NUR 3029 Head to Toe Practicum

NUR 3029 Head to Toe Practicum

*** Chapter 4 – The Complete Health History ***

Subjective data—what the person says about himself or herself

Objective data—what you observe through measurement, inspection, palpation, percussion, and

The Health History –The Adult
Record time & date of the interview

1. Biographic Data –includes name, address, phone number, age and birth date, birthplace,

gender, marital partner status, race, ethnic origin, and occupation.

• Record the person’s primary language

Source of History

• Record who furnishes the info—person him/herself is most reliable but may be an

interpreter or caseworker, relatives and friends are less reliable

• Judge how reliable the informant seems
• Note if the person seems well or ill
• Sample statements: Patient herself, who seems reliable or Patients son, John Ramirez,

who seems reliable, etc.

2. Reason for Seeking Care

• Brief, spontaneous statement in the persons own words that describes reason for the


• States one (maybe two) symptoms of signs & their duration
• Symptom = subjective sensation that the person feels from the disorder
• Sign= objective abnormality that you as the examiner could detect on a physical

examination or in lab reports

• Record persons exact words and record a time frame
• Sample statements: “Chest pain for 2 hours” or “Sore throat for 3 days now and just

getting worse”

3. Present Health or History of Present Illness

• For healthy person – “I feel healthy right now”
• For ill person—your final summary of any symptom the person has should include

these 8 characteristics:

1. Location—specific, ask person to point to the location. If pain is the problem,

note the precise site (ex. head pain is vague, whereas pain behind the eyes or
jaw pain is more precise. Is the pain localized to this site or radiation? Is it
superficial or deep?

2. Character or Quality—specific descriptive qualities (burning, sharp, dull,

aching, shooting, etc.) Use similes—ex. does blood in the stool look like sticky

3. Quantity or Severity—try to quantify the sign or symptom ex. profuse

menstrual flow soaking 5 pads/hr. With pain, avoid adjectives and ask how it
affects daily activities. Record if person says something like “I was able to go
to work but then I came home and went to bed” (Also use Pain scale 1-10)

4. Timing—(onset, duration, frequency) à when did the symptom first appear?

Report must include answers to Q’s such as:

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• how long did the symptom last (duration)?
• Was it steady (constant) or did it come and go during that time


• Did it resolve completely and reappear days or weeks later (cycle of

remission and exacerbation)?

5. Setting—where was person or what were they doing when the symptom

started? What brings it on?

6. Aggravating or Relieving Factors—what makes pain worse? Is it aggravated by

weather, activity, food, medication, standing bent over, fatigue, time of day, or
season? What relieves it (rest, medication, ice pack)? Ask what they have tried
or what seems to help?

7. Associated Factors—is primary symptom associated with any others (ex.

urinary frequency and burning associated w/ fever and chills)

8. Patients Perception—find out the meaning of the symptom by asking how it

affects daily activities

• Organize question sequence into: PQRSTU



Provocative or Palliative

– what brings it on? What were you doing

during onset? What makes it better/worse?



Quality or Quantity

– how does it look, feel, sound? How

intense/severe is it?



Region or Radiation

– Where is it? Does it spread?



Severity Scale

– How bad is it (on scale 1-10)? Getting better, worse,

staying the same?




– onset (when did it first occur), duration (how long did it

last), and frequency (how often does it occur)




Patient’s Perception of the problem (“what do you think

it means?”)

4. Past Health

• Childhood illnesses
• Accidents or Injuries
• Serious or chronic illnesses
• Hospitalizations
• Operations
• Obstetric history
• Immunizations
• Last examination date
• Allergies
• Current medications

5. Family History

• Accurate family history can help with prevention (patient may seek early screening and

periodic surveillance)

• Pedigree/genogram—graphic family tree

Review of Systems

• General overall health state – weight (gain/loss over what period of time), fatigue, weakness or

malaise, fever, chills, sweats or night sweats

• Skin—history of skin disease, pigment or color change, excessive dryness or moisture,

excessive bruising, rash, lesion
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• Hair—recent loss or change in texture (nails: change in shape, color, or brittleness)
• Head—unusually frequent or severe headache; head injury, dizziness or vertigo
• Eyes—difficulty with vision, eye pain, redness or swelling, watering or discharge
• Ears—earaches, infections, discharge, tinnitus, vertigo
• Nose and sinuses—discharge and its char. Sinus pain, nosebleeds, change in sense of smell
• Mouth and throat—mouth pain, frequent sore throat, bleeding gums, toothache, lesion in

mouth or tongue, hoarseness or voice change, altered taste

• Neck—pain, limited motion, lumps or swelling, enlarged or tender nodes, goiter
• Breast—pain, lump, nipple discharge, history of breast disease, surgeries done
• Axilla—tenderness, lump, swelling or rash
• Respiratory system –history of lung disease, chest pain while breathing, wheezy or noisy

breathing, shortness of breath, cough, sputum

• Cardiovascular—chest pain, pressure, tightness or fullness, palpitation, cyanosis, dyspnea or

exertion, etc. specify amount of exertion ex. walking one flight of stairs, walking from chair to
bath, or just talking

