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Chapter 27 Health Assessment
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Preparing for the Health Assessment
Environment Ensure privacy Quiet, warm room Special needs of the client Surface for placement of equipment Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Preparing for the Health Assessment
Equipment Maintenance Isolation precautions Adequate number of gloves Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Preparing for the Health Assessment
Positioning Ensures accessibility to the body part being assessed. Draping Prevents chilling. Prevents unnecessary exposure. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Conducting the Health and Physical Assessment
Aimed at establishing a data base against which subsequent data can be compared. Comprehensive Assessment (head to toe) Assessment of a body part (focused) Assessment of a body system (focused) Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Conducting the Health and Physical Assessment
Conducted in an aseptic, systematic, and efficient manner. Requires the fewest position changes for the client. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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General Survey Initial Observations Client’s physical appearance
Mood and behavior Speech patterns and voice intonations Signs and symptoms of distress Vital signs Height and weight Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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General Survey Special Considerations Elderly clients Disabled clients
Abused clients Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Measurement of Height and Weight
Height is expressed in inches (in), feet (ft), centimeters (cm), or meters (m). A scale for measuring height is usually attached to a standing weight scale. Infant’s length is measured from vertex (top) of head to soles of feet while infant is lying with knees extended. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Measurement of Height and Weight
Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg). Daily weights should be obtained at the same time of the day, on the same scale, with the client wearing the same type of clothing. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Measurement of Height and Weight
Types of scales available include chair, stretcher, bed, and platform scales. Infants are weighed on platform or cradle scales. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Measurement of Height and Weight
Nursing Considerations Accurate recordings are necessary for drug dosage calculations and evaluation of effectiveness of drug, fluid, and nutritional therapy. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Measurement of Height and Weight
Documentation Height and weight are recorded on the admission assessment form. Daily weights are usually recorded on the vital signs record. Measurements taken at different times or on different scales should be recorded. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Vital Signs The taking of vital signs refers to measurement of the client’s body temperature (T), pulse (P) rate, respiratory (R) rate, and blood pressure (BP). Vital signs are the first step in the physical examination. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Vital Signs Assessment of vital signs provides specific data regarding the client’s current condition. Variations from baseline values may indicate potential problems with the client’s health status. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Vital Signs The sequence for recording vital sign measurements in the nurses’ notes is T-P-R and BP. Vital signs are plotted on graphic forms that facilitate data comparison at a glance. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Thermoregulation The body’s physiological function of heat regulation to maintain a constant internal body temperature Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Physiologic Function Thermoregulation
The heat of the body is measured in units called degrees. The core internal temperature of 98.6 degrees Fahrenheit (F) does not vary more than 1.4 degrees F. Core internal temperature is higher than the skin and external temperature. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Thermoregulation Heat Production Basal Metabolic Rate (BMR)
Vasodilation Vasoconstriction Piloerection Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Thermoregulation Heat Loss Insensible Heat Loss Radiation Conduction
Convection Evaporation Insensible Heat Loss Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Thermoregulation Behavioral Control of Body Temperature
The person makes appropriate environmental adjustments in response to the body’s signaling conditions of either being overheated or too cold. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Respiration Respiration is the act of breathing.
Terms related to respiratory function are: External respiration Internal respiration Inspiration Expiration Vital capacity Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Respiration Major physiological pulmonary functions are: Ventilation
Circulation Diffusion Transport Regulation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Hemodynamic Regulation
The circulatory system transports nutrients to the tissues, removes waste products, and carries hormones from one part of the body to another. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Hemodynamic Regulation
Systemic Circulation Arteries Arterioles Capillaries Veins Venules Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Hemodynamic Regulation
Cardiac Cycle Systole Diastole Stroke Volume Cardiac Output Compensatory Mechanisms Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Hemodynamic Regulation
Pulse The pulse is caused by the stroke volume ejection and distension of the walls of the aorta. The bounding of blood flow in an artery is palpable at various points in the body (pulse points). Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Hemodynamic Regulation
Blood Pressure Measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Blood Pressure Systolic Pressure Diastolic Pressure
Maximum pressure exerted against arterial walls during systole Diastolic Pressure Pressure remaining in the arterial system during diastole Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Hemodynamic Regulation
Hemodynamic regulators for blood pressure control are: Blood volume Cardiac output Peripheral vascular resistance Viscosity Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Factors Influencing Vital Signs
Age Gender Heredity Race Lifestyle Environment Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Factors Influencing Vital Signs
Medications Pain Exercise Anxiety and Stress Postural Changes Diurnal (daily) Variations Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Body Temperature
Temperature Scales Centigrade or Fahrenheit scales are used to measure temperature. Glass or electronic thermometers are used. Temperature Sites Oral Rectal Axillary Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Body Temperature
Alterations in Body Temperature Pyrexia Hyperthermia Heat Exhaustion Heat Stroke Hypothermia Frostbite Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Pulse Sites The most accessible peripheral sites are the radial and carotid sites. The carotid site should always be used to assess the pulse in a cardiac emergency. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Pulse A peripheral pulse is palpated by placing the first two fingers on the pulse point with moderate pressure. A Doppler ultrasound stethoscope is used on superficial pulse points. A stethoscope is used to auscultate the heart’s rate and rhythm. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Pulse Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Pulse A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate. Pulse Characteristics Pulse quality Pulse rate (bradycardia, tachycardia) Pulse rhythm (dysrhythmias) Pulse volume Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Pulse Nursing Considerations
An irregular pulse rate, if not previously documented, should be reported immediately. Clients on certain cardiac medications may need to monitor their pulse rate. Routine exercise lowers resting and activity pulses. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Respirations
