HEALTH

ASSESSMENT
POCKET
GUIDE
for
AGUSTINIAN HEALTH
HISTORY

NURSES
Edition 2020

KAELA MERYL E. ESPAÑA

FRAY JOHN LOUIS S. RICAMORA

 CHAPTER 1

WHAT IS HEALTH HISTORY?

The health history is a current collection of organized
information unique to an individual. Relevant aspects of the
history include biographical, demographic, physical, mental,
emotional, sociocultural, sexual, and spiritual data.

PURPOSE
The purpose of obtaining a health history is to
gather subjective data from the patient and/or the patient’s
family so that the health care team and the patient can
collaboratively create a plan that will promote health,
addresses acute health problems, and minimizes chronic health
conditions. The health history is typically done on admission to
hospital, but a health history may be taken whenever additional
subjective information from the patient may be helpful to inform
care (Wilson & Giddens, 2013).

SUBJECTIVE AND OBJECTIVE DATA

o Subjective data is information reported by the patient
and may include signs and symptoms described by the
patient but not noticeable to others.

o Objective data is information that the health care

professional gathers during a physical examination and
consists of information that can be seen, felt, smelled, or
heard by the health care professional.

HEALTH HISTORY GUIDE

A. Biographical Data
Name:
Gender:
Address:
Phone Number:
 Date and Place of Birth:
Marital Status:
Nationality:
Educational Level:
Occupation and Working Status:
Religion:
Significant Others Living with the Client:
Caregivers and Support People for the Client:
Primary and Secondary Language:
B. Reasons for Seeking Health Care
What is your major health care and concern?
Are you comfortable with seeking care from this organization?
C. History of the Present Health Concern
Use COLDSPA when appropriate:
1. CHARACTER of the symptom
2. ONSET (when did it begin;
3. LOCATION
4. DURATION
5. SEVERITY
6. PATTERN
7. ASOCIATED FACTORS
D. Past Health History
E. Family Health History
F. Review Systems
G. Lifestyle and Health Practice Profile

CHAPTER 2

HOLISTIC PHYSICAL
ASSESSMENT
 Assessment is a key component of nursing practice,
required for planning and provision of patient and family centred
care.
BASIC METHODS
INSPECTION is a visual examination of the patient
like observation of patients skin.

PALPATION is done when the person doing the

assessment places their fingers on the body to
determine things like swelling, masses, and areas of
pain. There are two kinds of palpation light and
deep palpation.
 Figure A (Light Palpation)
During light palpation gentle pressure against
underlying skin and tissue can detect areas of
irregularity and tenderness.
 Figure B (Deep Palpation)
During deep palpation depress tissues to assess the
condition of underlying organs.

