NURS 1145 Introduction to Health Assessment for Nursing Practice

WHY ASSESSMENT MATTERS

Assessment is THE most important nursing skill you have

Mom had pacemaker surgery → heart rate subtly went from 34 to 90 (still 'normal' alone but a huge change for her) & Family flagged it to the nurse → nurse caught 250 mL of blood in the pericardium

Subtle changes matter. Know your patient's baseline.

Patient arrived sweaty, pale → student put on heart monitor → saw abnormal QRS → identified V-Tach & Patient sent back to ICU immediately

Sweatiness at rest ≠ normal. Recognize abnormals and act.

The nursing process is the framework for everything in this class.

Assessment is Step 1 = you can't do anything else without it.

NURSING PROCESS (ADPIE)

Assessment, Diagnosis, Outcomes/Planning, Implementation, Evaluation

Assessment

Collect all relevant patient data (subjective + objective). Called 'Recognize Cues' in NCLEX clinical judgment model.

Diagnosis

Identify the problem. Analyze cues → nursing diagnosis (e.g., constipation, fluid overload).

Outcomes/Planning

Set SMART goals: Specific, Measurable, Attainable, Realistic, Timely.

Implementation

Carry out nursing interventions (prune juice, meds, positioning, etc.).

Evaluation

Did the patient improve? Was the goal met? Reassess.

Comprehensive (TYPES OF HEALTH ASSESSMENT)

Full head-to-toe on every body system. Takes ~20–30 min. Done at admission. Your 100-step lab checklist.

Problem-Based / Focused (TYPES OF HEALTH ASSESSMENT)

Zoom in on ONE problem. E.g., femur fracture → neurovascular assessment of that leg only.

Episodic / Follow-Up (TYPES OF HEALTH ASSESSMENT)

Track a known problem over time. E.g., diabetic patient returns in 1 month; hypertensive patient tracks BP.

Shift Assessment (TYPES OF HEALTH ASSESSMENT)

Minimum assessment every nurse does every shift. Head-to-toe but faster (~3 min). Can be done in every setting.

Screening Assessment (TYPES OF HEALTH ASSESSMENT)

Quick check to find unknown problems. E.g., BP at a health fair, A1C screening, mammogram.

Chief Complaint (Health History Components)

Why is the patient here? Main problem.

Review of Systems = ROS (Health History Components)

Ask about every body system (respiratory, GI, cardiac, neuro, extremities…)

Past Medical History = PMH (Health History Components)

Prior illnesses (note: patients often forget or don't mention their diagnoses even when on meds for them)

Past Surgical History = PSH (Health History Components)

Prior surgeries, procedures

Social History (Health History Components)

Smoking, alcohol, drug use, international travel, living situation, support system

Functional Ability / ADLs (Health History Components)

Can they shop, cook, pay bills, feed themselves?

P – Previous History

Have you had this problem before?

O – Onset

When did it start?

L – Location

Where exactly? Does it move?

D – Duration

How long has it been going on?

C – Character

What does it feel like? (aching, sharp, burning, throbbing)

A – Alleviating/Aggravating

What makes it better? What makes it worse?

R – Radiation

Does the pain/symptom spread anywhere? (calf → thigh → groin?)

T – Timing

Constant or comes and goes? Worse at certain times?

S – Severity / Self-treatment

Rate 1–10. What have you already tried?

Subjective Data (Symptoms)

What the PATIENT tells you. Only they can feel it. Nausea, pain, dizziness, nervousness. Ask open-ended or closed questions.

Objective Data (Signs)

What YOU observe, measure, or find. Vital signs, fever, edema, abnormal heart sound, wheezing, CVA tenderness.

Clinical Manifestations

Umbrella term for both signs AND symptoms together.

Open-Ended (Types of Interview Questions)

Requires a full answer. 'What do you do to take care of yourself?' — Good for getting broad information.

Closed-Ended (Types of Interview Questions)

Yes/no or specific answer. 'Do you have chest pain?' — Good for getting precise data quickly.

Used for every body system (Physical Exam Techniques)

Inspection → Palpation → Percussion → Auscultation.

Abdomen (Physical Exam Techniques)

Inspection → Auscultation → Percussion → Palpation, to avoid altering bowel sounds.

