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Conducting a health assessment involves:
collecting,
validating,
and analyzing subjective data (also called symptoms)and objective data (also called signs) to determine the over-all level of physical,
psychological,
sociocultural,
developmental,
and spiritual health of a patient.
The information from the nursing health assessment is used to:
formulate nursing diagnoses that require nursing care and is also used to identify health problems that require interdisciplinary care or immediate referral to other healthcare providers..
The health assessment involves explanation to the patient that
the first part of the assessment will involve questions about the patient’s health concerns, health habits, and lifestyle and that the information will only be shared with the patient’s other healthcare providers . Inform the patient that after the health history is completed, body structures will be examined.
A physical assessment is the:
systematic collection of objective information. The physical assessment is usually conducted in a head-to-toe sequence or a system sequence but can be adapted to meet the needs of the patient.
CAUTION Model for an assessment for risk factors for cancer:
Change in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in the breast or elsewhere
Indigestion or difficulty in swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
Equipment used during a Health Assessment:
Stethoscope
is used to auscultate heart, lung, abdomen, and cardiovascular sounds.
The bell of the stethoscope is used to listento low-pitched sounds (such as heart murmurs). Use gentle pressure against the body part being examined when assessing low-pitched sounds.
The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds,breath sounds, and bowel sounds. Use firm pressure against the body part being examined when assessing high-pitched sounds.
Equipment used during a Health Assessment:
Opthalmoscope
a lighted instrument used to visualize the interior structures of the eye. It consists of two parts:
a body that contains the light source and
a detachable head that contains lenses used to magnify the internal eye structures.
Each lens is labeled with a positive (black) or negative (red) number, with units of strength called diopters.
Red numbers are used for near-sighted (myopic) patients,
black numbers for far-sighted (hyperopic) patients.
The zero lens is used when either the examiner or the patient has refractive (visual) errors.
Otoscope
An otoscope is a lighted instrument used to examine the external ear canal and the tympanic membrane. A speculum,which is attached to the body of the otoscope, directs the light in a narrow beam to improve visualization of ear
structures.
Specula come in various sizes; use the largest speculum that will extend into the patient’s ear canal.
Alternatively, the otoscope can be used to visualize the internal nares.
Snellen Chart
used as a screening test for distant vision,
consists of characters arranged in 11 lines of different-sized type;
the line of largest characters is at the top of the chart and
the line of smallest characters is at the bottom.
Scores ranging from 20/10 (the smallest line of characters) to 20/200 (the largest line of characters) are shown in the left-hand column,and
distances are in the right-hand column next to the numbers.
Nasal Speculum
A nasal speculum is used to visualize the lower and middle turbinates of the nose.
A penlight or flashlight is used for illumination.
The blades of the speculum are inserted about 1 cm(1/2) into each nostril and opened so that they do not press on the septum. Alternatively, the otoscope can be used to visualize the internal nares. The light is provided by the scope, and the shortest, widest speculum that will fit into the nostril is used.
Vaginal Speculum
A vaginal speculum is a two-bladed instrument used to examine the vaginal canal and cervix.
The speculum is inserted into the vagina and the speculum blades are opened, allowing visualization and assessment of the vagina and cervix.
The speculum must be warmed and lubricated with warm water or a water-soluble agent before insertion.
Tuning Fork
A tuning fork is a two-pronged metal instrument used to test auditory function and vibratory perception.
Percussion Hammer
A percussion hammer (also called a reflex hammer) is an instrument with a triangular-shaped rubber head, used to test deep tendon reflexes.
The handle of the hammer is held between the thumb and inde the broad end of the head on the selected body area.
The quick, firm tap is made with a rapid downward and backward wrist action.
The pointed end of the hammer is used for smaller areas.
Various body positions are used during a physical assessment:
During positioning, it is important to consider the patient’s age,
culture,
health status,
mobility,
physical condition,
energy level, and
privacy.
Positioning patients who are weak or have physical limitations may require assistance.
Uncomfortable or embarrassing positions should not be maintained for long periods.
The assessment should be organized so that several body systems can be assessed with the patient in one position.
The Body Positions used during an Assessment:
Standing,
Sitting,
Supine,
Dorsal Recumbant,
Sims Position,
Prone,
Lithotomy and
Knee-chest.
The four primary assessment techniques are:
inspection,
palpation,
percussion, and
auscultation.
These techniques are most often used in the sequence listed.
BUT, When assessing the abdomen, the sequence is inspection, auscultation, percussion, and palpation.