Sites Observation of chest wall expansion and bilateral symmetrical movement of the thorax Placement of back of hand next to client’s nose and mouth to feel expired air Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Respirations
Rate is counted by number of breaths taken per minute. Observation of thoracic and abdominal movements includes: Depth, rhythm, and symmetry Costal (thoracic) breathing Diaphragmatic breathing Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Respirations
A stethoscope is used to auscultate breath sounds throughout the respiratory system. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Respirations
Dyspnea, Bradypnea, tachypnea, apnea Hypoventilation Hyperventilation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Respiratory Function
Cyanosis Bluish appearance in the nail beds, lips, and skin Reduced oxygen levels in the arterial blood Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Respiratory Function
Clients with respiratory alterations require additional nursing assessment. Pulse oximetry Apnea monitor Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Respiratory Function
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Blood Pressure
The direct method of measuring blood pressure requires an invasive procedure. The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Blood Pressure
The most common site for indirect measurement is the client’s arm over the brachial artery. Accurate measurement requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Blood Pressure
Korotkoff sounds are five distinct phases of sound heard with a stethoscope during auscultation. The forearm or leg sites can be palpated to obtain a systolic reading when the brachial artery is inaccessible. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Blood Pressure
Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure. Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Blood Pressure
Orthostatic Hypotension (postural hypotension) Sudden drop in systolic pressure when client moves from a lying to a sitting to a standing position Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Assessing Blood Pressure
False Readings Clients who have recently eaten, ambulated, or experienced an emotional upset Improper cuff width Improper technique in deflating cuff Improper positioning of extremity Failure to recognize an auscultatory gap Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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The Physical Examination
Techniques Inspection Palpation Percussion Auscultation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Integumentary System Skin Hair and Scalp Nails
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Skin Assessment Skin assessment provides a noninvasive window to observe the body’s physiological functions. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Skin Assessment Color Lesions Moisture Temperature Texture
Mobility and Turgor Edema Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Integumentary System Hair
The amount and texture of hair vary with age, sex, race and body part. Vellus Terminal hair The scalp should be smooth, clean, intact, and free of lumps or tender areas. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Integumentary System Nails Clubbing Koilonychia (spoon nail)
Beau’s line Paronchia Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Physical Examination Head
Skull and face assessment involves inspection and palpation. The client’s face has its own unique characteristics related to race, state of health, emotions, environment. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Physical Assessment Eyes
Conjunctive and sclera are assessed for color, redness, swelling, exudate, foreign bodies Visual acuity Fundoscopy Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Physical Assessment Ears Nose and Sinuses Auditory screening
Inspection and palpation of external ear Placement, symmetry Otoscopic assessment Nose and Sinuses Inspection and palpation Use of a penlight Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Physical Examination Mouth and Pharynx Breath Lips Tongue
Buccal mucosa Gums and teeth Hard and soft palate Pharynx Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Physical Examination Neck Neck muscles Lymph nodes of head and neck
Thyroid gland Trachea Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Physical Examination Thorax and Lungs
Landmarks for inspection, auscultation, and percussion Anterior and posterior examination Shape and symmetry Thoracic expansion Tactile fremitus Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Thorax and Lungs Auscultation of Normal Breath Sounds Vesicular sounds
Bronchovesicular sounds Bronchial sounds Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Thorax and Lungs. Auscultation of Adventitious Breath Sounds Crackles
Rhonchi Wheezes Pleural friction rub Stridor Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Heart and Vascular System
Landmarks for inspection, palpation, auscultation Heart sounds Palpation for thrills and heaves Abnormal auscultatory findings Murmurs Bruits Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Heart and Vascular System
Blood perfusion of peripheral vessels Peripheral pulses compared bilaterally Skin temperature, color Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Physical Examination Lymphatic System Lymphatic drainage Lymph nodes
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Breasts and Axillae Palpation of four quadrants of breasts
Palpation of supraclavicular, infraclavicular, and axillary nodes Education and encouragement of questions about breast self-examination (BSE) Breast cancer can also occur in males. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Breasts and Axillae Drainage patterns of the left breast.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Abdomen Inspection Contour Symmetry Umbilicus Surface motion Scars
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Abdomen Auscultation All four quadrants in a systematic fashion
Beginning with the RLQ Tympany Dullness Bruits Hyperactive or hypoactive bowel sounds Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Abdominal Quadrants Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Abdomen Light palpation in all four quadrants beginning with the RLQ
Resistance Tenderness Rebound tenderness Organ enlargement Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Female Genitalia and Anus
Cultural Considerations Inspection and Palpation Mons pubis and vulva Labia majora, labia minora Clitoris Urethral meatus and vaginal introitus Perineum and anus Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Male Genitalia, Anus, and Rectum
Testes and male gonads Seminal vesicles and bulbourethral glands Epididymis, vas deferens, ejaculatory ducts Scrotum, penis, spermatic cord Anorectral exam including the prostate Monthly testicular self-examination (TSE) Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Musculoskeletal System
Inspection Palpation Range of Motion (ROM) Bilateral Comparison Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Musculoskeletal System
Muscle Hypertrophy Atrophy Hypertonicity Hypotonicity Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Musculoskeletal System
Joints Arthritis Osteoarthritis Crepitus Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Neurologic System Mental Status Physical appearance and behavior
Communication Level of consciousness Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Mental Status Cognitive Abilities and Mentation Attention Memory
Judgment, insight Spatial perception Calculation Abstraction Thought process and content Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Neurological Assessment
Sensory Assessment Exteroceptive sensations Proprioceptive sensations Cortical sensations Dermatome map Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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Neurological Assessment
Cranial Nerves Assessment Motor Assessment Cerebellar Assessment Reflex Assessment Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
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