Health History & Physical Examination Techniques - Concept Map
Nursing Health Assessment
Related concepts
Health Assessment Foundation
Sub concepts
- Subjective Data (Symptoms/Covert)
- Objective Data (Signs/Overt)
- Baseline Establishment
- Problem Identification
Relationship to central
Core purpose and definition of nursing assessment
Assessment Types
Sub concepts
- Initial/Comprehensive Assessment
- Focused/Problem-Oriented Assessment
- Emergency Assessment
- Ongoing/Time-Lapsed Assessment
Relationship to central
Different approaches based on clinical context
Health History Interview
Sub concepts
- Preparatory Phase
- Introductory Phase
- Working Phase
- Closing Phase
- Communication Techniques
- Components of Complete History
Relationship to central
Structured data collection through therapeutic communication
General Survey
Sub concepts
- Physical Appearance
- Body Structure and Nutrition
- Mobility Assessment
- Behavioral Observation
Relationship to central
Initial overall impression preceding detailed examination
Vital Signs
Sub concepts
- Temperature 36.5-37.5°C
- Pulse 60-100 bpm
- Respirations 12-20/min
- Blood Pressure <120/80 mmHg
- SpO2 95-100%
- Pain as Fifth Vital Sign
Relationship to central
Objective baseline measurements essential to assessment
Physical Examination Techniques (IPPA)
Sub concepts
- Inspection
- Palpation
- Percussion
- Auscultation
- Abdominal Examination Order
Relationship to central
Systematic methods for objective data collection
Client and Environmental Preparation
Sub concepts
- Environment Setup
- Client Readiness
- Positioning Techniques
- Equipment Preparation
Relationship to central
Foundational elements ensuring quality assessment
Documentation and Legal Standards
Sub concepts
- Objective Recording
- RA 9173 Compliance
- Code of Ethics Standards
- Confidentiality and Privacy
Relationship to central
Professional accountability in nursing practice
Concept connections
- Nursing Health AssessmentSubjective DataAssessment foundation requiring both types of data
- Nursing Health AssessmentObjective DataMeasurable, observable findings that validate subjective reports
- Health History InterviewSubjective DataInterview is primary source of subjective information
- Physical Examination IPPAObjective DataIPPA techniques generate objective observable and measurable findings
- Vital SignsObjective DataVital signs are baseline objective measurements
- General SurveyPhysical Examination IPPAGeneral survey precedes and provides overview for detailed IPPA
- Health History InterviewCommunication TechniquesTherapeutic communication enables effective history gathering
- Communication TechniquesCultural SensitivityCultural awareness enhances communication effectiveness
- PalpationLight PalpationLight palpation precedes deep palpation in proper sequence
- PalpationDeep PalpationDeep palpation follows light palpation for complete assessment
- Physical Examination IPPAInspectionInspection is first technique in standard IPPA sequence
- Physical Examination IPPAAuscultationAuscultation is final technique except in abdominal exam
- PercussionPercussion SoundsDifferent sounds indicate different tissue densities
- AuscultationStethoscope UseStethoscope is primary tool for auscultation technique
- Client and Environmental PreparationClient ReadinessClient readiness is essential component of preparation
- Client and Environmental PreparationPositioning TechniquesProper positioning ensures examination access and client comfort
- Documentation and Legal StandardsRA 9173 CompliancePhilippine nursing law governs documentation requirements
- Documentation and Legal StandardsCode of Ethics StandardsEthical standards guide confidentiality and documentation practices
- Assessment TypesInitial Comprehensive AssessmentComprehensive assessment includes full health history and IPPA
- Assessment TypesFocused Problem-Oriented AssessmentFocused assessment targets specific presenting complaint
- Assessment TypesEmergency AssessmentEmergency assessment prioritizes ABC over comprehensive approach
- Health History InterviewChief ComplaintChief complaint is starting point of history
- History of Present IllnessOLD CARTSOLD CARTS framework organizes symptom analysis
- Pain AssessmentPQRSTPQRST is specialized framework for pain analysis
- Vital SignsBMI CalculationBMI calculated from vital sign measurements for nutritional status
- Abdominal Examination OrderAuscultationAbdominal exam differs: auscultation precedes percussion and palpation
- Standard PrecautionsHand HygieneHand hygiene is cornerstone of infection prevention
- Standard PrecautionsGlove UseGloves required when contact with body fluids anticipated
- Client ComfortPositioning TechniquesPosition selection balances examination access with client tolerance
- DocumentationObjective Accurate RecordingDocumentation must reflect only observed findings
- Preparatory PhaseEnvironment SetupEnvironment preparation occurs during preparatory phase
Diagrams
Nursing Health Assessment: Complete Concept Map
Comprehensive mind map showing the hierarchical relationships of all major concepts in health history and physical examination techniques, organized from the central nursing assessment concept outward to specific techniques, components, and considerations.
Phases of the Health History Interview
Sequential flowchart detailing the four phases of the health history interview: preparatory, introductory, working, and closing phases. Shows decision points, key activities, and documentation requirements aligned with therapeutic communication principles.
Physical Examination Technique Selection and Sequence
Decision tree showing the proper sequencing of physical examination techniques. Highlights the critical difference between abdominal examination order IAPP versus standard IPPA order for all other body regions, with emphasis on avoiding bowel sound distortion.
Palpation Technique Selection Based on Assessment Goal
Detailed flowchart for palpation technique selection, guiding nurses to choose the correct hand part for specific assessments and proper sequence (light before deep, tender areas last) based on clinical objectives.
Percussion Sound Interpretation and Clinical Significance
Clinical decision tree for percussion sound interpretation, showing what each sound indicates, where it is normally heard, and when abnormalities are present. Critical for identifying pathology like consolidation, effusion, and emphysema.
Client Positioning for Physical Examination by Body Region
Comprehensive flowchart matching examination body regions to appropriate client positions, including considerations for client tolerance and the importance of proper draping for privacy and dignity.
Symptom Analysis Framework: OLD CARTS and PQRST
Framework for systematic symptom analysis using OLD CARTS mnemonic for any complaint and PQRST specifically for pain. Shows all components, examples, and how to synthesize findings into clinical documentation.
Data Types in Nursing Assessment: Subjective vs. Objective
Visual representation showing the approximate distribution of subjective (what client reports: symptoms, feelings, perceptions) versus objective data (what nurse observes/measures: signs, vital signs, physical findings) in comprehensive health assessment. Both types are essential for complete clinical picture.
Assessment Data Collection States and Transitions
State diagram showing the logical progression through assessment phases: from preparation through interview, general survey, vital signs, physical examination, and documentation, with feedback loops for clarification and concurrent activities.
Standard Precautions and Safety During Health Assessment
Procedural flowchart emphasizing standard precautions, hand hygiene, glove use, client comfort, privacy maintenance, and confidentiality throughout the assessment process, aligned with infection control and RA 9173 compliance.