Health Assessment

Chapter 25
Competencies for Ch 25, Health
Assessment
 By the end of this unit, the student will:
 Demonstrate techniques to obtain patient
information
 Describe the components of a health assessment
 Describe how to prepare the patient for the exam
 List the equipment needed for an examination
 Demonstrate a brief head to toe physical
assessment
Health Assessment

 Two components of the health

assessment
 Health History

 Physical Assessment
What happens during a health
assessment between a patient and
nurse?
 Establish the nurse-  Identify patient
patient relationship strengths
 Gather data-  Identify actual and
physiological, potential health
psychological,cognitive, problems
sociocultural,  Establish a base for
developmental, spiritual the nursing process
(Assessment)
General Guidelines for Physical
Assessment
 Instrumentation
 Positioning
 Draping
 Preparation of the environment
 Patient preparation
 Techniques of physical assessment
 Positioning
 Sitting –used in an
upright chair or dangling
off exam table
 Supine-lie flat on your
back
 Dorsal recumbent-lie
back with knees bent
 Sims’s-lies on either right
or left side lower arm
behind the body and the
upper arm is bent at the
shoulder and elbow and
knees are both bent
•Prone-Pt. Lies on
abdomen
•Lithotomy- patient is
in a dorsal recumbent
position with buttock at
the edge of the
examining table and
feet support in stirrups.
•Knee to Chest-using
the knees and chest to
bear the weight of body.
•Standing
Draping, preparing the environment

 Draping prevents
unnecessary exposure,  Prepare examination
provides privacy, and table
keeps the patient warm  Place a gown and drape on
during the physical the table
exam (P.E.).  Set up any supplies that
are needed.
-Example: otoscope,
tuning fork,
ophthalmoscope.
 Pull curtain around or
close door to exam room
Techniques for examination

 Inspection- observing, listening or smelling to

gather data
 Palpation-assessment that uses sense of touch
 Percussion-act of striking on e object against
another to produce a sound
 Auscultation-act of listening with a stethoscope to
sounds produced with in the body.
Inspection

 Deliberate,  Nurse use the

purposeful, physical senses:
observations in a visualizing,
systematic manner hearing, and
smelling
Instrumentation or Equipment used
for inspecting
 Ophalmoscope-
 Exam the eyes
 Otoscope- examine the
ears, mouth and nostrils
 Tuning fork - hearing
 Nasal speculum-visualized
the turbinates of the nose
 Stethoscope
Instrumentation or Equipment used
for
vision screening
Snellen chart- used
to check eye sight
Palpation
technique using the sense of touch
 The hands and fingers are sensitive tools and
assess:
 Temperature- use the dorsum of the hand
 Turgor
 Texture
 Moisture Use the palmer (front side) of
the hand
 Vibrations
 Shape
Percussion-the act of striking one object against
another to produce a sound
 Percussion tones are  Percussion Tones
used to assess  Flat
location, shape, size  Dull
and density of tissue  Resonance
 Hyper resonance
 Tympany
Auscultation-act of listening with a stethoscope to
sounds produced with in the body

 Four characteristics assessed by auscultation

 Pitch- ranging from high to low
 Loudness- ranging from soft to loud
 Quality- gurgling or swishing
 Duration (short, medium, long)
General Survey
 Gather information
regarding
 Patient's appearance,
behavior
 Measuring vitals signs
 Height, and weight
 General appearance
 Gender and race
 Body build, posture and
gait
General appearance
 Hygiene, grooming
(note body odor,
cleanliness).
 Signs of illness
 Affect, mood, attitude
(speech and facial
expressions)
 Cognitive process
(speech content,
patterns, orientation,
appropriate verbal
responses)
Vital Signs, Height and Weight

 Take Vital signs (VS)  Height and weight-

and determine normal document
or abnormal -document (Check the height and
weight table to
determine if a patient is
under, normal or over
weight.)
 Physical Assessment
Head to Neck
 General survey
 Height and weight  Neck
 Skin
 Vital Signs  Lymph nodes
•Head  Muscles
–Skin  Thyroid
 Trachea
–Face, skull, scalp, hair
 Carotid arteries
–Eyes  Neck veins
–Nose and sinuses
–Mouth and or pharynx
–Cranial nerves
Integument structures

 Skin  Obtain history of rashes,

lesions, changes of color or
 Nails itching
 Hair  History of bruising or
 Scalp bleeding
 Exposure to sun
 Note presence of wounds,
abrasions
 Changes in mole size,
shape or color
SKIN

