Health assessment | Nursing

During history-taking, it is important to gather the following information:

Demographic data, including age, sex, address, and marital status.
Presenting complaints.
History of presenting illnesses and previous illnesses.
Treatment history.
Family history.
Social and occupational history.

Now, let’s delve into each piece of information that should be collected during history in detail. Demographic data, also referred to as biographical data, encompasses the following information that needs to be collected and documented:

When collecting demographic data or biographical information, it is essential to gather and record the following details:

Full name of the client.
Age of the client.
Gender or sex of the client.
Residential address of the client.
Marital status of the client.
Next of kin, including their relationship to the client and their contact information.
Religion of the client.
Denomination (if applicable) within their religious affiliation.
Nationality of the client.
Tribe or ethnic group to which the client belongs.
Occupation or employment status of the client, including details about their job role or profession.

The presenting complaint

The presenting complaint is the primary issue that prompted the patient to seek medical assistance. It involves defining the main problem and its duration. Understanding the timing and duration of symptomatic events is crucial because the sequence of the illness can offer valuable insights into its underlying pathological process.

It’s common for some patients, particularly the elderly, to have difficulty recalling the exact duration of their illness. In such cases, they may use significant events as reference points for timing. It can be helpful to inquire about when the patient last felt completely well, as this may jog their memory regarding earlier symptoms that they might have initially dismissed as insignificant.

Obtaining the history of the present illness

When obtaining the history of the present illness, encourage the patient to narrate the sequence of events from the onset of the illness. Ideally, allow the patient to recount their experience without interruption. Offer gentle encouragement if the patient appears anxious or hesitant. For patients who tend to be verbose, gently guide the conversation to focus on relevant details.

Some patients may use medical terms without understanding their significance. Encourage these patients to express their symptoms in their own words. If friends or relatives accompany the patient, always address the patient directly. Once the patient has provided an initial overview of their symptoms, inquire about specific aspects to clarify the onset and duration of the main symptoms. Explore whether any symptoms fluctuate or are linked to specific times, seasons, or events in the patient’s life. After comprehending the patient’s narrative, delve into each symptom in detail to gain a thorough understanding of the illness.

Symptom Analysis

Symptoms, such as pain, serve as valuable indicators guiding clinical examination and subsequent investigations to diagnose and treat underlying conditions. In symptom analysis, it is crucial to consider the course of the illness, the reason for presentation, and conduct a thorough review of systems. For instance, when analyzing pain, it is essential to explore the following aspects and ask the client relevant questions:

Onset: When did the pain initially manifest?
Location: Where is the pain localized within the body?
Duration: How long have you been experiencing this pain? When did it first occur?
Characteristics: How would you describe the pain? Is it sharp, burning, or tingling? Is it localized, or does it radiate from one area to another?
Aggravating Factors: What exacerbates the pain? Does coughing or breathing intensify it?
Relieving Factors: Are there any actions or treatments that alleviate or reduce the pain?
Treatment: What medications or treatments are currently being administered for the pain?

By thoroughly analyzing each symptom, healthcare providers can gain valuable insights into the nature of the condition, allowing for targeted interventions and effective management strategies.

To aid in recalling the components of symptom analysis, the mnemonic OLDCART can be used:

O: Onset of symptoms: When did the symptoms first appear?
L: Location: Where is the symptom localized within the body?
D: Duration: How long have the symptoms been present? When did they start?
C: Characteristics: How would you describe the symptom? Is it sharp, dull, intermittent, or constant?
A. Aggravating factors: What worsens or exacerbates the symptom? Are there specific triggers or activities that make it worse?
R: Relieving factors: What alleviates or reduces the symptom? Are there any actions or treatments that provide relief?
T: Treatment: What medications or interventions are currently being used to manage the symptom?
S: Severity: How intense or severe is the symptom? Can it be rated on a scale from mild to severe?

