Health History and Physical Examination

Lewis: Health History and Physical Examination

Assessing house data is the aggregate of all Health measures for individuals in the community and includes data such as life expectancy birth and death rates and mortality from different maladies general foundation information comprises of parts like age sensitivities clinical history propensities financial status ways of life convictions and tactile shortages pee yield gastric reflux and gut propensities are noteworthy only if the disease affecting these functions are present so in an emergency ask questions and interview while you're getting vital signs a registered nurse with necessary knowledge skills and ability may collect information pertaining to the patients.

Health History and perform a physical examination that includes finding out if there are other areas that are a concern to the patient remembered Nursing is holistic care it's body mind and spirit so when performing a history and physical exam the nurse should take a timely report to and consult with other members of

The Health  care team and then make referrals as necessary a registered nurse who is not an advanced practice nurse when collecting a patient's history and performing a physical examination should not form a medical diagnosis the data from history and physical examination should be recorded as soon after the event as possible from a legal perspective if it's not documented it's not done brief notes can be taken during an exam and when documenting the use short clear phrases and avoid redundant phrases and descriptions now remember you cannot delegate a general survey to a nursing assistant personnel remember no teaching no assessment no judgment can be delegated the nurse can direct a nursing assistant to obtain vitally signs but remember not an initial set subsequent measurements if the patient is stable remember the nurse does everything including vital signs on admissions discharges and transfers only after they're stable will the nurse then vital signs to be done the nurse can direct a nursing assistant to report a patient's subjective signs and symptoms they can measure a patient's height and weight monitor oral intake and urinary output obtaining a patient's
Health  history and performing examinations are activities completed by the nurse during the assessment phase of the nursing process assessment as we previously talked about is identified as the first step of the nursing process information obtained during this phase contributes to the database that identifies a patient's current and past

Health state and it gives a baseline against which to measure changes the purpose of the nursing assessment is to enable the nurse to make a judgment about the patient's Health  state however it is performed continuously throughout the nursing process to validate the diagnosis evaluate a patient's response to nursing interventions and determine the extent to which patient outcomes and goals have been met a medical history is a standard format designed to collect data to be used primarily by the physician to determine risk for disease and diagnose a medical condition the physician's physical exam lab and diagnostic tests assist in establishing that medical diagnosis and evaluate specific medical therapy the information collected and reported by the physician is also used by the nurses and other
Health care providers but within their focus and scope of practice an For example a physician is done a neurological exam and a patient now has an abnormal result which is a brain lesion the nurse may use those same results to identify a nursing diagnosis of risk for Falls a the physical therapist may also use those same results to plan therapy involving exercise splints or ambulatory aids functional Health  patterns behaviors are strongly linked to many

healthcare problems and Health  care disparities are due to stereotyping biases and The prejudice of Health  care providers and the nurse can decrease these through staff education inclusion of a review of mental status is highly recommended when a nurse performs an examination of an older adult allow extra time and be patient be relaxed and unhurried with the geriatric population do not assume that aging is always accompanied by an illness or disability many older adults are able to adapt to change and maintain functional independence provide adequate space for the exam particularly if the patient uses a mobility aid so how would you examine a patient with a lung issue well position them patient sitting upright because this promotes full lung expansion during the exam patients with chronic respiratory disease will likely need to sit up throughout the examination because of shortness of breath only if the patient is unable to tolerate sitting in a supply position or a sideline position be used so beginning with the first Health perception
Health management pattern includes information about the patient's ideas about risk factors, this includes Health care behaviors such as health promotion and illness prevention activities medical treatments and follow-up care nutritional metabolic this includes daily consumption of food and fluids what is the patient's favorite foods do they use dietary supplements do they need dietary supplements to miss a patient have any skin lesions an ability to heal or is there a problem with healing so looking at the condition of the skin check their height weight their temperature and a general survey can describe the patient's general nutritional status elimination patterns describe the regulation control and removal of by-products and wastes in the body patterns of bowel and urinary excretion and perceived regularity or irregularity of elimination use of laxatives and changes in time modes quality or quantity of excretions should be documented activity exercise pattern this is patterns of patient's exercise activity leisure and Recreation ADL's require energy expenditure and the nurse identify any factors that interfere with their lifestyles such as illness or injury sleep rest pattern this is a pattern of sleep and rest or relaxation in a 24-hour period this also includes the perception of the quality and quantity of sleep rest and if
they use any sleep aids the cognitive-perceptual pattern is the adequacy of vision hearing touch smell pain perception and management it also includes language judgment memory and decisions the role relationship pattern is perception of major roles in their lifestyle relationships and responsibilities in the current situation whether there are a wife a mother a daughter a husband a father a son and satisfaction with our disturbance in the roles and relationships would follow under the role relationship pattern sexuality reproductive pattern this is satisfaction with their sexuality or sexual relationships this also includes reproductive pattern female menstrual and premenopausal history coping stress tolerance patterns includes information about Another major stressors confronting a patient the capacity to resist challenges to self-integrity methods of handling the stress do they have support systems in place what is their perceived ability to control and manage situations what kind of coping mechanisms have they used in the past that has worked and then valuable leave pattern the values goals are beliefs including spirituality that guide choices or decisions should be discussed perceived conflicts and values believe our expectations could affect their
Health issues now we've talked about the inspection is probably the first part of major techniques as an experienced nurse learns to make multiple visual examinations of body parts or areas almost simultaneously while becoming very perceptive of the abnormalities performing a physical examination of the chest uses inspection palpation percussion and auscultation to determine the respiratory status and differentiate primary lung problems from cardiac problems when assessing the abdomen auscultation is done before palpation or percussion because palpation and percussion can cause changes in the bowel sounds and then alter the findings palpation uses the sense of touch percussion involves tapping the body with the fingertips to evaluate the size the borders consistency of the body organs and to discover fluid and body cavities auscultation is listening with the stethoscope to sounds produced by the body to remember how to do the physical exam of the abdomen is what I call in a
perfect place IAA inspection auscultation percussion palpation the dorsum which is the back of the hand is more sensitive to temperature variation the pads of the fingertips detect any subtle changes in textures shape size consistency and if their pulses in the body parts by manual palpation involves one hand placed over the other while the pressure is applied the upper hand exerts downward pressure as the other hand feels for the subtle characteristics of underlying organs and masses now focused assessment is needed when a patient has clinical symptoms that indicates a problem the screening examination or assessment is used to assess for possible problems like colorectal cancer and patients who are age 50 or older an emergency assessment is done when the nurse needs to obtain information about life-threatening problems quickly while simultaneously taking action to maintain vital function the nurse may need to ask only the most impertinent questions for a specific problem and then obtain more information later a complete
The health history will include subjective information that is not available in the healthcare providers medical history family members maybe able to provide some subjective data but only the patient will be able to give subjective information about their shortness of breath when obtaining an initial Health history from a patient who immigrated to the United States several years ago it is most important for the nurse to first the correct answer is C determine the extent

of a patient's identification with the cultural group, the nurse must be sensitive to potential cultural influences like issues of eye contact space modesty and touching to avoid violating any cultural-based practices the nurse should ask the patient about culture identification and practices the nurse takes a
Health history and performs a physical examination on a patient admitted to the hospital the nurse would be most concerned if what occurs the correct answer is the patient suddenly developed severe shortness of breath signs and symptoms of problems that are life-threatening such as breathing problems take priority and an emergency assessment should be performed and life-saving interventions initiated based on those assessment findings the key is to prioritize remember you can take vital signs and address the problem would you medicate first no not without having more information

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