Inspection

1.First technique used & takes the most time 2.Use eyes AND nose (smell is part of inspection) 3.Look at: movement, posture, skin color/condition, breathing pattern, drainage, swelling 4.Smell for: fruity breath (diabetic ketoacidosis), C. diff (very strong foul odor), urine, stool 5.You must expose the body part to inspect it = can't assess through a gown 6.Requires practice and a critical, focused eye

Palmar / Finger Pads (front of fingertips) = Palpation Hand Surface

Texture, size, shape, consistency, masses, fluid, crepitus (bubblewrap feeling = air under skin), position

Ulnar Surface (pinky-side edge of hand) = Palpation Hand Surface

Vibration (e.g., tactile fremitus on chest wall)

Dorsal Surface (back of hand) = Palpation Hand Surface

Temperature comparing extremities (e.g., one leg hot vs. the other)

Light palpation (Depth of Palpation)

~1 cm depth = checking surface, tenderness, superficial masses

Deep palpation (Depth of Palpation)

~4 cm depth = deeper organs and structures

Bimanual Palpation

1.Use BOTH hands: one anterior, one posterior 2.'Trap' the organ or mass between your fingertips 3.Used to assess size, shape, location (e.g., kidneys, uterus, fetal position)

Palpation Rules

1.Warm hands, short nails, gentle touch 2.Always tell the patient what you are doing and why 3.Watch the patient's FACE (not just your hands) = you'll see pain before they say it 4.Wear gloves when contacting body fluids or mucous membranes

Crepitus feels like bubble wrap under the skin

Can indicate air that escaped from a traumatic chest injury.

Percussion is the…

Least commonly used technique but know what it is and when it's used.

Why We Do Percussion?

1.Assess size and borders of organs 2.Detect tenderness (e.g., CVA tenderness for kidney infection) 3.Identify fluid in a body cavity (pleural effusion, ascites, full bladder)

Direct percussion

Tap directly on the body. Used for sinuses (tenderness) and kidney area (CVA fist percussion).

Indirect percussion

Two-hand technique. Nondominant hand lies flat on body (pleximeter), dominant hand taps it (plexor). 2–3 taps per spot.

Tympany (Percussion Sounds)

Abdomen = loud, high-pitched, drum-like. Normal air in GI tract. (Dull over full bladder instead)

Resonance (Percussion Sounds)

Normal lung tissue = lower pitch. Normal finding.

Hyperresonance (Percussion Sounds)

Overinflated lungs = emphysema (COPD). More air than normal.

Dullness (Percussion Sounds)

Liver, heart, solid organs or over a full bladder instead of tympany.

Flatness (Percussion Sounds)

Bone and muscle = very dense tissue.

Auscultation

1.Listening with a stethoscope 2.Describe sounds by: Intensity (loud/soft), Pitch (high/low), Duration (short/long), Quality (wheezing, crackling, etc.) 3.Place stethoscope DIRECTLY on skin not through clothing 4.Quiet room, close eyes to improve focus 5.If patient is cold and shivering → muscle contractions interfere with sounds 6.For difficult-to-hear sounds: lean patient forward, roll to side, lift arm to expand thorax

Diaphragm (flat side) = Stethoscope Parts

Higher-pitched sounds: lung sounds, normal heart sounds, bowel sounds

Bell (concave side) = Stethoscope Parts

Lower-pitched sounds: abnormal heart murmurs, bruits

Stethoscope Parts

1.Earpieces angle TOWARD the nose so sound projects toward the tympanic membrane 2.Clean with alcohol after EVERY patient = stethoscopes carry bacteria

Stethoscope (Assessment Equipment)

Auscultate lung sounds, heart sounds, bowel sounds, blood pressure

Doppler (Assessment Equipment)

Amplifies weak vascular sounds (peripheral pulses, fetal heart tones). Use gel. If you can't palpate a pulse, get the Doppler. Chart: 'pulse present per Doppler.'

Tuning Fork (Assessment Equipment)

Two uses: (1) vibration sensation in feet (neuropathy screen), (2) auditory/hearing screening

Monofilament (Assessment Equipment)

Tests sensation in the feet = press plastic wire on 6–7 spots. Patient closes eyes and says 'now' when they feel it. Can't feel it = peripheral neuropathy.

Penlight (Assessment Equipment)

Pupil assessment, inspect mouth/throat, look for bugs (head lice, ticks)

Snellen Chart (Assessment Equipment)

Distance vision = 20 feet, one eye at a time. Results = 20/20, 20/200, etc.

Rosenbaum/Jaeger Chart (Assessment Equipment)

NEAR vision = held 14 inches away. One eye at a time.

Otoscope (Assessment Equipment)

Inspect ear canal and tympanic membrane

Percussion/Reflex Hammer (Assessment Equipment)

Test deep tendon reflexes (tap on tendons)

Goniometer (Assessment Equipment)

Measure joint range of motion (flexion/extension degrees). Common in rehab/PT.

