Health Assessment

Purposes of a Health Assessment

* Establishment of nurse-patient relationship
* Gather data of pt general health status
* Identify pt strengths
* Identify actual and potential health problems
* Establish base for nursing process

Different Types of Health Assessment

* Comprehensive
* Ongoing/Partial/Follow Up
* Focused
* Emergency

Comprehensive Health Assessment

A health assessment done upon admission, a broad health assessment that includes a complete health history and a physical assessment.

Ongoing/Partial/Follow Up Health Assessment

A type of health assessment done at regular intervals. This assessment concentrates on specific problems to monitor positive or negative trends and evaluate interventions effectiveness. These assessments are also used to find new problems.

Focused Health Assessment

A type of health assessment done to assess a specific health issue and focuses on pertinent history and body regions, usually involving 1 or 2 systems. Thus type of assessment can also be used to address immediate and highest priority concerns.

Emergency Health Assessments

A type of focused assessment done when addressing life-threatening or unstable conditions.

What are some ways that you may prepare a patient for a physical assessment?

* Consider physiologic and psychological needs of patient
* Explain general process to patient to decrease fear and anxiety
* Explain each procedure more in depth as you do them
* Have patient change into a gown and empty bladder
* Answer questions directly and honestly

How would you prepare the environment for a physical assessment?

* Ensure privacy and respect
* Agree on specific time for assessment
* Ensure patient is free of pain
* Prepare bed/examination table
* Provide gown and drape
* Gather needed supplies beforehand

Standing

Position used to assess posture, balance, and gait. Do not use for pt who are weak, dizzy, or fall-risk.

Sitting

Position that allows for visualization of upper body, full lung expansion, VS assessment, and assessment of the body above the abdomen.

Supine

Position that allows for relaxation of abdominal muscles, assessment of VS, and assessment of the anterior body.

Dorsal Recumbent

Position used for patients that have difficulty maintaining supine position. Used for assessment of the anterior body with exception to the abdomen as this position causes abdominal muscle contraction.

Sim’s

Position used for assessment of rectum or vagina.

Prone

Position used to assess hip joint and posterior thorax.

Lithotomy

Position used for assessment of female genitalia and rectum.

Knee-Chest

Position used for assessment of anus and rectum.

What factors should you assess during a health history?

* Biographical data
* Reason for seeking care
* History of present illness
* Past medical history
* Family history
* Functional health
* Psychosocial and lifestyle factors
* Review of systems

What type of questions would you ask regarding present health history?

Questions that are directly related to the primary problem the patient is complaining of.

What type of questions would you ask regarding past health history?

Questions related to the patient’s health in the past (Ex. childhood injuries) or simply not related to the illness the patient is currently presenting with (Ex. Prescribed medications).

What types of questions would you ask regarding family history?

Health history of the patient’s family that can be explicitly or implicitly related to the patient.

What type of questions would you ask regarding functional health?

Questions regarding the daily/typical life of the patient.

What are the techniques used during a physical assessment?

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Inspection

A technique used in a physical assessment that starts upon initial contact and continues throughout the assessment. Appearance, behavior, movement, size, color, shape, position, and symmetry are assessed.

Palpation

A technique used during a physical assessment that uses touch to assess for temperature, turgor, texture, moisture, vibrations, and sharp or structures. There are two types of palpation: light (1-2cm) and deep.

Percussion

A technique used during a physical assessment that assesses location, shape, size, and density of tissues. Fingertips are tapped over body tissues to produce sounds/vibrations.

Auscultation

A technique used during a physical assessment that assesses the four characteristics of sound: pitch, loudness, quality, and duration. Auscultation is performed using a stethoscope.

How would safety be assessed?

* Bed position
* Call light position
* Appropriate emergency equipment
* Assistive devices
* Fall risk/hazards

List the Vital Signs

* Temperature
* Pulse
* Respirations
* BP
* O2 sat
* Pain

How would you assess mental status?

* LOC
* A&O x? (Person, place, time, event)
* Speech

How would you assess the psychosocial status of a patient?

Assess behavior and affect.

How would you assess the head, eyes, ears, and nose of a patient?

Assess the following:

* Eyes
* Pupils
* Mouth
* Carotid arteries
* Swallowing
* Throat
* Neck and facial color
* Moisture
* Lesions
* Wounds
* Glasses?
* Hearing aids?
* Ability to hear
* Ability to see

How would you assess the chest of a patient?

* Color
* Moisture
* Lesions
* Wounds
* Respirations and their quality
* Heart sounds
* Lung sounds
* Cough
* Sputum

How would you assess the abdomen of a patient?

* Color
* Moisture
* Lesions
* Wounds
* Bowel sounds
* Tenderness
* Distention
* Pain/discomfort
* Ability to eat
* Urine elimination patterns
* Urine characteristics
* Bowel elimination pattern
* Stool characteristics

How would you assess the upper and lower extremities of a patient?

* Skin
* Color
* Pulses
* Temperature
* Tenderness
* Edema
* Capillary refill
* Strength
* Sensation
* ROM
* Lesions
* Wounds

How would you assess the activity of a patient?