PERCUSSION is tapping the patient's bodily

surfaces and hearing the resulting sounds to
determine the presence of things like air and solid
masses affecting internal organs. The sounds that
are heard with percussion are:
 Resonance which is a hollow sound
 Flatness which is typically hear over
solid things like bone
 Hyper resonance which is a loud
booming sound
 Tympanic this is a drum type sound.
AUSCULTATION is listening to an area of the body
using a stethoscope. For example, bowel sounds,
lung sounds and heart sounds are auscultated with
a stethoscope. The sounds that are heard with
auscultation are classified and described according
to their duration, pitch, intensity and quality.
 Duration of a breath sound can be
described in terms of seconds of
 GENERAL SURVEY
PHYSICAL APPEARANCE
 AGE  LEVEL OF CONCIOUSNESS
Normal Normal
The patient appears his or her stated The patient is alert, oriented, attends
age. to questions and responds
Abnormal appropriately.
Appears older than stated age as Abnormal
with chronic illness, chronic Confused, drowsy, lethargic.
alcoholism.
 SEX  FACIAL FEATURES
Normal Normal
Sexual development is appropriate Facial features are symmetric with
for gender and age. movement.
Abnormal Abnormal
Delayed or precocious puberty. Immobile, masklike, asymmetric,
drooping.
 OVERALL
Normal
No signs of acute distress present.
Abnormal
Respiratory signs: shortness of breath, wheezing
Pain: indicated by facial grimace, holding/ guarding body part, knees drawn up over
the abdomen.
BODY STRUCTURE
 SATURE  NUTRITION
Normal Normal
The height appears within normal The weight appears within normal range for
range for age, genetic heritage. height and body build; body fat
Abnormal distribution is even.
Excessively short or tall. Abnormal
Emaciated, cachectic; obviously obese with
even fat distribution; fat concentrated in
face, neck, trunk, with thin arms and legs.
  POSITION
Normal
The patient sits comfortably in a
chair or in the bed or examination
table, arms relaxed at the sides,
head turned to the examiner.
Abnormal
Curled up in fetal position. Leaning
forward with arms braced on chair
arms or over the thighs. Sitting up
and desists lying down.
MOBILITY
 GAIT
Normal
The base is as wide as the shoulder
width; foot placement is accurate;
the walk is smooth, even, and well-
balanced; and associated
movements, such as symmetric
arm swing are present.
Abnormal
Exceptionally wide base, staggered,
stumbling. Limping with injury.
Tiptoe walking.
BEHAVIOR
 FACIAL EXPRESSION
Normal
The patient maintains eye contact,
expressions are appropriate to the
situation.movements, such as
symmetric arm swing are present.
Abnormal
Flat, depressed, angry, sad, anxious.
 PERSONAL HYGIENE
Normal
The patient appears clean and groomed
appropriately for his on her age,
occupation and socio economic group.
Hair is groomed, brushed.
Abnormal
In a previously carefully groomed
woman, unkempt hair and absent make-
up may indicate malaise or illness.
 BODY BUILD AND CONTOUR
Normal
Arm span stretch your arms to the sides
equals height.
Abnormal
Elongated arms, greater than height.
Missing extremities or digits; extra digits;
webbed digits; shortened limb.
 RANGE OF MOTION
Normal
Full mobility of each joint, movement is
deliberate, accurate, smooth and
coordinated. No involuntary,
unpurposeful movement.
Abnormal
Limited joint range of motion. Paralysis –
absent movement. Movement jerky,
uncoordinated. Tics, tremors and
seizures.
 MOOD AND AFFECT
Normal
The patient is comfortable and
cooperative with the examiner and
interacts pleasantly.
Abnormal
Hostile, distrustful, suspicious, crying.
 SPEECH
Normal
The patient speaks clearly. The
stream of talking is fluent, with an
even pace. Word choice is
appropriate.
Abnormal
Difficulty in talking, with abnormal
pitch or volume. Voice is hoarse or
whispered. Slurred speech. Constant
 DRESS
Normal
Clothing is appropriate to the climate, looks clean and fits the body, and is appropriate
to age group.
Abnormal
Trousers too large and held up by belt. Looks unclean. Inappropriate to the climate.

HEAD TO TOE ASSESSMENT

o Skin
o Head and Face
o Eyes
o Ears
o Nose and Sinuses
o Mouth and Throat
 SKIN ASSESSMENT
ANATOMY OF THE SKIN
PROCEDURE
Inspection
Assess for skin color, vascularity, lesion, and edema.
Palpate
 Skin  temperature, moisture, turgor, elasticity deformities,
hematomas and crepitus

Kinds of Skin Color

Pallor Cyanosis Jaundice

is the result of (a bluish tinge) (a yellowish tinge)
inadequate is most evident may first be
circulating blood in the nail beds, evident in the
or hemoglobin lips, sclera of the eyes
and subsequent and buccal and then in the
reduction in mucosa. mucous
tissue membranes and
oxygenation. the skin

Erythema Vitiligo
 Skin Vascularity

Ecchymosis Petechiae
Is a subcutaneous spot of are tiny purple, red, or
bleeding with diameter larger brown spots on the
than 1 cm. A discoloration of skin.
the skin resulting from
bleeding underneath,
typically caused by bruising

Skin Lesion

Edema
 is the presence of excess interstitial
fluid

PITTING EDEMA -
applying pressure to the
swollen area causes an
indention that persists
for some time.

HEAD AND
FACE ASSESSMENT
Ref:
Health History
https://opentextbc.ca/clinicalskills/chapter/2-4-
health-history-subjective-assessment/

Gen survey
Udan book

Physical assessment

https://www.registerednursing.org/nclex/technique
s-physical-assessment/

https://www.rch.org.au/rchcpg/hospital_clinical_gu
ideline_index/Nursing_assessment/#Introduction