6-7. COMPONENTS OF A PHYSICAL ASSESSMENT
Health History. During this assessment step, you interview the patient to obtain a history so that the nursing care plan may be patterned to meet the patient's individual needs. The history should clearly identify the patient's strengths and weaknesses, health risks such as hereditary and environmental factors, and potential and existing health problems. Both the seating arrangement and the distance from the patient are important in establishing a relaxed and comfortable environment for data collection. Chairs placed at right angles to each other about 3 feet apart facilitate an easy exchange of information. If the patient is in bed, be seated in a chair at a 45-degree angle to the bed. If possible, communicate with the patient at eye level. State your name and status and the purpose of the interview. During the introduction, assess the patient's comfort and ability to participate in the interview. Terminate the interview when you have obtained the data you need or the patient cannot provide more information. You need the following information in order to form the subjective database.
* Chief complaint. Record the chief complaint as a brief statement of whatever is troubling the patient and the duration of time the problem has existed. The chief complaint is the signs and symptoms causing the patient to seek medical attention. Generally, it is the answer to the question, "What brought you into the hospital (or clinic) today?" If a well person is seeking a routine physical, there is no actual chief complaint. Record his reason for the visit and the date of his last contact with a medical treatment facility.
* Past medical history. This provides background for understanding the patient as a whole and his present illness. It includes childhood illnesses, immunizations, allergies, hospitalizations and serious illnesses, accidents and injuries, medications, and habits.
* Family health history. This enhances...