Auscultation follows inspection because percussion and palpation stimulate bowel sounds.
Bilateral body parts are always compared such as movement or pulses.
Bilateral body parts are normally symmetric;that is, they have the same size and shape as well as the same characteristics, such as pulses or movements.
Inspection:
is the process of performing deliberate, purposeful observations in a systematic manner.
The nurse observes visually but also uses hearing and smell to gather data throughout the assessment.
Inspection begins with the initial patient contact and continues through the entire assessment.
Each area of the body is inspected for size,
color,
shape,
position, and
symmetry,
noting normal findings and any deviations from normal.
Inspection, followed by palpation,may sequentially be used during the assessment of each body part.
Palpation
uses the sense of touch. The hands and fingers are sensitive tools and can assess:
skin temperature,
turgor (turgor is determined by various factors, such as the amount offluids in the body and age),
texture,
and moisture,
as well as vibrations within the body (such as the heart) and
shape or structures within the body (e.g., the bones).
Palpation
Using specific parts of the hand:
The dorsum (back) surfaces of the hand and fingers are used for gross measure of temperature.
The palmar(front) surfaces of the fingers and finger pads are used to assess:
texture,
shape,
fluid,
size,
consistency, and
pulsation.
Vibration is palpated best with the palm of the hand.
Palpation.
Light (gentle), moderate, or deep palpation may be used:
For light palpation, apply pressure with the fingers together and depressing the skin and underlying structures less than 1 cm (0.5") . Moderate palpation is conducted by depressing the skin surface 1 to 2 cm (0.5 to 0.75").
For deep palpation, press inward about 2 cm (1") .
Deep palpation, which carries a risk of internal injury, should be used cautiously and only by experienced practitioners.
Palpation.
Bimanual
Two hands are used for bimanual palpation (e.g., palpating breast tissue);
one hand applies pressure and the other hand feels the tissue or structure.
Quality of Masses determined by Palpation
shape,
size,
consistency,
surface,
mobility,
tenderness,
pulsatile.
Percussion
the act of striking one object against another to produce sound. The sound waves produced by the striking action over body tissues are known as percussion tones. Percussion is used to assess the location, shape, size, and density of tissues.
Both hands are used to produce sound waves.
Characteristic sounds produced are:
tympany(gastric air bubble)
resonance(normal lung)
hyperresonance(emphysematous lung)
dull(liver)
flat(thigh)
Auscultation
the act of listening with a stethoscope to sounds produced within the body. Auscultation is performed by placing the stethoscope diaphragm or bell against the body part being assessed
Used as the last step except for an abdominal exam.
Auscultation
Four characteristics of sound are assessed by auscultation:
(1) pitch (ranging from high to low),
(2) loudness (ranging from soft to loud),
(3) quality (e.g., gurgling or swishing),and
(4) duration (short, medium, or long).
Head to Toe Assessment
usually done in morning after report while in an acute setting.
assess abdominal pain first but perform painful procedures last.
Be objective when recording findings:
DO NOT use terms: GOOD or NORMAL.
Assessing the Integument
The integument is comprised of the skin, nails, hair, and scalp. It provides data about self-care activities to maintain health, hygiene, and nutrition.Assessing for skin cancer is essential and provides the base for teaching skin cancer prevention.
The skin, hair, and nails are assessed by inspection and palpation.
Inspect the skin for color, vascularity, and lesions , and palpate for temperature,moisture, turgor, and texture.
Assessing the Integument
Inspecting for changes in skin color
Changes in skin color include erythema,
cyanosis,
jaundice, and
pallor.
Erythema:
(redness of the skin) is more often seen in the face and the neck. It is associated with sunburn, inflammation, fever, trauma, and allergic reactions.
Cyanosis
a bluish or grayish discoloration of the ski nin response to inadequate oxygenation.
Cyanosis is assessed as a blue tinge in patients with white skin and as dullness in patients with dark skin.
Jaundice
is a yellow color of he skin resulting from liver and gallbladder disease, sometypes of anemia, and excessive hemolysis (breakdown ofred blood cells).
It usually develops first in the sclera of the eyes and then in the skin and mucous membranes. Jaundice in dark-skinned people is more difficult to observe on the trunk of the body, but the sclera, oral mucous membranes,palms, and soles appear yellow to yellow-orange.
Pallor
rpaleness of the skin, often results from a decrease in the amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues. Depending on severity, pallor may be visible over the entire skin surface or only in the lips,
nailbeds,
mucous membranes, and
conjunctiva.
