ASSESSING HEALTH III – HISTORY TAKING/PHYSICAL EXAM
Assessing health status is a major component of nursing care. Smith (1982) remarked that if good nursing care entails meeting the needs of the clients, then these needs must first be identified. As such, the skill of observation becomes an invaluable asset. Assessment technique is therefore a skill that nurses must develop right from the very beginning of their training. Speaking in the same vein, Swash and Mason (1986) submitted that one statement that gets near to the truth is that diagnosis should precede treatment whenever possible.
They observed that are two steps critical to making a diagnosis: the first is observation by history taking, physical examination, and ancillary investigations; and the second – interpretation of information obtained in terms of a disorder of function and structure, then in terms of pathology. These two steps put together form part of the assessment phase of the Nursing process, which incidentally has become the decision making tool in Nursing practice.
However, as beginners, will be limiting ourselves to the first step, knowing fully well that a thorough understanding of it is vital to elucidating our clients problem(s) without which the resolution of such problem(s) will be elusive. Therefore, this unit focuses on the purpose, components, and techniques related to the health history and physical examination.
Types of Assessment
Generally speaking, three types of assessment are employed in evaluating the health status of patients/clients. They are:
Comprehensive Assessment, Focused Assessment, and Ongoing Assessment. However, it is health care setting and needs of the patient that literally dictates what type of assessment that is needed.
Comprehensive Assessment – As the name suggest, this is a comprehensive assessment that is usually collected upon admission to a health care agency. It includes a complete health history to determine the current needs of the client.
This database provides a baseline against which changes in the client health status can be measured and should include assessment of physical and psychosocial aspects of client’s health, the client’s perception of health, the presence of health risk factors and the client’s coping patterns (Moffett, 1998).
While it is true that comprehensive assessment is the most desirable in the initial assessment of client’s health needs, time constraint or special circumstances may indicate the need for the abbreviated data collection, the focused assessment.
Focused Assessment – As insinuate in the preceding paragraph, this assessment is limited in scope (in comparison with comprehensive assessment) in order to focus on a particular need or health care problem or potential health care risks. It is often used in health care agencies in which short stays are anticipated (e.g. Emergency departments), in specialty areas such as labor and delivery, and in mental health settings or for the purposes of screening for specific problems or risk factors as obtainable in well child clinic (Moffett, 1998).
Ongoing Assessment – An ongoing assessment is a continuous systematic assessment and reassessment or evaluation of a client’s health status with revision of care plan. This type of assessment allows the nurse to broaden the database or to confirm the validity of the data obtained during the initial assessment and to measure the effectiveness of nursing interventions.
Indications for Health Assessment
The purposes of health assessment include to:
Collect data about the client through observation, interview and physical examination.
Assess the patient’s current physical condition.
Establish a database for future comparisons.
Continuously update database.
Detect early signs of developing health problems
Evaluate responses to medical and nursing interventions.
Make clinical judgments about a client’s changing health status and management.
This is the process of gathering information about a client’s health status. It must be both systematic and continuous to prevent omission of significant data and reflect a client’s changing health status. A database (baseline data) is all information about a client; it includes the nursing health history, physical assessment, the physician’s history and physical examination, results of laboratory and diagnostic tests, and materials contributed by other health personnel (Wilkinson, 2000).
Types of Data
There are basically two types of data: objective data and subjective data. Objective data also referred to as signs or overt data are factual measurable and observable information about the patient and his overall state of health i.e. they can be seen, heard, felt, or smelled, and they can be obtained by observation or physical examination. Example includes vital signs; height; weight; urine colour, volume and odour; skin rashes e. t. c.
Subjective Data sometimes called symptoms or covert data are data client’s point of view that cannot be empirically validated. Encompasses patient’s opinion or feelings, client’s sensation, values, beliefs, and perception of personal health status and life situation. For instance, only the patient can tell you that he/she is afraid or has pain or experiencing itching.
Methods of Data Collection
The basic methods employed in data collection or data gathering are:
The term observation is defined as a systematic and exhaustive search for any significant physical deviation from the normal. Observation has two aspects: (a) noticing the stimuli and (b) selecting, organizing, and interpreting the data including distinguishing stimuli in a meaningful manner. Observation as an assessment techniques involve the use of all the five senses:
Visual Observation: Sight provides an abundance of visual clues about general appearances, mannerisms, facial expressions, mode of dress, family – friend’s interaction, to mention but a few.
