HEALTH ASSESSMENT

Assessing a client's health is a major component of

nursing care and has 2 aspects:
1. Nursing health history
2. Physical examination
 A physical examination can be:
1. Complete assessment (when admitted to a
hospital)
2. Examination of a body system
3. Examination of a body area
 Physical Health Assessment
•A complete health assessment can be conducted at
the head and proceeding in a systematic manner
(head-to-toe assessment)
•It should be conducted in a systematic and efficient
manner that results in the fewest position changes
Purpose of the physical examination:
•To obtain data about the client's functional abilities
•To supplement, confirm, or refute data obtain in the
nursing history
•To obtain data that will help establish nursing
diagnoses and plans of care
•To evaluate physiological outcomes of health care
and thus the progress of a client's health problem
•To make clinical judgments about client's health
status
•To identify areas for health promotion and disease
prevention
 Preparing the Client
•Client can be assured during physical examination
by explanations at each step
•Instruct that all information gathered and
documented during assessment is kept confidential
•It is important to determine in advance any
positions that are contraindicated for a particular
patient
•The nurse assist the client as needed to undress
and put on a gown
•Clients should empty their bladders before examination
helps them feel relaxed
facilitates palpation of the abdomen and pubic area
when U/A is required: urine should be collected in a
sterile container
!TN:
The sequence of the assessment differs with children
and adults.
 Preparing the Environment
•The environment needs
to be well-lighted
•Equipment should be
organized for efficient
use
•The room should be
warm enough to be
comfortable for the
client
•Providing privacy is
important
 Health Assessment of the Adult
•Be aware of normal physiological changes that
occur with aging.
•Be aware of stiffness of muscles and joints from
aging or history of orthopedic surgery.
may need modification of the usual positioning
•Expose only areas of the body to be examined in
order toavoid chilling.
•Permit ample time for the client to answer your
questions and assume and assume the required
positions.
•Be awareof cultural differences. The client may want a
family member present during disrobing.
•Arrange for an interpreter if the client's language differs
from that of the nurse.
•Ask how they wish to be addressed, such as “Mrs.” or
“Miss”.
•Adapt assessment techniques to any sensory
impairment
•make sure eyeglasses or hearing aids are nearby.
•If clients are older or frail, it is wise to conduct the
assessment in several segments in order to not overtire
them.
 Positioning
•The client's physical condition, energy level, and
age should be taken into consideration
•Some positions are embarassing and
uncomfortable
therefore should not be maintained for long
Dorsal recumbent
back lying with knees
flexed and hips
externally rotated
small pillow under the
head
soles of feet on the
surface
•For examination of:
✔ female genitalia
✔ rectum
✔ female reproductive
tract
•May be contraindicated for clients who have
cardiopulmonary problems
Supine (horizontal
recumbent)
back-lying with with legs
extended
with or without pillow
under the head
•Used for assessing:
✔ head, neck, axillae,
anterior thorax, lungs,
breasts, heart, abdomen,
extremities, peripheral
pulses
•Tolerated poorly by clients with cardiovascular and
respiratory problems
Sitting
a seated position
back unsupported
legs hanging freely
•Used for assessing:
✔ head, neck, posterior
and anteriro thorax,
lungs breasts, axillae,
heart, vital signs, upper
and lower extremities,
reflexes
•Older adults and weak
clients may require
support
Lithotomy
back-lying position with
feet supported in
stirrups
the hips should be in
line with edge of the
tabe
•Used to assess:
✔ female genitals, rectum,
and female reproductive
tract
•May be uncomfortable
and tiring for older
adults and often
embrassing
Sims'
side-lying with
lowermost arm behind
the body
uppermost leg flexed
at hip and knee
upper arm flexed at
shoulder and elbow
•Used to assess:
✔ rectum, vagina
•Difficult for older
adults and people with
limited joint movement
Prone
lies on the abdomen with
head turned to the side
with or without a small
pillow
•Used to assess:
✔ posterior thorax, hip joint
movement
•Often not tolerated by
older adults and people
with cardiovascular and
respiratory problems
 Draping
•Drapes should be
arranged so that the
area to be assessed is
exposed and other body
areas are covered
•Drapes provide not only
a degree of privacy but
also warmth
 Equipment and Supplies Used for a Health
Examination
Flashlight or penlight
•Used to:
✔ assist viewing of the
pharynx
✔ dtermine the reactions
of the pupils of the eye
Opthalmoscope
•A lighted instrument to
visualize the interior of
the eye
Otoscope
•A lighted instrument to
visualize the eardrum and
external auditory canal
a nasal speculum may be
attached to the otoscope
to inspect the nasal
cavities
Percussion or reflex
hammer
•An instrument with rubber
head to test reflexes
Tuning fork
•A two-pronged metal
instrument used to test
hearing acuity and
vibratory sense
Cotton applicator
•Used to obtain specimens
Gloves
•To protect the nurse
Tongue blade
(depressors)
•To depress the tongue
during assessment of the
mouth and pharynx
 Methods of Examining
Inspection
•It the visualmexamination, which is assessing by
using the sense of sight
deliberate, purposeful, and systematic
can be with the naked eye or lighted instrument
(otoscope and opthalmoscope)
•Olfactory and auditory cues are also noted