Pallor in dark-skinned people is seen as an ashen gray or yellow tinge.
Inspecting skin for vascularity and lesions
The skin is inspected for vascularity, bleeding, or bruising;
these signs might relate to a cardiovascular,
hematologic, or
liver dysfunction.
Ecchymosisis
a collection of blood in the subcutaneous tissues, causing purplish discoloration.
Petechiae.
are small hemorrhagic spots caused by capillary bleeding.
If they are present, assess their location,
color, and
size.
Skin Lesions are
areas of diseased or injured tissue such as:
bruises, scratches, cuts, burns, insect bites, and wounds(breaks in the continuity of the skin).
Assess lesions and wounds for size, shape, depth, location,and
presence of drainage or odor.
Assess Lesions by ABC's
A- asymmetry
B- border
C- color
D- diameter
Skin Lesions are categorized as:
primary or secondary.
Primary lesions are
those that may arise from previously normal skin.
Secondary Lesions result from
changes in primary lesions.
Turgor is
the fullness or elasticity of the skin. It is usually assessed on the sternum or under the clavicle by lifting a fold of skin with the thumb and first finger.
Skin turgor is normal when the fold returns to its usual shape when released.
When the patient is dehydrated, the skin’s elasticity is decreased,and the skin fold returns slowly. However, this may be a normal finding in older patients
Edema is
(excess fluid in the tissues). Edema is characterized by swelling, with taut and shiny skin over the edematous area.
Difficulty in lifting a skin fold may indicate edema.
Edema may be the result of overhydration,
heart failure,
kidney failure,
trauma,or
peripheral vascular disease.
Pitting Edema
when the area of edema is palpated with the fingers, an indentation (measured in mm for depth of the indentation) remains after the pressure is released;
Edema may be graded as
0 (none),
+1 (trace, 2 mm),
+2 (moderate, 4 mm),
+3(deep, 6 mm), or
+4 (very deep, 8 mm).
The nails are inspected for:
shape,
angle,
texture, and
color.
The nails should be somewhat convex and should follow the natural curve of the finger. The angle between the nail and its base should be about 160 degrees. The nails should be smooth, and the nail base, when palpated, should
be firm and nontender.
Abnormal nail findings include:
indentations called Beau’s lines (from acute illness),
infection, pain-less separation of the nail plate from the nailbed (onycholysis) due to infection or trauma, increased brittleness or thickness and angulation (from anemia or iron deficiency anemia), and clubbing (from long-term lack of oxygenation).
Assessment of the head and neck includes:
the skull,
face,
eyes
,ears,
nose and
sinuses,
mouth and
pharynx,
trachea,
thyroid gland,
and lymph nodes.
Assess the structures of the head and neck with the patient in a
sitting position.
Inspect and palpate the head for size and shape.
The parts of the head and face should be in proportion to each other and symmetric.
Inspect mouth and mucous membranes,
inspect teeth and /or dentures,
inspect pharnyx with tongue depressor and penlight.
inspect tongue color and texture.
Inspecting the Eyes
The structures and functions of the eyes are assessed by using a penlight, an ophthalmoscope, and an eyechart.
Inspection is the primary assessment technique used.
Assessment includes the:
external and internal eye structures,
presence of discharge
visual acuity,
extraocular movements, and peripheral vision.
Ptosis
Abnormal drooping of the upper eyelids which may be attributable to damage to the:
oculomotor nerve,
myasthenia gravis, or
a congenital disorder.
Entropion
inward turning of the lower eyelid and lashes
Ectropion
outward turning of the lower eyelid and lashes
Miosis
pupil constriction can be caused by certain drugs.
Mydriasis
pupil dilation
can be caused by Injury to the eye, glau-coma, and certain medications.
Neurologically Assess the pupils for:
reaction to light,
accommodation and
convergence
Neurologically Assess the pupils
PERRLA
abbreviation for:
pupils equal,
round,
react to light,
accommodation.
While performing an assessment of the eyes, one evaluates the size and shape of the pupils,
their reaction to light, and
their ability to accommodate.
Neurologically Assess the pupils
Testing Pupillary Reaction
•Ask the patient to look straight ahead at an object.
•Bring the penlight from the side of the patient’s face and briefly shine the light on the pupil.
•Observe the pupil’s reaction; it normally rapidly constricts (direct response)
.•Repeat the procedure and observe the other eye; it too normally will constrict (consensual reflex).
•Repeat the procedure with the other eye.
Neurologically Assess the pupils
Testing for Accommodation
•Hold the forefinger, a pencil, or other straight object about 10 to 15 cm (4"to 6") from the bridge of the patient’s nose.