Tactile Observation: Touching or palpating any part of the patient can provide information such as hotness/coldness of the body, swelling, edema, muscle strength e.t.c.
Auditory Observation: The sense of hearing. Quite a lot of information can be gathered through mere listening to the patient or using specialized equipment like the stethoscope to listen to breath sounds, bowel sounds, and heart sounds.
Olfactory or Gustatory Observation: The sense of smell identifies odors that can be specific to a patient’s condition or state of health. This include body and breath odour which might indicate Gamalin poisoning, alcohol intoxification, poor hygiene, diabetic ketoacidosis e.t.c.
This is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy (Wilkinson, 2000). During assessment, the purpose of interview is to gather information about client’s health history.
The goal of history taking is to get from the client an accurate account of his complaint and see this against the background of his life as a whole. How well this is achieved is a factor of the nurse’s knowledge and skill at eliciting information from the client using appropriate techniques of communication and observation of nonverbal cues. Effective communication is therefore a key factor in the interview process (Cecere & McCash, 1992).
There are two approaches to interviewing: directive and nondirective. The directive interview is highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview, at least at the outset, by asking closed-ended questions that call for specific data.
During the nondirective interview, or rapport-building interview, the nurse allows the client to control the purpose, the subject matter, and pacing. The nurse encourages communication by asking open-ended questions and providing empathetic responses (Wilkinson, 2000).
Guidelines for an Effective Interview/History Taking
Be prepared – The interview is more productive if the nurse has an opportunity to prepare for the interaction. Such preparation includes the review of client’s clinical record, conversation with other health care personnel, and literatures about client’s health problem (Moffett, 1998, Wilkinson, 2000). This will focus the interview and prevent tiring the client, and save your time.
Appropriate Timing – Schedule interviews with client at a time when the client is physically comfortable and free of pain, and when interruptions by friends, family, and other health professionals are minimal.
Create a Pleasant Interviewing Atmosphere – A quiet, well-lighted, well-ventilated and relaxed setting, relatively devoid of noise and interruptions enhances communication. A relaxed atmosphere eases the patient’s anxiety, promotes comfort, and conveys your willingness to listen. Ensure privacy, as some clients will not share personal information if they suspect others can overhear. In all instances, the client should be made to feel comfortable and unhurried.
Establish a Good Rapport – Greet the client by name if possible; sit and chat with the client before the interview. Be sure to explain the purpose of the interview and show concern for the patient’s story.
Set the Tone and be Focused – Encourage the client to talk about his chief complaint. This helps you to focus on his most troublesome symptoms. Keep the interview informal while still being professional. Speak clearly and simply, avoiding medical jargons and be sure patient understands you.
Choose your Words Carefully – Ask open-ended questions to encourage the client to provide complete and pertinent information.
Take Notes – Avoid documenting everything during the interview but make sure you jot down important information such as date, times.
Health History and Nursing History
The primary focus of the data collection interview is the health history and Nursing history. A health history is designed to collect data to be used primarily by the physician to diagnose a health problem and it usually collected by the medical team. Often the admitting nurse also collects this same information during the admission interview. However, there is a growing disapproval of the nurse repeating this process, as credibility is lost when the nurse repeats virtually all the questions that others have already asked.
A nursing history on the other hand has a different focus – the client’s response to the health problems, which assist the nurse more accurately in identifying nursing diagnoses (Cecere, & McCash, 1992). While the health history concentrate on symptoms and progression of disease, the nursing history focuses on client’s functional patterns, responses to changes in health status and alterations in lifestyle.
Health History – The components of a health history include:
Demographic Information – encompasses demographic variables such as name, date, age, sex, e.t.c.
Chief/Presenting Complaint – try to define what has motivated the client to seek health care and its duration.
History of Present Illness (HPI) – HPI provides detailed data about the chief complaint or reason for entering the health care system.
Past Health History – provides information about the client’s prior state of health. Includes questions about childhood and adult illnesses, immunizations, injuries, hospitalizations, surgeries, therapeutic regimens, allergies, travels, habits, and use of supportive devices.
Family Health History (FHH) – FHH notes illnesses that have environmental, genetic, or familial tendency or that are communicable. A genetic chart or family tree of three generations can be developed to illustrate the family health history.
