Health History and Physical Assessment

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Questions and Answers

What is the primary source of information in a health history assessment?

The patient, relatives, or existing records (correct)

The patient's relatives only

Healthcare staff observations

Health records only

Which area is NOT part of the 'Eight Areas of Investigation' in the history of present illness?

Setting

Medication history (correct)

Frequency

Character of complaint

What is the primary focus during the psychosocial assessment?

Vocation, family, social, spiritual, sexual, daily living activities, and health habits (correct)

Family and occupational data

Personal health conditions only

Medical history and immunizations

Which of the following is an essential tool for physical assessment?

Inspection/Observation, Palpation, and Auscultation Signup and view all the answers

Which of the following is a key part of client preparation before a physical examination?

Asking the client to void if necessary Signup and view all the answers

What is the main purpose of conducting a general survey during health assessment?

To assess patient's vital signs and overall appearance Signup and view all the answers

Which of the following describes deep palpation in physical assessment?

Using two hands, one supporting while the other presses deeper Signup and view all the answers

What is NOT included in the past history section of a health history assessment?

Current medication use Signup and view all the answers

What does the 'S' in the SMART goal-setting guideline represent?

Specific Signup and view all the answers

Which of the following best describes independent actions of health personnel?

Actions conducted without orders and for which the personnel is responsible Signup and view all the answers

In priority setting, which of the following is considered a low priority issue?

Normal developmental needs requiring minimal support Signup and view all the answers

What is the primary focus of the evaluation phase in patient care?

Assessing responses to interventions against set goals Signup and view all the answers

Which of the following best describes potential problems in patient assessment?

Problems that have not yet manifested but pose a high risk Signup and view all the answers

Which type of intervention is performed on behalf of clients rather than through direct interaction?

Indirect intervention Signup and view all the answers

Which of these is NOT a reason for discharging a patient?

Patient funds have been exhausted Signup and view all the answers

What is considered a medium priority issue in patient care?

Health-threatening conditions that may cause developmental delays Signup and view all the answers

What position is best for examining the abdomen?

Supine Signup and view all the answers

Which assessment instrument is specifically used for examining the eyes?

Ophthalmoscope Signup and view all the answers

In which position is the head of the bed raised between 15° and 45°?

Semi Fowler's Signup and view all the answers

What is the primary purpose of using a percussion hammer?

To test reflexes and tissue density Signup and view all the answers

What can the Trendelenburg position help with?

Promotes venous circulation Signup and view all the answers

Which of the following is true about the lithotomy position?

Commonly used for delivery Signup and view all the answers

What is the main advantage of the Sims position?

Permits drainage of mucus secretions Signup and view all the answers

Which type of auscultation involves using an unaided ear?

Direct auscultation Signup and view all the answers

Study Notes

Health History

Primary information source: Patient, relatives, or existing records.
Demographic data: Name, address, phone, sex, age, status, religion, race.
Chief complaint (CC): Patient's reason for consultation (own words).
History of present illness (HPI): Includes eight areas of investigation.
- Sequence and chronology
- Frequency
- Location and radiation
- Character of complaint
- Intensity or severity
- Setting
- Associated manifestations
Past history: Childhood illnesses, immunizations, allergies, past hospitalizations, medications, prenatal history.
Review of systems: Subjective data from head to toe regarding patient's health.

Physical Assessment

Systematic data collection method using observational skills to detect health problems.
Preparation:
- Environment: Private, quiet, good lighting.
- Equipment: Hand washing, proper table height.
- Client preparation: Psychological and physical comfort, procedure explanation.
- Physical preparation: Ask client to void if needed.
- Positioning: Comfort and facilitate examination.

Psychosocial Assessment

Includes vocation, family, social, spiritual, sexual, daily living activities, health habits.
Review of literature: Essential for obtaining and maintaining up-to-date knowledge.

Order of Assessment

General Survey: Appearance, behavior, vital signs.
Body system assessment: Integumentary, respiratory, cardiovascular, etc.
Cephalocaudal (head-to-toe) assessment.

Tools of Physical Assessment

Inspection/observation: Systematic use of senses to observe.
Palpation: Light and deep palpation for texture, tenderness, etc.
Light palpation: Pads of fingers to identify tenderness and muscle resistance.
Deep palpation: Use two hands for deeper examination of areas like the abdomen.
Percussion: Striking body parts to elicit sounds or vibrations.
Auscultation: Listening to body sounds using a stethoscope.

Types of Auscultation

Direct: Using unaided ear.
Indirect: Using a stethoscope.

Commonly Used Assessment Instruments

Ophthalmoscope: Examining eyes.
Otoscope: Examining external ear canal and eardrum.
Vaginal Speculum: Examining vagina and cervix.
Percussion Hammer: Testing reflexes and tissue density.
Tuning Fork: Testing hearing.
Tonometer: Measuring pressure within the eyes.

Different Positions

Supine: Lying on back; good for abdominal examination.
Prone: Face down.
Lithotomy: For pelvic exams.
Trendelenburg: Head of bed lowered, feet elevated; useful for some procedures.
Sims: Side-lying position; good for examinations of the pelvic area.
Knee-chest: Kneeling with face on the bed.
Dorsal Recumbent: Supine with legs bent; good for lower back or abdomen exams.

Validating Data

Double-checking observations, equipment, and consulting with team members to confirm accuracy.

Planning

Goals: Short-term (days/weeks), long-term (weeks/months).
Priority setting: Immediate life-threatening issues, safety issues, patient-identified issues.
Guidelines: S (Specific), M (Measurable), A (Attainable), R (Realistic), T (Time-bound).

Priority Setting

Immediate life-threatening issues (breathing, heartbeat, blood pressure).
Safety issues.
Patient-identified issues.
Midwife-identified priorities based on the patient, time, resources, and overall condition.

Intervention/Implementation

Putting the care plan into action.
Types of Interventions:
- Direct: Actions performed through client interaction.
- Indirect: Actions performed on behalf of clients.

Different Functions of Health Personnel

Independent: Actions without orders.
Dependent: Actions following orders.
Interdependent: Actions in collaboration with other team members.

Evaluation

Assessing patient responses to interventions against set goals.

Discharge Planning

Begins on admission; preparing the patient for continuity of care.
Reasons for discharge:
- Patient returns to normal health.
- Transfer to another facility.
- Patient's choice.
- Patient has died.

Discharge Against Medical Advice (DAMA)

Occurs when a patient leaves without physician permission; special documentation is needed.

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Description

This quiz covers essential components of collecting health history and conducting physical assessments. It includes demographic data, patient complaints, investigation areas, and preparation methods for effective assessments. Test your knowledge on the systematic approach to evaluating patient health.