• Peripheral vascular—coldness, numbness and tingling, swelling of legs (time of day and

activity), discoloration of hands or feet, varicose veins, ulcers

• Gastrointestinal—appetite, heartburn, indigestion, pain (assoc. with eating), other ab pain,

nausea and vomiting, vomiting blood, black stools, rectal bleeding, frequency of bowel
movement, flatulence

• Urinary system—frequency, urgency, nocturia (# of times person wakes up to pee at night,

recent change), dysuria, polyuria, UTI, kidney stones

• Male genital system—penis or testicular pain, sores/lesions, penile discharge, lumps, hernia
• Female genital system—menstrual history, vaginal itching, discharge and char, age at

menopause, menopausal signs and symptoms, postmenopausal bleeding

• Sexual health—“I usually ask all patients about their sexual health”—then: “are you presently

in a relationship involving intercourse?” contraceptives? STIs?

• Musculoskeletal system—history of arthritis or gout. In joints: pain stiffness, swelling (location,

migratory nature, deformity, limitation of motion, noise with joint motion? In muscles: pain,
cramps, weakness, gait problems, coordination problems? In the back: any pain, stiffness,
limitation of motion, history of back pain or disk disease?

• Neurologic System—history of seizure disorder, stroke, fainting, blackouts. Motor function:

weakness, paralysis, coordination problems? Sensory function: numbness, tingling?
Cognitive function: memory disorder (recent or distant, disorientation?), mental status:
nervousness, mood change, depression, hallucinations, etc

• Hematologic System—bleeding tendency of skin or mucous membranes, excessive bruising,

lymph node swelling, blood transfusion and reactions

• Endocrine system—history of diabetes or thyroid disease, excessive sweating, relationship

b/w weight and appetite, abnormal hair distribution, tremors, nervousness, need for hormone

Functional Assessment (including Activities of Daily Living)

• Measures a person’s self-care abilities in the areas of general physical health or absence of


• Self esteem/concept: education, financial status, value-belief system (religious)
• Activity/exercise: a daily profile reflecting usual daily activities (note ability to perform ADLs)
• Sleep/rest: sleep patterns, day naps, any sleep aids used?
• Nutrition/elimination: record diet by recall of all food + bev taken over the past 24 hours. Ask

about usual bowel movement pattern and urination

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• Interpersonal relationships/resources: social roles—ask how they describe their role in family
• Spiritual resources
• Coping and stress management
• Personal habits—tobacco, alcohol, street drugs. Smoker? How many packs?
• Alcohol—ask about amount and frequency of intake? (CAGE test)
• Illicit or street drugs: ask about prescription pain killers, cocaine, heroine, marijuana, crack.
• Intimate partner violence
• Occupational health: ask person to describe work place

Perception of Health

• Ask the person to define health for you and how they view their situation now. Ask if they

have any concerns or goals

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Chapter 8 – Physical Assessment in Clinical Setting

-Physical examination requires examiner to develop technical skills = the tools to
gather data

-Use your senses to gather data

-The skills required for the physical examination are:

o Close/careful scrutiny – first of an individual as a whole and then of each body


o Inspection always comes FIRST
o Compare the client’s R & L sides (symmetry)
o Begins the moment you first meet the person and develop a “general survey”

o pay attention to their affect (their temperament, mood), how their dressed,

hygiene, etc.


observe for: symmetry, norms, size, shape, color, & behavior


general inspection – front to back/ side to side, symmetry, injuries, abnormalities
(overall appearance)


systemic inspection – each body system from head to toe

o inspection requires: good lighting, adequate exposure, occasional use of

instruments (including otoscope, ophthalmoscope, penlight, or nasal and vaginal
specula) to enlarge your view

o Often confirms points you made during inspection
o sense of TOUCH to asses: texture, temperature, moisture, organ location and size,

swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps
or masses, and presence of tenderness or pain

o Different parts of the hand are best suited for assessing different factors:


Fingertips –best for fine tactile discrimination, as of

skin texture




, and determining presence of



Grasping action of the fingers and thumb – to detect the position,
shape, and consistency of an organ or mass


The dorsa (backs) of hands and fingers—best for determining


b/c the skin here is thinner than on the palms


Base of fingers or ulnar surface of hand – best for


o Bimanual palpation – requires use of both hands to envelop or capture certain body

parts or organs such as kidneys, uterus, or adnexa for more precise delimitation


Skin, organs, glands, vessels, thorax


Light palpation – rigidity, tenderness, masses


Deep palpation – enlarged organ, tenderness, masses


Bimanual palpation – size, tenderness


Use back of the hand for TEMP


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NUR 3029 Head to Toe Practicum