By systematically considering each aspect represented by the mnemonic OLDCART, healthcare providers can conduct a thorough analysis of symptoms, aiding in accurate diagnosis and appropriate management of the patient’s condition.

History of previous illnesses

Reviewing the history of previous illnesses provides valuable insights into the patient’s overall health status. It is essential to document all significant illnesses, surgeries, and injuries from infancy onwards. During this assessment:

Inquire about the nature of each illness to assess the likelihood of accurate diagnosis.
Ask about the treatments received for previous illnesses to understand the management approach.
Explore any prior hospital admissions to gain further understanding of the patient’s medical history.

Additionally, consider the following points when evaluating the history of previous illnesses:

Duration and severity of each illness.
Any recurring or chronic conditions.
Complications or side effects experienced during treatment.
Impact of previous illnesses on the patient’s daily life and functioning.
Any family history of similar illnesses or medical conditions.

Assessing the family history

Assessing the family history of your client is crucial for understanding the health status of immediate family members and identifying potential genetic risks. By evaluating family history, healthcare providers can:

Determine if the client is predisposed to certain conditions that run in families.
Note the client’s position in the family and the ages of siblings or children, if applicable.
Document the health status, significant illnesses, and causes of death of immediate relatives.
Inquire about hereditary disorders within the family.
Ask if any family members have experienced similar symptoms.

The social history of the patient

The social history of the patient encompasses their physical and emotional environment, including their home and work surroundings, as well as their habits and attitudes toward life and work. These factors are crucial in assessing the impact of illness on the patient and their family. During the assessment, inquire about the patient’s leisure activities, alcohol consumption, smoking habits, and exercise routine. Understanding these aspects can provide valuable insights into the patient’s lifestyle and potential factors contributing to their health status.

Occupational history

Occupational history is important, as certain occupations may increase the risk of specific health conditions. During the assessment, inquire about the following aspects of the patient’s occupation:

Exposure to hazardous substances at work.
Number of hours worked per week.
Nature of work, including specific job titles such as secretary, director, underground mine worker, street vendor, bartender, shop assistant, or nursery nurse.

Assessing menstrual history

When assessing menstrual history in women, it is important to inquire about various aspects related to menstruation:

Last normal menstrual period: Determine the date of the patient’s most recent menstrual period to assess regularity and identify any abnormalities.
Menstrual regularity: Ask about the regularity of menstrual cycles, including the usual duration between periods.
Amount of flow: Inquire about the typical amount of menstrual flow, such as light, moderate, or heavy bleeding.
Dysmenorrhea: Assess whether the patient experiences any menstrual pain or cramping (dysmenorrhea) and its severity.
Menstrual tension: Explore whether the patient experiences any emotional or physical symptoms, such as mood changes or bloating, before or during menstruation.
History of taking oral contraception: Determine whether the patient has a history of using oral contraceptives or other hormonal contraceptives and inquire about any associated side effects or complications.

Obstetric History

When obtaining an obstetric history from a woman, gather information about her childbirth experiences, including:

Number of pregnancies.
Types of deliveries (normal or complicated).
Health during pregnancy.
History of abortions or miscarriages.
Status of children (alive or deceased).

Physical Examination

Following the patient’s history, it is essential to conduct a routine physical examination. This process may cause discomfort for the patient due to the necessary undressing. Thus, it’s crucial to reassure and comfort the patient.

During the examination, ensure gentleness and minimize unnecessary exposure and fatigue for the patient. In cases of acute illness, it may be prudent to delay routine examinations and only perform those necessary for initial diagnosis and treatment. Both history-taking and physical examinations are integral components of patient assessment, with each complementing the other in providing comprehensive care.

History and physical examinations

History and physical examinations work together to provide a comprehensive understanding of a patient’s health. A thorough physical examination necessitates a cooperative patient and a serene, warm, and well-illuminated environment. Natural daylight is preferable over artificial light, as it allows for accurate observation of subtle changes in skin color, such as the faint yellow hue of mild jaundice.

