Embed Size (px)
Citation preview
Health History and Physical Examination
Chapter 3 Overview
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Data CollectionMedical Focus
2
Table 3-1. Medical History Format.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Data CollectionNursing FocusTypes of DataInterview ConsiderationsSymptom InvestigationData Organization
3Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Data Collection
4
Fig. 3-1. Obtaining a nursing history is an important role of the nurse.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Culturally Competent Care
Assessment
5Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing History:Subjective Data
Important Health InformationPast health historyMedicationsSurgery or other treatments
6Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing History:Subjective Data
Functional Health PatternsHealth perception–health management pattern
Nutritional-metabolic Elimination patternActivity-exercise patternSleep-rest pattern Cognitive-perceptual pattern
7Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing History:Subjective Data
Functional Health Patterns, continuedSelf-perception–self-concept pattern
Role-relationship pattern Sexuality-reproductive pattern
Coping–stress tolerance pattern
Value-belief pattern 8Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical Examination:Objective Data
General SurveyPhysical Examination
Techniques Inspection Palpation
9Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical Examination:Objective Data
10Fig. 3-2. Palpation is the examination of the body through the use of touch.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical Examination:Objective Data
Physical ExaminationTechniques, continued Percussion Auscultation
11Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical Examination:Objective Data
12
Fig. 3-4. Auscultation is listening to sounds produced by the body to assess normalconditions and deviations from normal.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical Examination:Objective Data
13
Fig. 3-3. Percussion technique. Tapping the interphalangeal joint. Only the middle finger of the nondominant hand should be in contact with the skin surface.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical Examination:Objective Data
Physical Examination, continuedEquipment
14
Table 3-4. Equipment for Physical Examination*.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical Examination:Objective Data
Physical Examination, continuedOrganization of examination
15Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical Examination:Objective Data
Physical Examination, continuedRecording physical examination
16
Table 3-6. Gerontologic Differences in Assessment.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Types of AssessmentComprehensive Assessment
Focused AssessmentEmergency Assessment
17Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Types of AssessmentLearning Assessment
18
Table 3-8. Clinical Application of Various Types of Assessment.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Problem Identification and Nursing Diagnoses
19
Fig. 3-5. Problem identification phase of the nursing process.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