Social and Occupational History – Enquire about what may be grouped as the client’s physical and emotional environment, his surroundings both at home and work, his habits and his own mental attitude to life and to his work.
Review of Systems – This is the final portion of health history. It is systematic collection of specific information about the client’s past and present health status related to common problems of body systems. (Swash & Mason, 1986; Cecere, & McCash, 1992).
It is important to mention here as Swash & Mason, (1986) noted, that in taking history, it neither possible nor desirable to tie a patient down to a particular sequence. The client must be allowed to tell his own story. Besides, a good clinician begins the examination of a patient as the latter walks into the room – his appearance, the way he walks, the way he answers questions and so on – and only finishes taking the history when the consultation is over.
Occasionally a vital piece of information may come out just when the patient is leaving. Swash & Mason, (1986) remarked that while the list of headings is formidable, it does take some experience to know in a given case which part of the history is particularly worth pursuing. And following the health history, a general survey statement is made, which is a statement of the provider’s impression of a client, including behavioral observations.
Nursing History – Numerous nursing history/database formats are available in literatures (Carpenito, 1989; Christensen & Kenney, 1990; Cecere, & McCash, 1992). The format in use in most clinical setting is the 11 functional patterns credited to Majory Gordon. This format (presented below) allows systematic data gathering and facilitates making inferences (nursing diagnosis).
Health-Perception-Health-Management Pattern – Focuses on client’s perceived level of health and well-being and on personal practices for maintaining health. It also embraces preventive screening activities such as breast and testicular examination; hypertension and cardiac risk factor screening e.t.c.
Nutritional-Metabolic Pattern – Assesses food and fluid intake, food References/Further Reading and taboos, cultural factors relating to food and nutrition, e.t.c. Also explores difficulties if any with ingestion, digestion, absorption, transport and metabolism of nutrients.
Elimination Pattern – Assesses bowel and bladder functions such as frequency, amount, relationship of output to intake, and any discomfort or difficulty associated with each function.
Activity-Exercise Pattern – Explores the client’s activities of daily living including client’s usual pattern of exercise, leisure and recreation.
Sleep-Rest Pattern – This inquires about the client’s pattern of sleep, rest and relaxation in a 24hour period, noting any deviation from client’s premorbid rest and sleep pattern.
Cognitive-Perceptual Pattern – Assessment of this pattern involves a description of all the senses (vision, hearing, taste, touch, smell and pain) and the cognitive functions (such as communication, memory, and decision making).
Self-Perception-Self-Concept Pattern – This pattern explores the client’s self-concept, which is critical to determining the way the client interacts with others. Attitudes about self, perception of personal abilities and body image, and general sense of worth are also addressed under this pattern.
Role-Relationship Pattern – Describes the client’s role and relationships including major responsibilities of the individual. It examines person’s self-evaluation of the performance of expected behaviors related to these roles.
Sexuality-Reproductive Pattern – This pattern describes satisfaction or dissatisfaction with personal sexuality and describes the reproductive pattern.
Coping-Stress Tolerance Pattern – This pattern explores the client’s general coping pattern and the effectiveness of the coping mechanisms. It encompasses analyzing the specific stressors or problems that confront the client, the client’s perception of the stressor and the person’s response to the stressor.
Value-Belief Pattern – Describes the values, goals, and beliefs (including spiritual) that guide health related choices. (Cecere, & McCash, 1992).
Physical examination or physical assessment is a systematic examination of the body structures. There are basically four techniques of conducting a physical examination and the examination may be done using the cephalocaudal (head – to – toe) approach or the body systems approach. The four techniques are:
Inspection: – Inspection is the most frequently used assessment It involves deliberate, purposeful and systematic observation to identify deviation from normal.
Percussion: – The assessment techniques least used by nurses. It requires considerable skills. Percussion involves striking or tapping a particular part of the body to produce vibratory sounds. The quality of sound aids in determining the location, size and density of underlying structures. If the sound is different from that which is normally expected, it suggests that there may be some pathologic changes in the area being examined.
Types of percussion: There are three types of percussion viz: Indirect, Direct, and Blunt percussion.
Indirect Percussion: The most commonly used. Produces clear, crisp sounds when performed correctly. To perform indirect percussion, use the middle finger of your non-dominant hand as the pleximeter by placing it firmly on the part that is to be percussed. The back of its middle phalanx is then struck with the top of the middle finger of the dominant hand (the plexor).
