CHAPTER

1 FUNDAMENTALS

1. HEALTH HISTORY
All assessments involve collecting two kinds of data: objective and subjective. The health

history gathers subjective and objective data about the patient.

OBJECTIVE DATA SUBJECTIVE DATA

 Are observed  Provided by the patient, or “subject”

 Are verifiable  Verified only by the patient
 Include findings such as red, swollen  Include statements such as “My head hurts”
arm in a patient or “I have trouble sleeping”
*The success of your patient interview depends on effective communication.

INTERVIEWING TIPS:

 Select a quit, private setting

 Choose terms carefully and avoid using medical jargon.

 Speak slowly and clearly.

 Use effective communication techniques, such as silence facilitation, confirmation, reflection, and

clarification.

 Use open-ended and closed-ended questions as appropriate.

 Use appropriate body language.

 Confirm patient statements to avoid misunderstanding.

 Summarize and conclude with “is there anything else?”

NCM 101
HEALTH ASSESSMENT
 REVIEW OF STRUCTURES AND SYSTEMS:

During the final part of the health history, ask about each body structure and system to make sure that

important symptoms weren’t missed. Start at the top of the head and work your way down to the toes.

 Your patient is vague in describing his chief complaint. Using your interviewing skills, you discover his

problem is related to abdominal distention. Now what? This flowchart will walk you through what to do

next.

EVALUATING A SYMPTOM

Ask the patient to identify the

NURSE symptom that’s bothering him. PATIENT

Form a first impression. Does the patient’s condition alert you to an emergency? For example, does he say
the bloating developed suddenly? Does he mention that other signs or symptoms occur with it, such as
sweating and light-headedness?

(Indicators of hypovolemia)

YES NO
Take a brief history. Take a thorough history. Note GI disorders that
can lead to abnormal distention.

Thoroughly examine the patient. Observe for

abdominal asymmetry. Inspect the skin,
Perform a focused physical examination to quickly
auscultate for bowel sounds, percuss and palpate
determine the severity of the patient’s condition
the abdomen, and measure abdominal girth.

Evaluate your findings. Are emergency signs or symptoms presents, such as abdominal rigidity and abnormal bowel sounds?

YES NO
Intervene appropriately to stabilize the patient, Review your findings to consider possible causes,
and notify the doctor immediately. such as cancer, bladder distention, cirrhosis, heart
failure, and gastric dilation.

After the patient’s condition stabilizes, review your

findings to consider possible causes, such as Devise an appropriate care plan. Position the
trauma, large-bowel obstruction, mesenteric artery patient comfortably, administer analgesics, and
occlusion, and peritonities prepare the patient for diagnostic tests.

NCM 101
HEALTH ASSESSMENT
2.) PHYSICAL ASSESSMENT

Assemble the necessary tools for the physical assessment. Then perform a general survey to form your

initial impression of the patient. Obtain baseline data, including height, weight, and vital signs. This information

will direct the rest of your assessment.

ASSESSMENT TOOLS:

 Cotton balls  Specula (nasal and

 Gloves  Penlight vaginal)
 Metric ruler  Percussion hammer  Sphygmomanometer
 Near-vision and visual  Safety pins  Stethoscope
acuity charts  Scale with height  Tape measure
 Ophthalmoscope measurement  Tuning fork
 Otoscope  Skin calipers  Wooden tongue blade

TIPS FOR INTERPRETING VITAL SIGNS:

 Analyse vital signs at the same time. Two or more abnormal values may provide clues to the patient’s
problem. For example, a rapid, thread pulse along with low blood pressure may signal shock.
 If you obtain an abnormal value; take the vital sign again to make sure it’s accurate.
 Remember that normal readings vary with the patient age. For example, temperature decreases with age,
and respiratory rate increase with age.
 Remember that an abnormal value for one patient may be a normal value for another, which is why
baseline values are so important.

 PHYSICAL ASSESSMENT TECHNIQUES

When you perform the physical assessment, you’ll use four techniques: Inspection, palpations,
percussion and auscultation. Use these techniques in this sequence except when you perform an
abdominal assessment.

Why? Because palpation and percussion can alter

bowel sounds, the sequence for assessing abdomen is
inspection, auscultation, percussion, and palpation.

NCM 101
HEALTH ASSESSMENT
General Instruction: Please answer all the questions/statements based on your readings, lectures, and notes.
Please support your answer by citing references. DO NOT COPY YOUR CLASSMATES’ WORK!
Draw and write it on a short bond paper, you may employ your creativity. Put your work under Maam Jham’s
table on Thursday, January 21, 2021 not later than 1pm. Late submission will not be accepted. Good luck!

Test I. Define or explain briefly the following and give examples each. And identify what assessment
tools being used when performing these:
1. Inspection
2. Palpation and its types
3. Percussion and its types
4. Auscultation

Test II. Provide illustrations or pictures of the different kinds of physical assessment tools, describe
its use and its body parts.

Test III. Essay.

Situation: On your first day of duty as a student nurse, you are assigned to interview a patient, 35
years old, female, to get her health history. Suddenly the patient shouted at you telling “No! How
can I trust you? You are just a student” how will you handle the situation?

NCM 101
HEALTH ASSESSMENT