Chapter 27: Health Assessment

Health Assessment

The systematic collection, validation, and analysis of patient data to determine health status.

Subjective Data

Information based on patient experiences and perceptions.

Objective Data

Measurable and directly observed information.

Health History

Collection of subjective information about the patient’s health status.

Physical Assessment

Collection of objective data related to changes in body systems.

Comprehensive Assessment

Conducted on admission to establish a health baseline.

Ongoing Partial Assessment

Performed at regular intervals to monitor changes in patient’s condition.

Focused Assessment

Conducted to assess a specific health problem or concern.

Emergency Assessment

Performed in life-threatening situations to identify immediate health needs.

Subjective data example

A patient's report of dizziness.

Nurse's role in assessments

To prepare patients for assessment and facilitate care.

Lifespan Considerations

Tailoring assessment approaches based on patient’s age.

Cultural Considerations

Respecting and acknowledging cultural differences in healthcare.

Biographical Data

Patient demographics such as name, age, and address.

Primary Source of Data

The patient themselves whenever possible.

Temperature

Measured as part of vital signs during health assessment.

Inspection

Systematic observation of physical attributes during assessment.

Palpation

Using touch to assess physical attributes like texture and moisture.

Percussion

Striking one object against another to assess tissue density.

Auscultation

Listening to body sounds using a stethoscope.

General Survey

A comprehensive overview including appearance and vital signs.

BMI

Body mass index used for nutritional assessment.

Erythema

Redness of the skin.

Ecchymosis

Collection of blood under the skin.

Petechiae

Small hemorrhagic spots on the skin.

Cyanosis

Bluish or grayish skin color indicating low oxygen.

Jaundice

Yellowing of the skin, often indicating liver issues.

Palpation technique

Used to assess consistency, shape, and mobility of masses.

Standing Position

Used for assessing posture and balance.

Sitting Position

Allows visualization of the upper body.

Supine Position

Used for abdominal assessments.

Sims Position

Position used to assess the rectum and vagina.

Dorsal Recumbent Position

Used for patients who cannot maintain supine.

Prone Position

Used for assessing the hip joint and posterior thorax.

Health Assessment Equipment

Includes thermometer, sphygmomanometer, and stethoscope.

Palpation of Abdomen

To assess for tenderness and masses.

Abdominal Quadrants

Regions for assessing underlying organs in the abdomen.

Assessment in Older Adults

Recognizes variations such as decreased lung capacity.

Neurologic Assessment

Evaluates cranial nerve function and mental status.

Glasgow Coma Scale (GCS)

Tool to assess consciousness level in patients.

Legal Documentation

Provides a legal record of patient care.

Patient Cooperation

Promoted through building rapport and trust.

Environmental Preparation

Ensures a conducive examination environment.

Functional Health

Ability to perform activities of daily living (ADLs).

Turgor

Skin elasticity, assessed during skin examination.

Edema

Fluid accumulation in tissues, often assessed during assessment.

Respiratory Rates

Monitored through lung auscultation and inspection.

Dizziness as Subjective Data

An example of information derived from patient’s report.

Risk Assessment

Identifies potential health threats based on history.

Accessory Muscles Use

Common in older adults during breathing assessments.

Thorax Inspection

Observing respiratory patterns and chest shape.

Auscultation of Heart

Listening to heart sounds for abnormalities.

Varicosities

Prominent and twisted veins often seen in older adults.

Abdominal Inspection

To observe contour, symmetry, and skin condition.

Height and Weight Measurement

Part of baseline assessments in health evaluation.

Cardiovascular Assessment

Includes inspection, palpation, and auscultation.

Vital Signs Importance

Critical for assessing overall health status.

Assessment Techniques

Include inspection, palpation, percussion, and auscultation.

Assessing Age-Related Variations

Recognizes physiological changes across the lifespan.

Patient Education Importance

Helps in understanding and preparing for assessments.

Evaluation of Muscle Strength

Part of the neurological assessment.

Mental Status Examination

Assesses cognitive abilities and emotional status.

Blood Pressure Measurement

Key vital sign indicative of cardiovascular health.

Cultural Sensitivity

Respect for diverse healthcare beliefs and practices.

Patient Anxiety Reduction

Explain procedures to reduce fear and tension.

Fluids in Tissues

Measured through assessment of edema.

Normal Respiratory Patterns

Evaluated during thoracic and lung assessments.

Physical Assessment Order

Inspection, auscultation, percussion, and palpation in sequence.

Order of Abdominal Assessment Steps

Inspection, auscultation, percussion, then palpation.

Subjective Symptoms Collection

Gathering patient-reported data about health issues.

Physical Examination Preparation

Includes gathering necessary tools and environment setup.

Understanding Normal Variations

Important for differentiating between normal and abnormal.

Nurses Observational Role

Vital for recognizing changes in patient condition.

Continued Assessment Importance

Ongoing assessments help in identifying shifts in health.

Auscultation Skills Development

Critical for identifying heart and lung sounds.

Documentation in Patient Care

Essential for communication and continuity in healthcare.

Assisting with Diagnostic Procedures

Involves preparing both physically and emotionally.

General Appearance Assessment

Includes posture, body build, and hygiene.

Volume Assessment

Assessing edema and hydration status through palpation.

Chronic Illness Impact

Considerable in health history and assessment outcomes.

Effective Communication with Patients

Key for accurate and comprehensive health assessments.

Joint Function Evaluation

Assessed through musculoskeletal range of motion.

Palpation for Tenderness

Critical for understanding abdominal conditions.

Common Skin Abnormalities

Recognized through inspection and palpation.

Emotional State Assessment

Part of the general survey in health evaluation.

Significance of Patient's History

Provides context for current health issues.

Nurse's Responsibility in Consent

Ensuring patient is informed before procedures.

Quality of Auscultation Sounds

Determined during cardiac and lung assessments.

Dehydration Signs

To be assessed through turgor and skin elasticity.

Assessment of Cranial Nerves

Evaluates neurological function during assessments.

Patient Follow-Up Importance

Ensures ongoing care and health monitoring.

Clinical Judgment in Assessment

Essential for interpreting collected data accurately.

Body Mass Index (BMI) Calculation

Used for nutritional assessments in patients.

Common Risk Factors Identification

Critical for targeted assessments across populations.

Emphasis on Patient-Centered Care

Involves respecting patient preferences and needs.

Nurse's Role in Patient Comfort

Promoted through clear communication and reassurance.

Physiological Needs Consideration

Important during patient assessment preparation.

Patient's Family Health History

Provides insights into genetic predispositions.

Cognitive Function Assessment

Part of the comprehensive neurological evaluation.

Holistic Assessment Approach

Combines physical, emotional, and cultural considerations.