1. Health Assessment Chapter 25

2. 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

3. Health Assessment Health History Physical Assessment
Two components of the health assessment
Health History
Physical Assessment
Nurses use communication skills and interviewing techniques during the health history to gather data.
Physical Assessment – may focus on one specific body system or health to toe or system by system assessment.
In performing a health assessment the nurse uses cognitive skills (the nurse has basic knowledge to individualize the assessments (for example treatment a pregnant women, who be different than care for an Alzheimer's pt.)
_Technical skills- ability to use the equipment to assess and document health status.
Interpersonal skills strong people skills, ability to communicate and interact with people
Confidence in your own abilities.
Ethical and legal skills- commitment to safety and quality
Ability to document health findings
Knowledge of special regulations and legalization dealing with nursing responsibilities.

4. What happens during a health assessment between a patient and nurse?
Establish the nurse-patient relationship
Gather data-physiological, psychological,cognitive, sociocultural, developmental, spiritual
Identify patient strengths
Identify actual and potential health problems
Establish a base for the nursing process (Assessment)

5. General Guidelines for Physical Assessment
Instrumentation
Positioning
Draping
Preparation of the environment
Patient preparation
Techniques of physical assessment

6. Positioning Prone-Pt. Lies on abdomen
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
Sitting-allows the visualization of the upper body and facilitates full lung expansion. Take VS and assess the head and neck, posterior and anterior thorax and lungs, breast, heart and upper extremities.
Supine- This position allow relaxation of abd.muscles and can be used to assess the head and neck, anterior thorax and lungs breasts, heart, abdomen, extremities, and peripheral pulses.
Dorsal recumbent- used to exam head and neck anterior thorax and lungs breast heart extremities and peripheral pulses.
Sims Used to assess the rectum or vagina
Lithotomy used to exam female rectum and genitalia.
Knee – chest- rectal area
Standing- assess posture, gait, and balance.

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

8. 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.

9. Inspection Deliberate, purposeful, observations in a systematic manner
Nurse use the physical senses: visualizing, hearing, and smelling

10. 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

11. Instrumentation or Equipment used for vision screening
Snellen chart- used to check eye sight
Consists of 11 lines of different sized letters. Scores range from 20/20 to 20/200.

12. 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
Vibrations
Shape
Use the palmer (front side) of the hand

13. Percussion-the act of striking one object against another to produce a sound
Percussion tones are used to assess location, shape, size and density of tissue
Percussion Tones
Flat
Dull
Resonance
Hyper resonance
Tympany

14. 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)

15. General Survey Gather information regarding 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)
Gather information regarding
Patient's appearance, behavior
Measuring vitals signs
Height, and weight
General appearance
Gender and race
Body build, posture and gait

16. Vital Signs, Height and Weight
Take Vital signs (VS) and determine normal or abnormal -document
Height and weight- document
(Check the height and weight table to determine if a patient is under, normal or over weight.)

17. Physical Assessment Head to Neck
General survey
Height and weight
Vital Signs
Neck
Skin
Lymph nodes
Muscles
Thyroid
Trachea
Carotid arteries
Neck veins
Head
Skin
Face, skull, scalp, hair
Eyes
Nose and sinuses
Mouth and or pharynx
Cranial nerves

18. Integument structures
Skin
Nails
Hair
Scalp
Obtain history of rashes, lesions, changes of color or itching
History of bruising or bleeding
Exposure to sun
Note presence of wounds, abrasions
Changes in mole size, shape or color

19. SKIN Inspect for color, vascularity, lesions and body odors
Color-pinkish white to various shades of brown.
NAILS- NOTE COLOR, SHAPE OF NAIL
NORMAL 160 DEGREE, SPOON, CLUBBING 180 DEGREES OR GREATER

20. Redness (erythema, flushing Facial area
Skin Color variations
Assessment areas
Possible causes
Redness (erythema, flushing
Facial area
Blushing, ETOH intake, fever, injury or infection
Bluish (cyanosis)
Exposed areas, ears,lips, inside of mouth, hands feet, nail beds
Cold environment, cardiac or respiratory
Yellowish (jaundice)
Overall skin areas, mucus membranes, sclera
Liver disease (increased bilirubin)
Vitiligo
Whitish patchy areas
De-pigmentation (autoimmune)
Tanned or brown
Sun-exposed
Melanin production Pregnancy brown spots?
Pediatric
Newborns may be jaundiced and have milia (white heads)
Newborns are covered with fine downy hair (lanugo for first 2 weeks of life)
Geriatrics- wrinkles, dryness, scaling, decreased turgor. (know the geriatric skin assessment p 466, cherry angioma, senile lentigines, senile keratosis)
Geriatrics – nails thick and yellow.

