Slide 1: Chapter 27 Health Assessment

• Title slide introducing the chapter on Health Assessment, covering the scope of assessment and its significance in nursing practice.

Slide 2: Health Assessment Overview

• Define health assessment, including the collection, validation, and analysis of data.

• Differentiate between subjective data (based on patient experiences and perceptions) and objective data (measurable and directly observed).

• Discuss the two main components of a health assessment:

  • Health History: Collection of subjective information about the patient’s health status.

  • Physical Assessment: Collection of objective data related to changes in body systems.

• Importance of combining both subjective and objective data for comprehensive care.

Slide 3: Types of Health Assessments

• Comprehensive Assessment: Conducted on admission to a healthcare facility to establish a baseline.

• Ongoing Partial Assessment: Performed at regular intervals to monitor changes in the 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.

• Examples of when each type of assessment would be used in clinical practice.

Slide 4: Question #1

• True or False: A patient’s report of dizziness is an example of subjective data.

  • Options:

    • A. True

    • B. False

• Highlight the importance of understanding subjective data in patient care.

Slide 5: Answer to Question #1

• Correct answer: A. True.

• Explanation: Subjective data is based on patient experiences and is reported in their own words. This includes symptoms like dizziness.

• Reinforce the role of subjective data in understanding patient symptoms.

Slide 6: Preparing the Patient for Physical Assessment

• Consider both the physiological and psychological needs of the patient.

• Explain the physical assessment process in simple, understandable terms to reduce anxiety.

• Assure the patient that assessments are not painful, maintaining a calm environment.

• Ensure privacy by using appropriate draping and answering questions directly and honestly.

• Importance of building rapport to promote patient comfort and cooperation.

Slide 7: Considerations When Performing Health Assessment

• Lifespan Considerations: Tailor assessment approaches based on the patient’s age and developmental stage.

• Cultural Considerations and Sensitivity: Respect and acknowledge cultural differences in healthcare beliefs and practices.

• Patient Preparation: Prepare the patient mentally and physically for the assessment.

• Environmental Preparations: Ensure the environment is conducive to a thorough examination (e.g., appropriate temperature, privacy).

Slide 8: Nurse’s Role in Diagnostic Procedures

• Assist the patient before, during, and after diagnostic tests.

• Witness informed consent for diagnostic procedures.

• Schedule tests and prepare the patient both physically and emotionally.

• Provide care and patient education after the procedure.

• Safely dispose of used equipment and transport specimens as necessary.

Slide 9: Factors to Assess During a Health History

• Biographical Data: Patient demographics (name, age, address, etc.).

• Reason for Seeking Healthcare: Patient’s chief complaint.

• History of Present Health Concern: Onset, duration, and description of symptoms.

• Past Health History: Previous illnesses, surgeries, and treatments.

• Family Health History: Genetic predispositions.

• Functional Health: Ability to perform activities of daily living (ADLs).

Slide 10: Question #2

• True or False: The primary source of data for health history is the patient’s significant others.

  • Options:

    • A. True

    • B. False.

Slide 11: Answer to Question #2

• Correct answer: B. False.

• Rationale: The primary source of data is always the patient whenever possible.

Slide 12: Preparing the Environment for Physical Assessment

• Ensure the patient is as free of pain as possible.

• Prepare the examination table and provide a gown and drape for privacy.

• Gather all supplies and instruments before starting the assessment.

• Maintain a comfortable room temperature and use a curtain or screen for privacy.

Slide 13: Equipment Used During a Physical Examination

• List of equipment:

  • Thermometer and sphygmomanometer (blood pressure cuff).

  • Scale for measuring weight.

  • Flashlight or penlight for visual examinations.

  • Stethoscope for auscultation.

  • Metric tape measure and ruler for measuring lesions or abnormalities.

  • Eye chart for visual acuity testing.

  • Watch with a second hand to measure pulse and respiratory rate.

Slide 14: Positions Used During a Physical Assessment

• Standing: Assessing posture, balance, and gait.

• Sitting: Allows visualization of the upper body.

• Supine: Allows relaxation of abdominal muscles for abdominal assessment.

• Dorsal Recumbent: For patients who have difficulty maintaining the supine position.

• Sim’s: Used for assessing the rectum or vagina.

• Prone: Used for assessing the hip joint and posterior thorax.

• Lithotomy: Assessment of female genitalia and rectum.

• Knee–chest: Assessment of the anus and rectum.

Slide 15: Question #3

• Which position is used in a physical examination to assess the rectum of a patient?

  • Options:

    • A. Supine

    • B. Sims

    • C. Prone

    • D. Dorsal Recumbent

Slide 16: Answer to Question #3

• Correct answer: B. Sims.

• Rationale: The Sims position is used to assess the rectum and vagina. Other positions are used for different body assessments.

