Nursing Unit 1: Health Assessment Techniques

Unit 1: Collecting Assessment Data, Health History & Assessment Techniques

• This unit covers collecting assessment data, health history, and assessment techniques for nursing.
• Objectives include defining and describing the nursing process and assessment.
• Differentiating between communication techniques (open-ended, closed-ended, and verbal/nonverbal) is a goal.
• Classifying subjective and objective components of a health assessment is also part of the learning objectives.
• Describing assessment techniques of inspection, palpation, percussion, and auscultation is important.
• Distinguishing holistic health history components is a key objective.
• Demonstrating interviewing and communication skills is a learning outcome.
• Applying assessment techniques and using health history-taking skills are essential learning goals.

Collecting a Health History

• Data collection should be organized.
• Subjective data followed by objective data.
• Holistic approach to assess social, emotional, physical, cultural, developmental, and spiritual support needs.
• Review patient strengths, deficits, and risks.

Collecting a Health History: Components of the Interview

• Why do we interview patients?
• Evaluation, Assessment, Nursing Diagnosis, and Planning are related.

Collecting a Health History: Tailoring the Interview

• Clinical situations (complete, problem-centered/focused, follow-up, emergency).
• Data collection (complete health history, full physical exam, one problem, short-term, and one system).
• Monitor identified problems and use rapid data gathering.

Collecting a Health History: How to Start

• Biographical data (name, DOB, etc.), reasons for seeking care (in patient's own words), and present health/history of illness.

Collecting a Health History: Symptom Assessment

• OPQRSTUV: Onset, Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity/Quantity, Timing, Understanding/Unacceptable Level, and Value.

Collecting a Health History: Past Health

• Last exams (physical, dental, vision, hearing, diagnostics), immunizations, allergies, what causes reactions and how they're managed, current medications (Rx & OTC), conditions/diseases, past surgeries, OB/Gyn, and GTPAL/date of last menstrual period (LMP).

Collecting a Health History: Allergy Form Example

• Allergy/intolerance record, information to be filled out including patient information and details about medications and reactions.

Collecting a Health History: Social Health

• Physical activity (what, how often, and intensity).
• Nutrition (habits, types of foods, special diets).
• Alcohol/Tobacco/Recreational drug use (amount, frequency, harm reduction assessment).
• Relationships (screening for supports and potential issues, including intimate partner issues).

Collecting a Health History: Functional Assessment

• Measures how patients manage daily activities.
• Records the effect of an illness on daily activities, quality of life, coping, relationships, self-esteem, and home safety.
• Activities of Daily Living (ADLs) (self-care).
• Instrumental Activities of Daily Living (IADLs) (functional abilities, such as cooking or finances).

Physical Assessment

• Systems approach (full system vs. focused or isolated).
• Subjective data plus objective data.

Physical Assessment Techniques: Inspection

• Always inspect first.
• Begins at the first patient encounter and uses senses (see, smell, hear).
• Be organized and only inspect.

Physical Assessment Techniques: Palpation

• Different parts of the hand (fingertips, fingers/thumbs, dorsum of hand, base of fingers) to assess variables (texture, pulsation, lumps, swelling, shape, consistency, temperature, vibrations).
• Different types of palpation (light, medium, deep).

Physical Assessment Techniques: Percussion

• Tapping a person's skin to assess underlying structures.
• Palpable vibrations and sounds indicate physiological or pathological conditions.
• Direct (striking hand directly on body) and indirect (striking hand on stationary hand on body).
• Placement on the distal interphalangeal joint.

Percussion Notes

• Resonant, hypersonant, tympany, dull, and flat sounds.

Physical Assessment Techniques: Auscultation

• Using a stethoscope.
• Listening for sounds produced by the body (heart, respiratory and bowel sounds).
• Diaphragm (high pitched sounds) and bell (low pitched sounds; murmurs and extra heart sounds).

Review Time: Assessment Order

• Possible sequences for assessing thorax and lungs (inspection, palpation, percussion, auscultation).

Review Time: Indirect Percussion

• Stationary finger placement areas for indirect percussion (ulnar surface, middle joint, distal interphalangeal joint, and anywhere touching skin).

Review Time: Vibration Assessment

• Parts of the hands used for palpation and assessment of vibration (fingertips, base of fingers, index finger/thumb opposition, dorsum of hands, ulnar surface).

References

• Jarvis, C. (Ed.) (2024). Physical examination and health assessment. (4th Canadian ed.). Elsevier.