Health History and Physical Assessment

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.

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.