•Ask the patient to first look at the object, then at a distant object, then back to the object being held. The pupil normally constricts when looking at a near object and dilates when looking at a distant object.
Neurologically Assess the pupils
Testing for Convergence
Move your finger toward the patient’s nose to assess convergence. The patient’s eyes should normally converge (assume a cross-eyed appearance).
Neuro Assessment of Motor Functions
tests for equality in hand and foot strength.
muscle tone assessed by gait, coordination, balance.
Neuro Assessment
Reflexes
blink-using a cotton ball near eyes
gag reflex
swallow reflex
Babinski-plantar response-toes bend or curl in an adult/ fanning of toes indicates opposite side brain damage.
fanning of toes normal for an infant.
Deep tendon Reflex
Grading of Reflexes on a 0 to 4+Scale
4+ = Very brisk, hyperactive; often indicative of disease; often associated with clonus (rhythmic oscillations between flexion and extension)
3+ = Brisker than average; possibly but not necessarily indicative of disease2+ = Average; normal
1+ = Somewhat diminished; low normal
0 = No response
Clonus
a tremor.
Testing Sensory Perception
Pain - a sternal rub is used
Temperature- heat and cold
Touch- -eyes closed
Positioning-
Neurologic assessment includes
cerebral function, cranial nerve function, cerebellar function, motor and sensory function, and reflexes.
Mental status assessment includes:
level of awareness,
level of consciousness,
behavior and appearance, memory,
abstract reasoning, and language. On initial contact, begin to evaluate the patient’s orientation to person, place, and time,as well as cognitive abilities and affect (whether the patient knows who he or she is, where he or she is, and the day or month or year). Observe the patient’s appearance,
general behavior,
ability to speak clearly, and respond to questions.
Note any variation in responses.
Assess the patients overall appearance. The patient should have a clean, neat appearance with erect posture; should be oriented to person, place, and time; should have memory recall (both short-term and long-term memory); and should be able to demonstrate coherent and logical thought processes.
The Glasgow Coma Scale is:
a standardized assessment tool that assesses level of consciousness.
Three parameters are evaluated: eye opening,
motor response,
and verbal response.
Scores are given in each category, and a total score is recorded, with higher scores indicating a more normal level of functioning.
A score of 7 or less defines coma.
Assessing Awareness
Assess awareness by evaluating orientation to time, place,and person.
The following questions may be used:
•Time:What is today’s date? What day of the week is it?What season of the year is this? What was the last holiday?
•Place:Where are you now? What is the name of this city? What state are we in?
•Person:What is your name? How old are you? Who came to visit you this morning?
Level of consciousness is described as follows:
:•Awake and alert: fully awake; oriented to person, place,and time; responds to all stimuli, including verbal commands
•Lethargic: appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentles haking and saying patient’s name
•Stuporous: unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse;can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements
•Comatose: cannot be aroused, even with use of painful stimuli; may have some reflex activity (such as gag reflex); if no reflexes present, is in a deep coma.
Ear Assessment
tests auditory acuity
presence of external lesions
presence of discharge
palpate external structures for tenderness.
Ear Assessment
Weber Test
The Weber test is used to assess for bone conduction of sound - the result of a problem with the transmission of sound waves through the outer and middle ear. tuning fork is placed in the middle of the forehead.
Ear Assessment
Rinne test
The Rinne test is used to compare bone and air conduction of sound and test nerve function. Tuning fork is placed behind ear.
Nose Inspection
Assessment of the nose involves examining the externalnose, the nares, and the turbinates.
Assess the nose for patency by occluding one nostril at atime and asking the patient to inhale and exhale.
Examine the mucous membranes for colorand the presence of lesions, exudate, or growths. Also,inspect the nasal septum for intactness and deviation.
The frontal and maxillary sinuses, located in the frontal and maxillary bones, respectively, are palpated for pain and edema.
Hair Assessment
check amount
texture
distribution
Neck Assessment
inspect for:
symmetry
ROM:
chin-chest,
flrxion and extension, hyperextension
Palpate trachea and thyroid
test swallow reflex.
Chest Inspection
shape,
symmetry
rate and rhythm of respirations
palpate for tenderness.
Anteroposterior Diameter of Chest
width should be double the diameter(sternum to spinal column)
Check for Barrel Chestedness.
Assess Lung by Auscultation
patient breathes through mouth while sitting up.
Auscultate at intercostal spaces anteriorlally and posteriorally using the diaphram end of stethoscope.