Assess the following:

* Movement and ambulating
* Ability to move in bed
* Ability to get out of bed
* Ability to walk and distance walkers
* Gait

What is important about vital signs?

They indicate the general physiologic functioning and health status of a patient.

Can VS be delegated?

Yes, only if the patient is stable.

What is the responsibility of the RN regarding VS?

* Accuracy
* Interpretation
* Reporting of abnormal findings

Redness

Also known as erythema or flushing, a skin color that can be found on the face or in a localized area of skin. Can be caused by blushing, alcohol, fever, trauma, or infection.

Bluish

Also known as cyanosis, a skin color that can be noticed in exposed area, ears, lips, mouth, hands, feet, nail beds, and exposed areas in general. Can be caused by coldness or hypoxemia.

Yellowish

Also known as jaundice, a skin color that can be seen throughout the body. Can be caused by liver disease due to increased bilirubin levels.

Paleness

Also known as pallor, a skin color that can be seen in the face, lips, conjunctivae, mucous membranes, and exposed areas in general. Can be caused by anemia (Decreased hemoglobin) or shock (Decreased blood volume).

White patchy areas on skin

Also known as vitiligo, a skin color assessment that can be seen throughout the body. Usually caused by congenital or autoimmune conditions leading to depigmentation.

Tanned or Brown

A skin color assessment that can be seen in sun-exposed areas. Usually caused by overexposure causing increased melanin production or pregnancy.

Purplish

Also known as ecchymosis, a skin color assessment caused by collection of blood within subcutaneous tissue.

Small, nonblanchable purple spots

Also known as petechiae, a skin color assessment where there are small hemorrhagic spots that do not blanch when pressure is applied.

Excessive Perspiration

Also known as diaphoresis, a skin color assessment in which the patient is excessively wet with sweat.

Skin Tension

Also known as turgor, a skin assessment measuring skin tension which is dependent upon hydration.

Excessive extracellular accumulation of fluid

Edema

What assessment tool would you use for melanoma?

* A (Asymmetry)
* B (Border)
* C (Color)
* D (Diameter)
* E (Evolving)

Describe asymmetry when assessing for melanoma

If a line is drawn through a mole, both sides will not match.

Describe border when assessing for melanoma

Early melanoma borders are usually uneven with the edges possibly being scalloped or notched.

Describe color when assessing for melanoma

Color variety is a warning sign. Melanomas can be different shades of brown, tan, black, red, white, or blue.

Describe diameter when assessing for melanoma

Melanomas are usually larger than the size of a pencil eraser, but may be smaller when initially detected.

Describe evolving when assessing for melanoma

Any change in the mole/site points towards danger.

How would you test for pupillary reaction?

* Darken a room and have the pt look ahead
* Using a penlight, move light from the side of the pt head towards his/her eyes
* Observes for contraction and size
* Repeat on the other side
* Equal bilateral pupil size and constriction upon contact with light are normal results

How would you assess for convergence?

* Hold an object 6-8 inches away from pt nose and have pt look at point/tip of object
* Move object closer to pt nose
* Eyes converging (Pt appearing cross-eyes) are normal results

How would you test for accommodation?

* Hold an object with a tip 4-6 inches away from pt nose
* Have pt look at object first ten a more distant object
* Finally, have pt refocus back on the near object
* Pt pupil constriction when looking at near object and pupil dilation when looking at distant object are normal results

How would you test extraocular movements?

* Position pt 2 ft away facing you at eye level
* Have patient hold still and follow movement of penlight with eyes
* Move penlight through cardinal positions
* Pt following penlight with no lag in eyes are normal results

How would you test peripheral vision?

* Have pt stand 2 ft away and face you at eye level
* Have pt cover one eye
* Have pt fix gaze upon your nose
* Outstretch your arm to one side so that neither you nor the pt sees your fingers
* Bring arm and fingers into your and the pts peripheral vision and tell pt to inform you when he/she sees tour fingers
* Repeat steps on other side
* Pt and you should see finger within peripheral vision around the same time for normal results

What are the characteristics of sound you can assess during auscultation?

1. Pitch
2. Loudness
3. Quality
4. Duration

Describe Pitch (Auscultation)

Ranges from high to low

Describe Loudness (Auscultation)

Ranges from soft to loud

Describe Quality (Auscultation)

Descriptions such as gurgling or swishing.

Describe Duration (Auscultation)

Short, medium, or long

What are the normal breath sounds?

* Bronchial/Tubular
* Bronchovesicular
* Vesicular

What are the adventitious/abnormal breath sounds?

* Wheeze (Sibilant)
* Rhonchi (Sonorous wheeze)
* Crackles
* Strider
* Friction Rub

Bronchial/Tubular Lung Sounds

A normal lung sound characterized as blowing, hollow sounds. This sound is auscultated over the larynx and trachea and expiration sound is longer, lower, and higher pitched.

Bronchovesicular Lung Sounds

A normal lung sound that is medium-pitched, medium intensity, and is characterized by blowing sounds. This sound is auscultated over the anterior first and second intercostal space and over the scapula posteriorly. Inspiration and expiratory sounds are similar.

