obtain patient’s health history by interviewing patient and/or caregiver..
• Perform physical examination using inspection, palpation, percussion, and
auscultation as appropriate.
• Record findings from the health history and physical examination in the
patient’s record.
• Organize patient data into functional health patterns (see Table 3.3).
• Develop and prioritize nursing problems for the patient.
•
Throughout hospitalization, perform focused assessments based on
patient’s history or clinical manifestations (see Table 3.8).
• Refer patients to the appropriate community-based services.
• Supervise aspects of data collection by AP:
• Vital signs, including oxygen saturation Fig. 3.1 Conducting a nursing focused interview. (Courtesy Linda
• Height and weight, oral intake, and output Bucher, RN, PhD, CEN, CNE, Staff Nurse, Virtua Memorial Hospital, Mt.
• Per agency policy, point-of-care testing, such as blood glucose Holly, NJ.)
nonjudgmental approach. You communicate through spoken lan-
Nursing Focus guage and actions, including your manner of dress, gestures, and
Nursing care is the diagnosis and treatment of human responses body language. Culture influences the words, gestures, and postures
to actual or potential health problems or life processes. The one uses and the information we share with others (see Chapter 2).
information obtained from the nursing history and physical In addition to understanding the principles of effective com-
examination is used to determine the patient’s strengths and munication, you will develop a personal style of relating to
responses to a health problem. For example, a patient with a patients. One style of communication does not fit all. The word-
diagnosis of diabetes may respond with anxiety or lack of knowl- ing of questions can increase the likelihood of obtaining the
edge about managing the condition. This patient may have the needed information. The ease of asking questions, particularly
physical response of the abnormal fluid loss caused by hyper- those related to sensitive areas such as sexual function, comes
glycemia. These human responses to the condition of diabetes with training and experience.
are diagnosed and treated by nurses. During the nursing history The amount of time you need to complete a nursing history
interview and physical examination, you will obtain and record varies with the format used and your experience. The nursing
the data to support decisions about nursing care (Table 3.1). history may be completed in 1 or several sessions, depending on
the setting and patient. For example, an older adult patient with
Types of Data a low energy level may need a few brief interviews to allow time
The database includes subjective and objective data. Subjective to give the needed information. You must judge the amount
data, or symptoms, are collected by interviewing the patient of information to collect on initial contact with the patient. In
and/or caregiver during the nursing history. This type of data interviews with patients with chronic disease, patients in pain,
includes information that can be described or verified only by and patients in emergency situations, ask only those questions
the patient or caregiver. It is what the person tells you, either that are pertinent to a specific problem. You can complete the
spontaneously or in response to a direct question. health history interview at a more appropriate time.
Objective data, or signs, are data that we can observe or mea- Judge the reliability of the patient as a historian. An older
sure. You obtain objective data using inspection, palpation, per- adult may give a false impression about their mental status
cussion, and auscultation. Objective data are also obtained by because of a prolonged response time or vision and hearing
diagnostic testing. Patients often provide subjective data while problems. The complexity and duration of health problems
you are performing their assessment. You will observe objective may make it hard for an older adult or a chronically ill younger
signs while interviewing the patient. All the findings related to a patient to be an accurate historian.
specific problem, whether subjective or objective, are known as It is important for you to determine the patient’s priority con-
clinical manifestations of that problem. cerns and expectations, since your priorities may be different from
the patient’s. For example, your priority may be to complete the
Interview Considerations health history, while the patient is interested only in relief from
The purpose of the patient interview is to obtain a health history symptoms. Until the patient’s priority need is met, you will prob-
(i.e., subjective data) about the patient’s past and present health ably be unsuccessful in obtaining complete and accurate data.
state (Fig. 3.1). Effective communication is used in the interview
process. Creating a climate of trust and respect is critical to estab- Symptom Investigation
lishing a therapeutic relationship.2 You need to communicate At any time during the assessment, the patient may report a
acceptance of the patient as a person by using an open, responsive, symptom such as pain, fatigue, or weakness. Because we do not
