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 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.

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)

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

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.

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

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, purposeful, observations in a systematic manner Nurse use the physical senses: visualizing, 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 Consists of 11 lines of different sized letters. Scores range from 20/20 to 20/200.

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

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

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 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

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.)

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

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

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

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.

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

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

                                                                                                                                                                                                                                                                                                                                                                                   cellulites cellulitis

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

Bacteria Conjunctivitis

Acute glacoma Acute Glaucoma

Normal ear, reflection of light Healthy Ear

Acute otitis media Acute otitis media

Chronic otitis media, stapes extruding

Cerumen in ear Cerumen in ear

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.

Hematoma Hematoma

Polyp Polyp

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).

tonsillitis Tonsillitis

Hairy tongue Hairy tongue

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

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 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

PULMONARY Use to show where

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

CARDIOVASCULAR

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

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

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

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

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

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

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.

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