Page 362 - Saunders Comprehensive Review For NCLEX-RN

CHAPTER 12

Health and Physical Assessment of the

Adult Client

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Priority Concepts
Clinical Judgment; Health Promotion

I. Environment/Setting
A. Establish a relationship and explain the procedure to the client.
B. Ensure privacy and make the client feel comfortable (comfortable
room temperature, sufficient lighting, remove distractions such as
noise or objects, and avoid interruptions).
C. Sit down for the interview (avoid barriers such as a desk),
maintain an appropriate social distance, and maintain eye level.
D. Use therapeutic communication techniques and open-ended
questions to obtain information about the client’s symptoms and
concerns; allow time for the client to ask questions.

E. Consider religious and cultural characteristics such as

language (the need for an interpreter), values and beliefs, health
practices, eye contact, and touch.
F. Keep note-taking to a minimum so the client is the focus of
attention.
G. Types of health and physical assessments (Box 12-1)
H. SOAP (subjective, objective, assessment, plan) notes are a
frequently used format for documenting client data including
health history, physical examination, assessment or diagnosis, and
plan of care. The nurse should be familiar with SOAP notes, how
to interpret the initial history and physical (H&P) SOAP notes, and
how to follow subsequent progress SOAP notes so as to maintain
abreast of changes in the client’s plan of care. See Table 12-1 for a
detailed list of information contained in SOAP notes.
II. Health History (refer to section titled “Subjective” in Table 12-1)
A. General state of health: Body features and physical characteristics,
body movements, body posture, level of consciousness, nutritional
status, speech

B. Chief complaint and history of present illness (document

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