The stroke should be delivered from the wrist and finger joints, not from the elbow, and the percussing finger (the plexor) should be held perpendicular to the pleximeter. Tap lightly and quickly, removing the plexor as soon as you have delivered each blow.
Direct Percussion: In direct percussion, the nurse strikes the area to be percussed directly with the pads of two or three or four fingers or with the pad of the middle finger. This method helps in assessing an adult sinus for tenderness.
Blunt Percussion: This is done by striking the ulnar surface of your fist against the body surface. Alternatively, both arms may be used with the palm of one hand placed over the areas to be percussed and then striking it’s back with the fist of the other hand. Both techniques aim at eliciting tenderness (not to create a sound) over such organs as the kidneys, gallbladder, or liver (another blunt percussion method used in the neurologic exam involves tapping a rubber – tipped reflex hammer against a tendon to create a reflexive muscle contraction).
Palpation: This is an assessment technique that uses sense of feeling and pressure to assess structure size, placement, texture, temperature, distension, mobility, pulsation and tenderness. There are two types of palpation:
Light Palpation: Involves the use of pads of fingertips, the dorsum (back) of the hand or the palm. Used because their concentration of nerve endings makes them highly sensitive to tactile discrimination. In light palpation, the body surface is indented gently using the slightest touch possible; too much pressure blunts your sensitivity. The nurse extends the dominant hand’s fingers parallel to the skin surface and presses gently while moving the hand in a circle.
Deep Palpation: Deep palpation is done with two hands (bimanually) or with one hand. In deep palpation, the hand is held flat and relaxed and molded to the body surface as in light palpation. The best movement is gentle but with firm pressure with the finger held almost straight but slightly flexed at the metacarpophalangeal joints. Indent the skin or tissue about 1-11/2 inches (2.5 – 4cm).
Place your other hand on top of the palpating hand to control and guide your movements. This approach (bimanual palpation) is usually employed while palpating for deep, underlying, hard – to – palpate organs (such as the kidney, liver or spleen) or to fix or stabilize an organ (such as the uterus) while palpating with the other hand. To perform a variation of deep palpation that allows pinpointing an inflamed area, press firmly with one hand, and then lift your hand away quickly. If the patient complains of increased pains as you released the pressure, you have identified rebound tenderness. Other variations of deep palpation are:
Light Ballottement usually performed by applying light rapid pressure from quadrant to quadrant of the patient’s abdomen. Hands are kept on the skin surface to detect tissue rebound.
Deep Ballottement on the other hand, is performed by applying abrupt, deep pressure and releasing it while maintaining contact.
NOTE: Palpation forms the most important of abdominal examinations. Tell the patient to relax as best as he can, to breathe quietly and that you will be as gentle as possible. Enquire for the site of any pain and come to this region last. It is helpful to have a logical sequence to follow and if this is done as a matter of routine, then no important point will be omitted. Presented below are the different regions of the abdomen and the different incision line employed in abdominal surgeries.
Auscultation: Auscultation is an assessment technique that involves listening to sounds created in body organs to detect variations from normal. Some sounds can be heard with unassisted ear, but most sounds are heard through a stethoscope. You must first become familiar with normal sounds before you can be able to pick abnormal sounds. The heart, lungs and abdomen are the structures that are most often assessed by this technique. To auscultate effectively therefore requires good hearing acuity, a good stethoscope and knowledge of how to use the stethoscope correctly.
Assessing High-Pitched Sounds – Example of high-pitched sounds are 1st and 2nd heart sounds (S1 & S2) and breath sound. This is done with the use of the diaphragm of the stethoscope. Ensure that the diaphragm entire surface is closely / firmly applied to the patient’s skin.
Assessing Low-Pitched Sounds – The heart murmurs, 3rd and 4th heart sounds (S3 and S4) are all low-pitched sounds. To pick such sounds lightly place the bell of the stethoscope on the appropriate areas. Do not exert pressure. If you do, the patient’s chest will act as diaphragm and you will miss low-pitched sounds.
Like all the other assessment techniques, it requires conscious effort and regular practice to become proficient in its use.
SELF ASSESSMENT EXERCISE 2
What is the use of the five (5) special senses in observation/physical examination?