Calipers (skinfold) = Assessment Equipment

Measure subcutaneous fat = most common site is posterior triceps

Transilluminator (Assessment Equipment)

Strong light to differentiate air vs. fluid vs. tissue in a cavity (e.g., sinuses)

Ruler / Tape Measure (Assessment Equipment)

Measure wounds, lesions, edema. Use transparent metric ruler for lesions.

Nasal Speculum (Assessment Equipment)

Opens nares to inspect nasal passages (look for polyps, turbinate inflammation)

Scales (Assessment Equipment)

Body weight = critical for fluid management. 1 kg = 1 liter of fluid. Weigh heart failure patients daily.

Doppler charting rule

Never chart 'pulse absent' get the Doppler first. If found: 'pulse present per Doppler.' No quality rating.

Monofilament + tuning fork both test peripheral sensation

Same patients at risk (diabetics, neuropathy).

Primary Prevention (Health Promotion)

Prevent disease before it starts. Exercise, healthy diet, no smoking/alcohol, immunizations, education.

Secondary Prevention (Screening) = Health Promotion

Detect disease early in people with no symptoms. Mammogram (breast cancer), colonoscopy (colon polyps), A1C (diabetes), bone density (osteoporosis), BP screening.

Tertiary Prevention (Treatment) = Health Promotion

Manage or treat existing disease to prevent complications. Chemo/radiation for cancer, insulin + diet for diabetes, diuretics for heart failure.

Economic Stability (Social Determinants of Health = SDOH)

Can they afford meds? Is there a generic? Do they have insurance?

Education Access & Quality (Social Determinants of Health = SDOH)

Health literacy, diabetes education, understanding discharge instructions

Health Care Access & Quality (Social Determinants of Health = SDOH)

Transportation to appointments, insurance coverage

Neighborhood & Built Environment (Social Determinants of Health = SDOH)

Bus service, safe environment, access to food

Social & Community Context (Social Determinants of Health = SDOH)

Support system, family, caregiver availability

Clinical example (Social Determinants of Health = SDOH)

Patient with diabetes who can't afford healthy food or medications. Ask → advocate → connect to resources → adjust the care plan.

Documentation rules

1.Use proper medical terminology = no slang, no opinions, no bias 2.Accurate, complete, concise, legible 3.'I clicked the wrong box' is NOT an acceptable error = think about what you are charting 4.Always ask: Is this finding normal or abnormal for THIS patient? 5.Social media rule: If you wouldn't want it on Facebook or read aloud in court, do NOT write it 6.Document by body systems = fatigue and SOB could go under cardiac or respiratory

Documentation example

Students charted 'pupils non-reactive' when pupils were reactive → would indicate a serious emergency

Documentation example #2

Student charted infant HR = 70 (actually counted 30 sec, forgot to multiply × 2 → HR was really 140, which is normal for a newborn)

Infection control

1.precautions apply to ALL patients every time 2.Hand hygiene before and after every patient contact 3.Wear gloves when palpating mucous membranes or areas with body fluids 4.Clean stethoscope with alcohol between patients 5.Latex allergy: More exposure = higher risk. Use non-latex gloves as needed. 6.High-risk populations for latex allergy: Healthcare workers, children with spina bifida, patients with multiple surgeries (especially genitourinary)

Elderly patients UNDER-REPORT symptoms (important clinical pearls from lecture)

If they do complain, take it seriously and follow up on everything

Don't let patients diagnose themselves (important clinical pearls from lecture)

Heart rate of 180 after walking to the bathroom is NOT normal

Weight monitoring: 1 kg of weight gain = 1 liter of extra fluid (important clinical pearls from lecture)

Especially important for heart failure patients

Fruity breath (important clinical pearls from lecture)

Possible diabetic ketoacidosis (DKA)

Exophthalmos (protruding eyes) = important clinical pearls from lecture

Can indicate hyperthyroidism → can cause atrial fibrillation

Crepitus (important clinical pearls from lecture)

Air under skin (feels like bubble wrap) = seen with chest trauma

Mottling of skin (important clinical pearls from lecture)

Decreased circulation, often associated with end-of-life care (sepsis, hospice patients)

Monofilament test (important clinical pearls from lecture)

Patients who can't feel feet are at very high risk for unnoticed wounds → infections → amputation. Teach daily foot inspection.

Distended abdomen at suprapubic area + dull percussion (important clinical pearls from lecture)

Full bladder (not tympany like normal abdomen)

Normal infant HR: 120–150+ bpm (important clinical pearls from lecture)

NOT 70 = that would be very abnormal

CVA tenderness (costovertebral angle) = important clinical pearls from lecture

Tap with fist → pain = kidney infection (pyelonephritis)