1. Health Assessment
Chapter 25

2. 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.

3. 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

4. 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.

5. 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.

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

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

8. 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?

9. 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.

10. 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)

11. 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)

12. 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.

13. 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.

14. 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

15. 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

16. 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)

17. 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)

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

19. 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 how many L/min
Heart sounds (S1 and S2 noted)

20. 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

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

22. 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

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

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

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

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

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