18 landmarks posteriorally & 10 landmarks anteriorally.
Listen for the duration,
pitch, and
intensity of the sounds.
Lung Sounds
Bronchial sounds
heard over the trachea are high-pitched, harsh sounds, with expiration being longer than inspiration.
Lung Sounds
Bronchovesicular sounds
are heard over the mainstem bronchus and are moderate “blowing” sounds, with inspiration equal to expiration.
Lung Sounds
Vesicular breath sounds
are soft, low-pitched sounds, heard best over the base of the lungs during inspiration, which is longer than expiration.
Lung Sounds
Adventitious breath sounds
are not normally heard in the lungs.
Stertorous breathing is
a general term used to refer to noisy,strenuous respirations.
Stridor is
a harsh, high-pitched sound heard on inspiration when there is a narrowing of the upper airway, such as the larynx or trachea.
Infants or young children with croup often manifest stridor when breathing.(whooping cough)
Crackles are
fine to coarse crackling sounds made as air moves through wet secretions;
they are most often heard on inspiration.
Crackles are described as “fine” when they are made by air passing through moisture in small air passages and alveoli and
as “coarse” when they are made by air passing through moisture in the bronchioles, bronchi, and trachea.
Rhonchi.
Coarse crackles that can also be during expiration over bronchi.
Wheezes are
continuous sounds that originate in small air passages that are narrowed by secretions, swelling, or tumors. They may be inspiratory or expiratory and are high-pitched sounds.
Pleural friction rub is
a grating sound caused by an inflamed pleura rubbing against the chest wall.
f a productive cough occurs during assessment of the thorax and lungs
the sputum should be assessed for color,consistency, and amount.
Palpating the posterior thorax excursion.
The examiner’s hands are placed symmetrically on the patient’s back with the fingers at the level of T9 or T10.
As the patient inhales, the examiner’s hands should move apart symmetrically.
Assessing the Heart
The techniques used for cardiovascular assessment are inspection, palpation, and auscultation.
Necessary equipment includes a stethoscope with a bell and diaphragm and a sphygmomanometer.
The patient may be in a sitting position or in a supine position with the head raised about 30 degrees
Precordium
The portion of the body over the heart and lower thorax, encompassing the aortic, pulmonic, tricuspid, and apical areas, and Erb’s point.
Apical impulse
located at about the fourth or fifth intercostal space at the left midclavicular line.
Auscultation of the heart is used to:
determine the heart sounds caused by closure of the heart valves. Ask the patient to breathe normally. Use systematic auscultation, beginning at the aortic area,
moving to the pulmonic area,
then to Erb’s point,
then to the tricuspid area, and finally to the mitral area
Use the diaphragm of the stethoscope first to listen to high-pitched sounds. Then use the bell to listen to low-pitched sounds. Focus on the overall rate and rhythm of the heart and the normal heart sounds
Assessing the Abdominal Cavity
The sequence of techniques used to assess theabdomen is inspection,
auscultation,
percussion, and
palpation.
Percussion and palpation are done after auscultation because they stimulate bowel sounds. Ask the patient to breathe slowly and deeply through the mouth during the examination to promote relaxation.
Ask the patient to empty the bladder.
Position the patient in the supine position with the head slightly elevated and arms at the sides. Place small pillows under the head and knees for comfort. Make sure that the patient is warm and comfortable to help prevent contraction of the abdominal muscles, which makes palpation difficult.
the Abdomen can be divided into four quadrants:
right upper,
right lower,
left upper, and
left lower
The abdominal cavity contains the:
stomach,
the small intestine,
the large intestine,
the liver,
the gallbladder,
the pancreas,
the spleen, the kidneys,
the urinary bladder and
also contains the female reproductive organs.
Abdominal assessments are also used to assess:
the return of bowel sounds (e.g., after surgery) and retention of urine in the urinary bladder.
bruits are
abnormal sounds heard over a blood vessel as blood passes an obstruction.
Using the bell of the stethoscope, auscultate over the abdominal aorta, femoral arteries, and iliac arteries.
Percussing the abdomen
Percuss the abdomen in all four quadranst in a systematic, clockwise manner to identify fluid, masses, or air.
Note the distribution of sounds. Normally, tympany, the dominant percussion tone, is heard over the abdomen while dullness is heard over the liver and a full bladder. Abnormal findings include decreased tympany and increased dullness,possibly caused by fluid or a mass.
PMI
Point of Maximum Impulse (PMI) related to contraction at the apex of the underlying left ventricle