Health Assessment Chapter 25

Health Assessment Integral component of nursing care and is the basis of the nursing process. Used to plan, implement, and evaluate teaching and care in order to promote an optimal level of health through interventions to prevent illness, restore health, and facilitate coping with disabilities or death. Two components: Health History and Physical Assessment.

Health History Biographical data Chief complaint – “Tell me why you are here today.” History of present illness Past medical history Family history Lifestyle Physical Assessment

Types of Assessment Comprehensive – entering healthcare setting. Ongoing partial – conducted at regular intervals (shift assessment). Focused – to assess a specific problem. Emergency – rapidly focused to determine potentially fatal situations.

Health Assessment Prepare the Patient Explain assessment Conduct in private area Prepare the environment Cultural Sensitivity Health History Guidelines, see Focused Assessment Guide 25-1, pg 563.

Equipment Stethoscope and Sphgmomanometer Ophthalmoscope Otoscope Snellen Chart Nasal Speculum Vaginal Speculum Tuning Fork Percussion Hammer

Positioning Standing Sitting Supine Dorsal recumbent Sims’ Prone Lithotomy Knee-chest

Techniques of Physical Assessment Inspection – observations of size, color, shape, position, and symmetry. May be combined with palpation, with inspection preceding palpation. Palpation – sense of touch Assess temp, turgor, texture, moisture, vibrations, and shape. Dorsum (back) of hand and fingers for gross measure of temp. Palmar (front) of fingers and finger pads to assess texture, shape, fluid, size, consistency, and pulsation. Vibration best with palm of hand. Nurse’s hands warm and fingernails short Any area of tenderness palpated last. WHY?

Techniques of Physical Assessment Percussion – the act of striking one object against another to produce sound. Used to assess location, shape, size, and density of tissues. Both hands used to produce sound waves Nondominant hand is placed directly on the area to be percussed with the fingers slightly separated and the middle finger placed firmly on the body surface. The dominant hand provides the striking force, initiated by a sharp downward wrist movement with the forearm stationary and the wrist relaxed. The tip of the middle finger of the dominant hand strikes the middle finger of the opposing hand.

Techniques of Physical Assessment Auscultation – the act of listening with a stethoscope to sounds produced within the body. Stethoscope diaphragm or bell against body part being assessed. Four characteristics Pitch (high or low) Loudness (soft to loud) Quality (gurgling or swishing Duration (short, medium, or long)

Components of the Health Assessment General Survey Health History Physical Assessment Neurologic (may be done in general survey) Vital Signs Integument Head and Neck Thorax/lungs/heart Breasts and axilla Abdomen Peripheral vascular Genitourinary Musculoskeletal IV site Misc. (drains or dressings)

General Survey Assess appearance, hygiene, posture, gait, thought processes, and speech patterns. EXAMPLE: Mr. E awake, alert, and oriented to person, place, and time. Sitting up in bed, well groomed, facial expressions appropriate, speech clear and appropriate.

Health History Age, living arrangements or marital status, history of education or employment, any Rx and/or OTC medications being taken and what for if known, alcohol consumption, tobacco use, children, immunizations (include flu shots, etch.). History: Diagnosed with? Being treated for? Include Surgical History (type of surgery and year performed). Family History: Family members include parents, grandparents (maternal and paternal), and siblings.

Neurologic Level of consciousness, orientation, speech, follows commands, responds appropriately, pupil size, shape and reactivity. (May duplicate some of general survey – just document once). Lethargic – drowsy or asleep most of time, but makes sponteneous movements, arousable Stuporous – unconscious most of the time, no spont movement, hard to arouse, responds to painful stimuli Comatose – cannot be aroused, even with painful stimuli; may have some reflex activity (gag), if not deep coma

Vital Signs BP (lying, sitting, standing). Temp (oral, axillary, tympanic). Pulse (radial and/or apical, Regular or Irregular, Telemetry #, Rhythm, Pedal Pulse). Respirations (regular, irregular, shallow, labored, guarding). Pain (rated on scale 0-10, and location). Height/Weight

Integument Skin turgor (tenting, < 3 sec, > 3 sec) Mucous membranes (moist, dry, pink, pale, yellow) Skin (warm, cool, dry, moist, smooth, rough, lesions (location) Skin Color (pink, appropriate for race, ashen, dusky, jaundiced) Scars (location and what from)

Skin Color Assessment Erythema (redness) Cyanosis (bluish, grayish) Jaundice (yellow) Pallor (pale) Ecchymosis (purplish) Petechiae (small hemorrhagic spots) Turgor (fullness or elasticity of skin – assess on sternum or under clavicle) Edema (excess fluid in tissues)

Head and Neck Contacts, Glasses Dentition (dentures or teeth) Hearing (any aids, responds to conversation appropriately at 2 ft away) Ears (symmetric, canals appearance)

Thorax, Lungs, Heart Thorax appearance, equal or unequal expansion. Lung sounds (clear, rales, rhonchi, wheeze, rub, decreased) note where these sounds are heard (right or left, upper, lower, middle) Cough (productive, nonproductive, characteristics O2 (room air, NC or Mask @ how many L/min Heart sounds (S1 and S2 noted)

Lung Sounds Wheeze Rhonchi Crackles Friction Rub Musical or squeaking, high-pitched and continuous sounds auscultated during inspiration and expiration, occurs in small air passages Rhonchi Sonorous or coarse, low-pitched and continuous sounds, auscultated during inspiration or expiration, occurs in large air passages (coughing may clear the sound) Crackles Bubbling, crackling, popping, low-to-high-pitched,discontinuous sounds, auscultated during inspiration, occurs in small air passages, alveoli, bronchioles, bronchi, and trachea Friction Rub Rubbilng or grating, loudest over lower lateral anterior surface, auscutated during inspiration and expiration

Breasts and Axilla Color Appearance (any dimpling or retraction) Areolae and Nipples (color, any crusting or drainage) Last mammogram and/or next scheduled

Abdomen Flat, rounded, distended Bowel Sounds (hypo, hyper, heard in all 4 quadrants) Umbilicus (midline?) Any pain upon palpation NGT: size, nare, suction, fluid PEG: type feeding, placement checked, residual BM: last, characteristics (is this a normal pattern for them). Continent or Incontinent

Peripheral vascular Pulses (equal or not in both arms or legs) Any edema present Presence of any varicose veins

Genitourinary Continent or Incontinent Foley (size) Urine (color, odor, characteristics)

Musculoskeletal Full ROM (moves all, limited, paralysis (where) Contractures Amputation Splint Prosthesis Muscle strength (equal or stronger on dominant side (R or L)

IV site Location Size Type (continuous, heplock) Appearance (redness, edema) IVF (type, rate, expiration date)

Miscellaneous Drains (location, type, drainage) Dressings (location, size, drainage)