Efforts should be made to help the patient relax, irrespective of the circumstances. For a comprehensive examination, the patient may be asked to undress, but they should be draped with a bed sheet or blanket for modesty and comfort. Patients may be permitted to retain their underwear, but it is essential to ensure examination of the buttocks and genitalia as well.

Having a chaperone present is essential during examinations involving male nurses and female patients, as well as during rectal and vaginal examinations. This presence provides reassurance to the patient and safeguards the nurse against potential allegations of misconduct.

Four primary techniques are employed during physical examinations:

Inspection
Palpation
Percussion
Auscultation

Let’s delve deeper into each technique, starting with inspection.

Inspection

Inspection involves visually examining a specific part or area of the body to evaluate its normal state or any deviations from the norm. It’s important to note that inspection goes beyond mere observation; it is a deliberate, systematic, and focused process.

During inspection, you must compare what you see with the known, typical characteristics of the body parts being examined. Ensure adequate lighting is available, and position and expose the body parts in a manner that allows for viewing of all surfaces. Additional lighting may be required to inspect cavities accurately.

Palpation

Palpation involves examining the body through touch. Both light and deep palpation techniques provide valuable information regarding various aspects such as masses, pulsations, organ enlargement, tenderness or pain, swelling, muscular spasm or rigidity, elasticity, vibration of voice sounds, crepitus, moisture, and differences in texture.

During practical training, you will discover that different parts of the hand are more sensitive to specific assessments. For instance:

The fingertips are used to palpate lymph nodes and assess pulse rate.
The backs of the hands and fingers are employed to evaluate temperatures.
The palm surface is best suited for detecting vibrations, while the abdomen is ideal for assessing tenderness or detecting masses.

Percussion

Percussion is a diagnostic technique used to produce sounds and gather information about underlying body structures. This technique can be performed directly or indirectly. Direct percussion involves tapping the body with one or two fingers to produce a sound. However, indirect percussion is more commonly used.

In indirect percussion, the middle finger of the non-dominant hand (known as the pleximeter) is placed firmly against the body surface. The tip of the middle finger of the dominant hand (known as the plexor) strikes the distal phalanx or the distal interphalangeal joint of the pleximeter finger. To produce optimal sounds, it’s important to maintain a relaxed wrist and deliver rapid strikes.

The sounds and vibrations produced during percussion are evaluated relative to the underlying structures. Any deviation from expected sounds may indicate an underlying problem. For instance, the typical percussion sound in the right lower quadrant of the abdomen is tympany. Dullness in this area may suggest a potential issue that requires further investigation. Specific percussion sounds of various body parts and regions are discussed in corresponding assessment notes.

Auscultation

Auscultation involves listening to sounds produced by the body to evaluate both normal and abnormal conditions. This technique is typically performed indirectly, using a stethoscope to enhance clarity by blocking out background noise.

The bell of the stethoscope is more adept at capturing low-pitched sounds, while the diaphragm is better suited for high-pitched sounds. Auscultation is particularly valuable for assessing sounds originating from the heart, lungs, abdomen, and vascular system.

Screening Physical Examination Outline

General Assessment:

Evaluate the patient’s overall appearance to determine if they appear healthy, unwell, or ill, as well as whether they are well cared for or neglected.
Assess your intelligence and educational level.
Evaluate the mental state, including cognitive function and mood.
Observe facial expressions and emotional states.

Build and posture:

Evaluate the body’s build and posture for any abnormalities or deviations from the norm.

Nutritional Status and Body Composition:

Assess for signs of malnutrition, obesity, or edema (fluid retention).

Skin Examination:

Evaluate skin color for signs of cyanosis (bluish discoloration), pallor (paleness), jaundice (yellowing), or abnormal pigmentation.
Note the presence of body hair and any abnormalities.
Look for deformities, swellings, or growths on the body.