Vesicular Lung Sounds

A normal lung sound characterized by soft, low-pitched, whispering sounds. Heard over most lung fields, inspiration is longer, louder, and higher pitched.

Wheeze (Sibilant)

An abnormal lung sound characterized by musical/squeaking sounds that are high-pitched and continuous. This sound can be heard during inspiration and expiration and indicated air passing through narrow airways.

Rhonchi (Sonorous Wheeze)

An abnormal lung sound characterized by sonorous/coarse, low-pitched continuous sounds. This lung sound is heard during inspiration and expiration and indicated air passing through or around secretions. Coughing may somewhat clear this sound.

Crackles

An abnormal lung sound characterized by bubbling, crackling, or popping sounds that have a low- to high-pitch and is discontinuous. Heard during inspiration and expiration, this sound indicates opening of small deflated airways and alveoli with air passing thru fluid in these airways.

Stridor

An abnormal lung sound characterized by harsh, loud, and high-pitched sounds that are heard upon inspiration. This sound indicates a narrowing of the upper airway and/or presence of foreign body in airway.

Friction Rub

An abnormal lung sound characterized by rubbing or grating sounds that are lowest over the lower lateral anterior surface. This sound is heard upon inspiration and expiration and indicates inflamed pleura rubbing against chest wall.

What are the two normal heart sounds?

1. S1 (“lub”)
2. S2 (“dub”)

Describe the S1 heart sound

Normal heart sound that sounds like “lub”. This sound represents the closing off the mitral and tricuspid valves and initiation of ventricular contraction and is best heard in the tricuspid and apical areas.

Describe the S2 heart sound

Normal heart sound that sounds like “dub”. This heart sound indicates the closing of the aortic and pulmonic valves, termination of systole, and initiation of ventricular diastole. This sound is best heard over the aortic and pulmonic areas.

What extra heart sounds may you auscultate?

S3 and S4

Describe S3 heart sounds

An extra heart sound that may follow S2 and can be heard as “dee”. This sound is best heard over the mitral area and is considered normal in children and young adults, but abnormal in middle-age and older adults.

Describe S4 heart sounds

An extra heard sound that may precede S1 and can be heard as “dee”. This sound is considered normal in older adults, but is considered abnormal in all other age groups.

What are the five areas for listening to the heart?

* Aortic (Right second intercostal space, sternal border)
* Pulmonic (Left second intercostal space, sternal border)
* Eros Point (Left third intercostal space, sternal border)
* Tricuspid (Left fourth intercostal space, sternal border)
* Mitral (Left fifth intercostal space, midclavicular line)

How is the female breast divided?

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How would you assess a female breast using the circular technique?

Using the pads of your first three fingers, gently compress the breast against the chest wall beginning at the tail of spence and going in gradually smaller circles.

How would you assess a female breast using the wedge technique?

Using the pads of your first three fingers, gently compress the breast against the chest wall and palpate from the periphery towards the areola. Go in a clockwise fashion.

How would you assess a female breast using the vertical strip technique?

Using the pads of your first three fingers, gently compress the breast against the chest wall and begin at the outer edge of the breast and palpate up and down, eventually covering the whole breast.

What structures are in the right upper quadrant (RUQ)?

* Pylorus
* Duodenum
* Liver
* Right kidney and adrenal gland
* Hepatic flexure of colon
* Head of pancreas

What structures are in the left upper quadrant (LUQ)?

* Stomach
* Spleen
* Left kidney and adrenal gland
* Splenic flexure of colon
* Body of pancreas

What structures are in the right lower quadrant (RLQ)?

* Cecum
* Appendix
* Right ovary and fallopian tube (Female)
* Right ureter and lower kidney pole
* Right spermatic cord (Male)

What structures are in the left lower quadrant (LLQ)?

* Sigmoid colon
* Left ovary and fallopian tube (Female)
* Left ureter and lower kidney pole
* Left spermatic cord (Male)

What structures are midline?

* Urinary bladder
* Urethra (Female)

What four things should you look for when assessing for scoliosis?

1. Head level and centered over trunk
2. Shoulders same height
3. Hips at same level
4. When bent forwards with arms drooping towards feet, is the rib cage level on both sides?

How would you assess grip?

Have pt squeeze your index and middle fingers.

How would you test knee flexion?

Have pt bend their knee and keep his/her foot on the table. Have the pt attempt to keep this position with foot down while you try to straighten his/her knee.

How would you test knee extension?

While you support pt knee and provide resistance at the ankle. Have patient attempt to straighten the leg.

How would you generally test for muscle strength?

Have patient move against resistance. Bilateral equal resistance should be present. Slightly high resistance on dominant side is normal.

How would you assess for shoulder flexion?

Have patient raise arm forward against resistance.

How would you test for wrist extension?

Pt makes fist and resists you attempt to pull wrist down.

How would you assess hip flexion?

Have pt raise thigh against resistance.

How would you assess ankle plantar flexion?

Have pt push using balls of feet against your resistance as if he/she was stepping on a pedal.