21. Head and Neck Assessment includes Skull Face Eyes Ears Nose Sinuses
Mouth
Pharynx
Trachea
Thyroid glands
Lymph nodes

22. Skull and face Inspect size and shape Symmetry Face- examine color
Distribution of facial hair
Assess facial nerve and facial muscles-
Symmetry (abnormality may be from trauma or disease effecting bone growth
Testing nerves and muscles of the face: raise eyebrows, tightly close eyes, puff out the cheeks and show their teeth,smile.
Document: any tremors

23.                                                                                                                                                                                                                                                                                                                                                                                   
cellulites
cellulitis

24. Eye and Ears EYE Inspect external structures Pupils and Iris
Internal structures
Vision
Extra ocular movement
Peripheral vision
EAR
Inspect external ear for shape, size, location bilaterally, ear should be smooth
Gently palpate ear for pain, edema, or presence of lesions
Check hearing
Inspect internal ear

25. Bacteria Conjunctivitis

26. Acute glacoma
Acute Glaucoma

27. Normal ear, reflection of light
Healthy Ear

28. Acute otitis media
Acute otitis media

29. Chronic otitis media, stapes extruding

30. Cerumen in ear
Cerumen in ear

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

32. Hematoma
Hematoma

33. Polyp
Polyp

34. MOUTH AND PHARYNX Composed of many structures Equipment needed:
Lips, tongue, teeth, gums hard and soft palate,salivary gland, tonsillary pillars, and tonsils
Equipment needed:
Penlight, tongue blade, 4X4 gauze sponge, and gloves
Lips should be pink, mosit and smooth
Tongue and mucous membranse are normally pink in color, moist, and free of swelling or lesions
IF the patient wears dentures, they are removecd for inspection of gums and roof of mouth.
The orpharyx is examined when tongue is depressed. Uvula is normmally centered and freely movable. Tonsils are small pink and symmetric in size. Theeth should be regualr and freeof caviites and or dental restoration.
Abnormal: pallor cyanosis nor redness and swelling of mucous membranes
Abnormal findings: red tonsils (indication of infections, bleeding gums (may be nutrional deficits infammation or infection, poorly fit dentures, or poor oral hygiene.)
Tongue: coated poor hygiene, irritaiton or smoking
Fissured tongue (from dehydration)
Bright red tongue (iron deficineces, Vit B12, or naicin, hairy tongue (antibiotic use).

35. tonsillitis
Tonsillitis

36. Hairy tongue
Hairy tongue

37. Neck Trachea- note location Lymph nodes Generally not palpable
Midline at the suprasternal notch
Thyroid- thyroid is normally not palpable. Palpate for size shape, symmetry tenderness and presence of any nodules
Lymph nodes
Generally not palpable
If palpated, should be small mobile, smooth non-tender
Abnormal- enlarged, indicate infection, autoimmune, or metastasis of cancer

38. ASSESSMENT Part I

39. 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

40. HEALTH ASSESSMENT Two components of the health assessment
Health History
Physical Assessment

41. 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

42. GENERAL GUIDELINES Instrumentation Positioning Draping
Preparation of the environment
Patient preparation
Assessment techniques

43. 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

44. ASSESSMENT part 2

45. PULMONARY HISTORY INSPECTION PALPATION PERCUSSION AUSCULTATION
BREATH SOUNDS
History: trauma, use of pillows,cp w/breathing, cough w/wo production, allergies, freq. Resp infections
Environmental exposure, beauty salons, black lung, smoking
Family hx of lung disease,
Inspect for symmetry breathing patterns, color, barrel chest, resp even,
Palp for vibrations, fremetis. Posterior, w/ fingers at t-10 or t9. Watch cest move
Percussion, flat over bony areas or thick muscle, tympany hollow over the stomach
Auscultation. Use to hear air flow in the lungs. patient sitting up. Best hear from back. Demonstrate. Assess lobes.
Breath sounds
Bronchial, high pitched over trachea
Bronchiovesicular, bronchus and are moderate blowing insp and exp. Equal
Vesicular soft low pitched best hear over the base of the lungs. Insp longer than exp..
Adventitious stertorous noisiy snoring
Stridor harshs high pitched
Crackles air moving through fluid
Wheezes heard w/o stethescope narrowing of small passages
Friction rub like sandpaper

