Health history and physical assessment

Assessment questions on the boards test two things: do you know the correct technique and sequence, and do you know a normal finding when you see one. This lesson covers both.

The health history

The health history is the subjective database collected through interview. Its components, in the usual order:

• Biographic data: name, age, sex, occupation, religion.
• Chief complaint: the client's own words about why care was sought. Record it in quotes.
• History of present illness: onset, location, duration, character, aggravating and relieving factors, timing, severity (many nurses use OLDCART or PQRST).
• Past health history: illnesses, surgeries, allergies, immunizations, medications including herbal remedies.
• Family history: heredofamilial diseases such as diabetes, hypertension, cancer.
• Lifestyle and psychosocial data, review of systems.

Interview technique matters: begin with open-ended questions to let the client tell the story, use closed questions to fill in specifics, and avoid leading questions and premature reassurance. Ensure privacy and sit at eye level.

Physical examination: IPPA

The standard sequence is Inspection, Palpation, Percussion, Auscultation. One famous exception: for the abdomen the order is inspection, auscultation, percussion, palpation, because palpating or percussing first can alter bowel sounds.

• Inspection: deliberate, systematic observation using sight and smell. It begins the moment you meet the client and requires good lighting and exposure of only the area examined.
• Palpation: use of touch. Light palpation (about 1 cm) comes before deep palpation. Use the finger pads for texture, masses, and pulses; the dorsum (back) of the hand for temperature; and the ulnar or palmar surface for vibration. Palpate tender areas last.
• Percussion: tapping to elicit sounds. Resonance is normal over lung, tympany over the gastric bubble and air-filled bowel, dullness over liver and a full bladder, flatness over muscle and bone.
• Auscultation: listening, usually with a stethoscope. The diaphragm picks up high-pitched sounds (breath, bowel, normal heart sounds); the bell, applied lightly, picks up low-pitched sounds such as murmurs and bruits.

Vital signs: normal adult values

Vital sign	Normal adult range
Temperature (oral)	36.5 to 37.5 degrees Celsius
Pulse rate	60 to 100 beats per minute
Respiratory rate	12 to 20 breaths per minute
Blood pressure	Below 120/80 mmHg (normal); 120-129 systolic is elevated
Oxygen saturation	95 to 100 percent

Assessment pointers the boards recycle: take an oral temperature 15 to 30 minutes after the client eats, drinks, or smokes; count an irregular pulse for a full minute and check an apical-radial deficit with two nurses; count respirations while your fingers remain on the wrist so the client is unaware; use a cuff bladder that covers about 80 percent of the arm circumference, since a cuff too small reads falsely high and one too large reads falsely low. Orthostatic hypotension is a drop of at least 20 mmHg systolic or 10 mmHg diastolic on standing.

Pain: the subjective vital sign

Pain is whatever the client says it is, occurring whenever the client says it does. The client's self-report is the single most reliable indicator; never downgrade a rating because the client "does not look in pain." Use a 0 to 10 numeric scale for adults, the Wong-Baker FACES scale for children about 3 years and older or clients with language barriers, and behavioral scales such as the FLACC for those who cannot self-report. Assess location, quality, intensity, onset, duration, and aggravating and relieving factors before and after every intervention.

Focused system checks worth memorizing

• Neurologic: level of consciousness is the most sensitive indicator of change; Glasgow Coma Scale ranges 3 to 15, with 15 fully alert and 8 or less indicating coma.
• Respiratory: vesicular sounds are normal over most lung fields; crackles suggest fluid, wheezes suggest narrowed airways.
• Cardiac: apical pulse at the fifth intercostal space, left midclavicular line.
• Abdomen: normal bowel sounds occur every 5 to 15 seconds; listen up to 5 minutes per quadrant before charting "absent."
• Skin: test turgor over the sternum or clavicle in older adults; tenting suggests dehydration.

Key points

• Chief complaint is recorded in the client's own words; open-ended questions open the interview.
• IPPA everywhere except the abdomen, which is inspect, auscultate, percuss, palpate; tender areas last.
• Diaphragm for high-pitched sounds, bell for low-pitched; dorsum of hand for temperature.
• Know the normal adult vital sign ranges cold; many items hinge on spotting the one abnormal value.
• Self-report is the gold standard for pain.

Exam-day strategy

• When a stem lists several findings, hunt for the value outside the normal range; that finding drives the answer.
• Sequence questions are free points: abdomen order and "light before deep" palpation are favorites.
• If the client just drank cold water, delay the oral temperature; timing distractors are common.