g. Attitude. The patient's attitude is reflected in his appearance, speech, and
behavior. The patient may be aloof and unwilling to participate in the interview. He may
verbalize anger or fear. Some patients have a "take care of me" attitude and expect
nurses and other health care personnel to magically know everything about them. Such
findings should be noted as part of your general impression.
h. Affect/Mood. Affect is the emotional state as it appears to others. Mood is the
emotional state as described by the patient. Observe the patient's facial expression. No
part of the body is as expressive as the face. Feelings of joy, sadness, fear, surprise,
anger, and disgust are conveyed by facial expression. Facial expressions generally are
not consciously controlled.
i. Speech. Assess the patient's speech for loudness, clarity, pace, and
coherence. Observe the patient for poor articulation of words and language difficulty.
Patients who are not fluent in English or have limited education are sometimes mistakenly
labeled as "indifferent" or "noncommunicative."
COMPONENTS OF A PHYSICAL ASSESSMENT
a. 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.
(1) 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
(2) 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