46. PULMONARY
Use to show where

47. CARDIOVASCULAR History Inspection Palpation Auscultation Heart sounds
Peripheral vascular system
Chest pain , palpitations, dixxiness
Swelling in lower extremeties
Pillow for sleep
Medications
Family history, defects,rheumatic fever, surgery,
HTN
MI, cholesterol, smoking alcohol, birth control pills, HRT,
Foods
Changes in color or temp of extremities
Pain in legs when sleeping blood clots or non healing sores
Inspection: no signs of palpation except at PMI 4-5 intercostal space.
Palpation systematic and covet the precordium area, aortc pulmonic tricuspid and apical areas. No pulsation
Auscultation use diaphram,
Lub-dub lub, s1 best heard at apex pulm aortic valve close squeeze
S2 dub vent asystole closure of tricuspid mitral
S3 lub dub de. Heard with bell at mitral area pt on left side. Abnormal in middle age to lder adults
S4, abnormal in children adults
Murmers. Valve abmormality
Bruits swooshing, best heard over a shunt.
Palpation, pulses scale of 1-4 phlebitis pain heat red, inflam of vein use cap refill don’t use allen or brueger
Inspect color, temp, turger, lesions, edema

48. CARDIOVASCULAR

49. BREAST/AXILLA History Inspection Palpation
Pain in on or both menstrual period
Hx of lumps, swelling redness change insize or dimpling
Discharge
Hx of ca
Use of hormones of contraceptives oral
Exposure to radiation or chemicals
Breast self exam, pregnancy, breast feeding
Inspect for size shape symmetry
Nipples for discharge or crusting, inversions
Palpate abnormal masses use 1st three fingers pads 4 quads upper outer inner and lower outer inner. Smooth, firm, granular
Palpate axilarry area for nodes non papable or tender

50. ABDOMEN History Inspection Auscultation Percussion Palpation
Pain, indigestion, n&v constipation, diarrhea
Appetite food, fluid intake
Hz of gi disorder such as ulcer gb disease, appendicitis
Uti disorders
Abdominal surgery
Medication use including otcs
Trauma
Inspect staie are fine white lines. See frequently in elderly symmetry
Auscultate for sounds. Clicks and gurgles. Move clockwise
Palpate for masses, and hardened areas . Should be soft and non tender

51. GENITALIA Female Male History Inspection
Hx mentration onset last period, character of flow,
Sexual hx, stds
Contraception, pregnancy, pap smears, prior exams smoking, family hx of disease, discharge pain itching
Hx of discharge, std, urinary difficulty, incontinence, erectile dysfunction, occupational exposure to chemicals, radiation, contraceptive use, testicular self exam, digital rectal exam
Usually role of nurse is to assist md w/exam

52. MUSCULOSKELETAL History Inspection Palpation Testing Bones and Joints
Tone
Strength
Bones and Joints
Trauma, arthritis neuro disorder
Pain or swelling in the joints
Pain in bones or muscles
Exercise history
Calcium in diet
Smoking
Alcohol
Hormone replacement therapy
Palpate for tone (condition at rest) and strength (assess by asking to move against resistance. Squeeze hand push with hand or feet should be bilat equal
Atrophy, wasting, flaccid, no tone assess rom
Bones, abnormal palpation, crepitation, grinding of bone on bone at joint.
Changes with age, loss of tone, strength, arthritic changes

53. NEUROLOGICAL History Mental Status Orientation Level of Consciousness
Memory
Abstract Reasoning
Language
History, numbness tingling seizures, h/a dizziness trauma infections stroke,
Changes in senses, loss of eimination control
Smoking
Htn, cvd, med hx exposure to environmental hazards

54. CRAINIAL NERVES Olfactory (I) Optic(II)
Oculmotor (III), Trochlear(IV), Abducens(V)
Trigeminal(VI)
Hypoclosseal (VII)
Facial (VIII)
Acuoustic (IX)
Glossopharyngeal (X)
Vagus (XI)
Accessory (XII)
See notes in lab

55. SENSORY MOTOR FUNCTION
Balance and gait
Coordination
Sensory
Abn. Shufling , wide based loss of balance
Holly, speech impact on coordination
Sensory distal to proximal.. Eval response to pain, touch, vibration, use of needle or pin.

56. REFLEXES Abdominal Babinskis Bicepts Triceps Patellar Achilles Tendon
Abd, light stroke from above to below umbilicus. Muscles contract
Babinskis stroke later aspect from heel to sole
Biceps see book