 Inspect for color,  Color-pinkish white to

vascularity, lesions and various shades of
body odors brown.
Skin Color Assessment areas Possible causes
variations
Redness (erythema, Facial area Blushing, ETOH
flushing intake, fever, injury or
infection
Bluish (cyanosis) Exposed areas, Cold environment,
ears,lips, inside of cardiac or respiratory
mouth, hands feet,
nail beds
Yellowish (jaundice) Overall skin areas, Liver disease
mucus membranes, (increased bilirubin)
sclera
Vitiligo Whitish patchy areas De-pigmentation
(autoimmune)
Tanned or brown Sun-exposed Melanin production
Pregnancy brown spots?
Head and Neck

Assessment includes
 Skull
•Pharynx
 Face
•Trachea
 Eyes •Thyroid glands
 Ears •Lymph nodes
 Nose

 Sinuses

 Mouth
Skull and face

 Inspect size and shape  Face- examine color

 Symmetry  Symmetry
 Distribution of facial
hair
 Assess facial nerve and
facial muscles-
cellulitis
Eye and Ears

EYE EAR
 Inspect external  Inspect external ear for
structures shape, size, location
 Pupils and Iris bilaterally, ear should
 Internal structures be smooth
 Gently palpate ear for
 Vision pain, edema, or presence
 Extra ocular movement of lesions
 Peripheral vision  Check hearing
 Inspect internal ear
Bacteria Conjunctivitis
Acute Glaucoma
Healthy Ear
Acute otitis media
Chronic otitis media, stapes extruding
Cerumen in ear
Nose and Sinuses

Nose Sinuses
 Inspect size, shape and  Inspect the sinuses
location and gently palpate
 Check for patency maxillary bone and
(open air frontal sinus
passageways.)  Normally the sinuses
 Inspect using otoscope are not painful.
nares and turbinates
Hematoma
Polyp
MOUTH AND PHARYNX

 Composed of many  Equipment needed:

structures  Penlight, tongue blade,
 Lips, tongue, teeth, gums 4X4 gauze sponge, and
hard and soft gloves
palate,salivary gland,
tonsillary pillars, and
tonsils
Tonsillitis
Hairy tongue
Neck

 Trachea- note location  Lymph nodes

 Midline at the  Generally not palpable
suprasternal notch  If palpated, should be
 Thyroid- thyroid is small mobile, smooth
normally not palpable. non-tender
Palpate for size shape,
 Abnormal- enlarged,
symmetry tenderness
and presence of any
indicate infection,
nodules autoimmune, or
metastasis of cancer
ASSESSMENT
Part I
COURSE OBJECTIVES

 Students will learn:

 Components of a health assessment
 To prepare the patient for the exam
 What equipment is needed for the exam
 A variety of techniques to obtain patient
information
 How to examine the patient head to toe
HEALTH ASSESSMENT

 Two components of the health assessment

 Health History
 Physical Assessment
WHAT HAPPENS DURING THE
ASSESSMENT
 Establish the nurse patient relationship
 Gather data in the following areas
 Physiological
 Psychological
 Cognitive
 Sociocultural
 Developmental
 Spiritual
 Identify patient strengths
 Identify actual and potential health problems
 Establish base for nursing process
GENERAL GUIDELINES

 Instrumentation
 Positioning
 Draping
 Preparation of the environment
 Patient preparation
 Assessment techniques
POSITIONING

 Sitting – use upright chairor

dangle of exam table.
 Supine – flat on the back
 Dorsal Recumbant – on
back with knees bent
 Sim’s – lie on side, lower
arm behind back, upper arm
bent at the shoulder and
elbow, knees both bent
ASSESSMENT part 2
PULMONARY

 HISTORY
 INSPECTION
 PALPATION
 PERCUSSION
 AUSCULTATION
 BREATH SOUNDS
PULMONARY
CARDIOVASCULAR

 History
 Inspection
 Palpation
 Auscultation
 Heart sounds
 Peripheral vascular system
CARDIOVASCULAR
BREAST/AXILLA

 History
 Inspection
 Palpation
ABDOMEN

 History
 Inspection
 Auscultation
 Percussion
 Palpation
GENITALIA

 Female
 History
 Inspection
 Male
 History
 Inspection
MUSCULOSKELETAL

 History
 Inspection
 Palpation
 Testing
 Tone
 Strength
 Bones and Joints
NEUROLOGICAL

 History
 Mental Status
 Orientation
 Level of Consciousness
 Memory
 Abstract Reasoning
 Language
CRAINIAL NERVES

 Olfactory (I)  Facial (VIII)

 Optic(II)  Acuoustic (IX)
 Oculmotor (III),  Glossopharyngeal (X)
Trochlear(IV),  Vagus (XI)
Abducens(V)  Accessory (XII)
 Trigeminal(VI)
 Hypoclosseal (VII)
SENSORY MOTOR FUNCTION

 Motor
 Balance and gait
 Coordination
 Sensory
REFLEXES

 Abdominal
 Babinskis
 Bicepts
 Triceps
 Patellar
 Achilles Tendon