RNSG 1115 Chapter 27 Health Assessment

Purpose of health assessment:

collect, validate, and analyze data

Subjective means:

based on patient experiences and perceptions

Objective means:

measurable and directly observed

Health history:

collection of subjective information about the patient’s health status

Physical assessment:

collection of objective data about changes in the patient’s body systems

Types of Health Assessments

• comprehensive

• ongoing/partial

• focused

• emergency

Comprehensive:

conducted upon admission to health care facility

Ongoing/Partial:

conducted to assess at regular intervals

Focused:

conducted to asses a specific problem

Emergency:

conducted to determine life-threatening or unstable conditions

Steps to prepare the patient for physical assessment

• consider the physiologic and psychological needs of the patient

• explain the process to the patient

• explain that physical assessments should not be painful (decrease patient fear/anxiety)

• explain each procedure in detail as it’s conducted

• explain that privacy will be maintained using drapes

• answer patient questions directly and honestly

Health history:

collection of data that provides a detailed profile of the patient’s health status

• biographical data

• reason for seeking health care

• history of present health concern

• past health history

• family history

• functional health

• review of systems

Preparation for physical assessment

• gather equipment

• prepare equipment

Patient Positioning During Physical Assessment: Standing

assessment of posture, balance, and gait

Patient Positioning During Physical Assessment: Sitting

allows visualization of upper body

Patient Positioning During Physical Assessment: Supine

allows relaxation of abdominal muscles

Patient Positioning During Physical Assessment: Dorsal Recumbent

used for patients having difficulty maintaining the supine position

Patient Positioning During Physical Assessment: Sim’s

assessment of rectum of vagina

Patient Positioning During Physical Assessment: Prone

assessment of hip joint and posterior thorax

Patient Positioning During Physical Assessment: Lithotomy

assessment of femal genitalia and rectum

Patient Positioning During Physical Assessment: knee-chest

assessment of anus and rectum

Patient Positioning During Physical Assessment:

• standing

• sitting

• supine

• dorsal recumbent

• sim’s assessment

• prone

• lithotomy

• knee-chest

Techniques of physical assessment:

• inspection

• palpation

• percussion

• auscultation

Patient Positioning During Physical Assessment: Inspection

assessing size, color, shape, position, and symmetry

Patient Positioning During Physical Assessment: Palpation

assessing temperature, tugor, texture, moisture, vibrations, and shape

Patient Positioning During Physical Assessment: Percussion

assessing location, shape, size, and density of tissues

Patient Positioning During Physical Assessment: Auscultation

assessing the four characteristics of sound that is, pitch, loudness, quality, and duration

Order of Physical Assessment

• general survey (what does the client look like)

• integument (skin assessment, completed throughout the exam)

• head and neck

• thorax and lungs

• cardiovascular and peripheral vascular systems

• breasts and axillae

• abdoment

• female and male genitalia

• anus, rectum

• musculoskeletal system

• neurologic system

General survey:

• general appearance

• vital signs

• height, weight, waist circumference, BMI

• assess level of consciousness (LOC)

• orientation

• hygiene, grooming, dress

• use of mobility aids, medical equipment, ostomies, dressings

General Appearance:

• overall appearance and behavior

• note any signs of distress or illness

• nonverbal communication

• mood and mental health (facial expression, ability to relax, eye contact, etc.)

• hygiene and dress

• use of mobility aids, medical equipment, ostomies, dressings