 •Inspection is used to assess:
✔ moisture
✔ color
✔ texture of body surfaces
✔ shape
✔ position
✔ size
✔ symmetry of the body
•Lighting must be
sufficient, either natural or
artificial
•When using auditory
senses, a quiet
environment is important
•Inspection can be
combined with other
assessment techniques
Palpation
•The examination of the
body using the sense of
touch
•Pads of the fingers are
used
highly sensitive to tactile
discrimination due to rich
concentration of nerve
endings
 •Palpation is used to determine:
a) texture (hair)
b) temperature (skin)
c) vibration (joints)
d) position, size, consistency and mobility of organs or
masses
e) distention (urinary bladder)
f) pulsation
g) tendness or pain
Light (Superficial)
Palpation
•The nurse extends the
dominant hand's
fingers parallel to the
skin surfface and
pressess while moving
the hand in circle
•The skin is slightly
depressed
•Should always precede deep palpation
heavy pressure on the fingertips can dull the sense of
touch
•If it is necesssary to determine the details of the
mass:
the nurse must press lightly several times rather than
holding the pressure
Deep Palpation
•It is done with two hands
(bimanual) or one hand
•In deep bimanual
palpation:
✔ the nurse extends the
dominant hand
✔ then places the
fingerpads of the
non-dominant hand on the
dorsal surface of the
distal interphalangeal
joint of the middle 3
fingers of the dominant
hand
•The top hand applies
pressure while the lower
hand remains relaxed to
percieve the tactile
sensations
•For deep palpation using
one hand:
the fingerpads of the
dominnant hand press
over the area to be
palpated
often the other hand is
used to support from
below
!TN:
•Deep palpation is usually not done during a routine
examination and requires significant practitioner skill.
•It is performed with extreme caution because pressure
can damage internal orans.
•It is usually NOT indicated in clients who have acute
abdominal pain or pain that is not yet diagnosed
To test skin temperature:
•It is best to use the dorsum
of the hand and fingers
the examiner's skin is
thinnest
To test for vibration:
•Used the palmar surface of
the hand
General Guidelines for Palpation:
•The nurse's hands should be clean and warm, and the
fingernails short.
•Areas of tenderness should be palpated last.
•Deep palpation should be done after superficial
palpation.
•The effectiveness of palpation depends largely on the
client's relaxation.
•A client can be relaxed by:
gowned or draped appropriatley
positioned comfortably
ensuring that the nurse's hands are before beginning
•During palpation the nurse should be senstive to
client's verbal and facial expression indicating
discomfort
Percussion
•The act of striking the body
surface to elicit sounds
that can be heard or
vibrations that can be felt
•It can be direct or indirect
percussion
Direct Percussion
• The nurse strikes the area
to be percussed directly
with the pads of two,
three, or four finger
• Or with the pad of the
middle finger
• The strikes are rapid, and
movement is from wrist
• Generally not used to
percuss the thorax but
useful in percussing adult
sinuses
Indirect Percussion
•The striking of the object
held against the body area
to be examined
•The middle finger of the
non-dominant hand
(pleximeter) is placed
firmly on the client's skin
only the distal phalanx and
joint of this finger should
be in contact with the skin
•Using the tip of the of the
flexed middle finger of
the other hand (plexor),
the nurse strikes the
pleximeter
•The striking motion
comes from the wrist; the
forearm remain
stationary
•The angle between the
plexor and pleximeter
should be 90º
•Blows should be firm,
rapid, and short to obtain
a clear sound
 •Percussion is used to determine the size and shape of
the internal organs by establishing their borders
•It indicates whether tissue is fluid, air filled, or solid
•It elicits 5 types of sounds:
1) flatness
2) dullness
3) resonance
4) hyperresonance
5) tympany
Flatness
•An extremely dull sound produced by very dense
such as muscle or bone
Dullness
•A thudlike sound produced by dense tissue such as
the liver, spleen, or heart
Reasonance
•A hollow sound such as that produced by lungs
filled with air
Hyperreasonance
•Not produced in the normal
body
•Described as booming and
can be heard over an
emphysematous lung
Tympany
•A musical or drumlike
sound produced from
air-filled stomach
•Flatness the most dense;
tympany the least dense
tissue
Auscultation
•The process of listening to sounds produced within
the body
Direct Auscultation
•Performed using unaided ear
listening to a respiratory wheeze or the grating of a
moving joint
Indirect Auscultation
•Performed using a
stethoscope, which
transmits sounds to
the nurses ears.
•A stethoscope is used
primarily to listen to
sounds from within the
body
•The diaphragm (flat)
best transmit
high-pitched sounds
bronchial sounds
•The bell best transmits
low-pitched sounds
heart sounds
 •The amplifier of the stethoscope is placed firmly but
lightly against the client's skin
if a client has escessive hair, it may be necessary to
dampen the hairs with moist cloth
•Auscultated sounds are described according to:
✔ pitch
✔ intensity
✔ duration
✔ quality
Pitch
•The frequency of the vibration (number of vibrations
per second)
•Low-pitched sounds (heart sounds) have fewer
vibrations per second than high-pitched sounds
Intensity
•Refers to the loudness or softness of a sound
loud sounds: bronchial sounds over the trachea
soft sounds: normal breath sounds over the lungs
Duration
•Is the length of a sound (short or long)
Quality
• A subjective description of a sound
✔ whistling
✔ gurgling
✔ snapping