Vital Signs:

Measure temperature, pulse rate, and respiratory rate to assess physiological function.
Look for features indicative of endocrine diseases such as hyperlipidemia, acromegaly, or Cushing’s syndrome.

Hair:

Note the distribution and texture of hair, as well as grooming practices.

Eyes:

Conduct simple tests of visual acuity by comparing one eye against the other.
Check for exophthalmos or enophthalmos.
Assess for eyelid edema.
Observe the conjunctivae for signs of anemia, jaundice, or inflammation.
Evaluate the pupils for size, equality, regularity, reaction to light, and accommodation.
Assess eye movement for nystagmus or strabismus.
Perform an ophthalmoscopic examination of the fundi and ocular chambers.

Face:

Check for facial symmetry or asymmetry.
Assess jaw movements.
Look for rash or features suggestive of endocrine disease or hyperlipidemia.

Nose/Sinuses:

Inspect the external nose, nasal mucosa, and septum.
Palpate the frontal and maxillary sinuses for tenderness.

Mouth and Pharynx:

Assess for breath odors.
Inspect the lips for color and eruptions.
Check for tongue protrusion and appearance.
Examine the teeth and gums, noting the fit of dentures and their usage.
Inspect the buccal mucous membrane for color and pigmentation.
Evaluate the pharynx for movement of the soft palate and the state of the tonsils.

Neck:

Palpate the thyroid gland and cervical lymph nodes.
Auscultate the carotid arteries for a pulse.
Note the presence of jugular venous distension and the angle of distension.
Assess the range of neck movements and neck rigidity.

Upper Limbs:

Conduct a general examination of the hands and arms.
Inspect the fingernails for clubbing or koilonychia.
Assess pulse rate, rhythm, volume, and character.
Evaluate the arterial walls of the radial and brachial arteries.
Check the axillae for lymph node enlargement.
Measure your blood pressure.
Assess muscles for wasting and fasciculations.
Perform tests for muscle power, tone, reflexes, and coordination.
Check cutaneous sensation to exclude root or nerve lesions.
Evaluate joint movement, pain, and swelling.

Thorax: anteriorly and laterally

Note the chest type and any asymmetry.
Inspect the breasts and nipples for size, shape, inversion, rashes, ulceration, and discharge.
Observe respiratory movement, rate, depth, and character.
Check for dilated vessels.
Palpate for the position of the trachea.
Palpate for the apex beat and pericardial thrills.
Estimate tactile vocal fremitus.
Percuss the lungs.
Auscultate heart sounds.
Estimate vocal resonance and check cervical and axillary lymph nodes.

Posteriorly (patient sitting):

Inspect and palpate respiratory movements.
Estimate tactile vocal fremitus.
Percuss lung resonance.
Auscultate breath sounds.
Estimate vocal resonance.
Note spine movements and deformities.
Palpate the cervical glands and thyroid.
Look for sacral edema.
Note any kyphosis or scoliosis, and assess for tenderness and range of motion of the back.

Abdomen:

Inspect for size, distension, and symmetry.
Check for movement, scars, and dilated vessels on the abdominal wall.
Look for visible peristalsis or pulsation.
Observe pubic hair and hernial orifices.
Palpate the abdomen for tenderness, rigidity, hyperesthesia, splashing, masses, and organs such as the liver, gallbladder, spleen, kidneys, and bladder.
Assess abdominal reflexes.

Rectal Examination:

Examine the anus and rectal wall for lesions, inflammation, and sphincter muscles.
Note any nodules or abnormalities.
Check for occult blood in fecal matter.
In males, palpate the prostate gland.

Lower Limbs:

Conduct a general examination of the legs and feet.
Assess stance, balance, and gait.
Look for pedal edema and varicose veins.
Evaluate muscles for wasting and fasciculations.
Perform tests for power, tone, reflexes (including plantar response), and coordination.
Check joints for movement, pain, and swelling.
Palpate peripheral pulses and assess the temperature of the feet.

We have now reached the conclusion of this unit. Let’s review what you have learned.