Slide 17: Question #4

• Which physical assessment technique is used to assess temperature, turgor, texture, moisture, vibrations, and shape?

  • Options:

    • A. Inspection

    • B. Percussion

    • C. Palpation

    • D. Auscultation

Slide 18: Answer to Question #4

• Correct answer: C. Palpation.

• Rationale: Palpation involves using touch to assess various physical attributes. Definitions for other techniques are also provided.

Slide 19: Techniques Used During a Physical Assessment

• Inspection: Systematic observation of size, color, shape, position, and symmetry.

• Palpation: Using the hands to feel temperature, turgor, texture, moisture, vibrations, and shape.

• Percussion: Striking one object against another to produce sound and assess tissue density.

• Auscultation: Listening with a stethoscope to sounds produced in the body, assessing characteristics like pitch and loudness.

Slide 20: General Survey

• General Appearance: Includes body build, posture, hygiene, and emotional state.

• Vital Signs: Measurement of temperature, pulse, respiration, and blood pressure.

• Height, Weight, and Waist Circumference: Baseline measurements.

• Calculating BMI: Body mass index for nutritional assessment.

• Importance of the general survey in identifying potential health issues early.

Slide 21: Physical Assessment Overview

• Areas of assessment:

  • Integument (skin): Color, texture, lesions.

  • Head and Neck: Eyes, ears, nose, mouth, and throat.

  • Thorax and Lungs: Respiratory patterns and breath sounds.

  • Cardiovascular and Peripheral Vascular: Heart sounds, peripheral pulses.

  • Breasts and Axillae: Inspection and palpation for abnormalities.

  • Abdomen: Inspection, auscultation, percussion, and palpation.

  • Musculoskeletal System: Mobility and joint function.

  • Neurologic System: Reflexes, motor, and sensory function.

• Importance of a systematic approach to physical assessment.

Slide 22: Integument Assessment

• Identify Risk Factors: Exposure to sunlight, chemicals, or skin trauma.

• History of Rashes, Lesions, Bruising, Allergies: Gather subjective information.

• Inspection and Palpation: Assess color, moisture, temperature, and texture.

• Describe common skin abnormalities and their significance.

Slide 23: Integumentary Assessment Terminology

• Erythema: Redness of the skin.

• Ecchymosis: Collection of blood under the skin.

• Petechiae: Small hemorrhagic spots.

• Cyanosis: Bluish or grayish skin color.

• Jaundice: Yellowing of the skin.

• Pallor: Paleness.

• Diaphoresis: Excessive sweating.

• Turgor: Skin elasticity.

• Edema: Fluid accumulation in tissues.

• Provide examples of conditions that may cause each of these symptoms.

Slide 24: Assessing the Head and Neck

• Identify Risk Factors: Changes in vision or hearing, history of allergies, chronic illnesses, or trauma.

• Inspection and Palpation: Assess head shape and symmetry, palpate lymph nodes, check for thyroid enlargement.

• Eye Examination: Visual acuity, extraocular movements, and peripheral vision.

• Ear Examination: Assess hearing acuity and inspect the ear canal for abnormalities.

• Thyroid Gland: Palpate for enlargement or nodules.

Slide 25: Assessing the Thorax and Lungs

• Identify Risk Factors: History of lung disease, smoking, allergies, and environmental exposures.

• Inspection: Observe respiratory rate, rhythm, depth, and chest shape.

• Palpation: Assess for tenderness or abnormalities.

• Percussion: Determine the density of lung tissue.

• Auscultation: Listen for breath sounds and note any abnormal findings (e.g., crackles, wheezes).

Slide 26: Lung Sounds

• Bronchial or Tubular Sounds: High-pitched, loud sounds heard over the trachea.

• Bronchovesicular Sounds: Moderate pitch and sound intensity, heard over major bronchi.

• Vesicular Sounds: Low-pitched, soft sounds heard over peripheral lung fields.

• Adventitious Sounds: Abnormal lung sounds such as wheezes, rhonchi, crackles, stridor, and pleural friction rub.

Slide 27: Question #5

• Which of the following terms is used to describe a musical or squeaking, high-pitched sound heard in the lungs?

  • Options:

    • A. Crackles

    • B. Stridor

    • C. Rhonchi

    • D. Wheeze

Slide 28: Answer to Question #5

• Correct answer: D. Wheeze.

• Rationale: Wheezes are high-pitched, musical sounds heard during inspiration or expiration, caused by narrowed airways.

Slide 29: Common Thorax and Lung Variations in Older Adults

• Increased Anteroposterior Chest Diameter: Often due to aging or chronic obstructive pulmonary disease (COPD).

• Kyphosis: Increased curvature of the thoracic spine.

• Decreased Thoracic Expansion: Due to decreased elasticity of the lungs.

• Use of Accessory Muscles: Older adults may use accessory muscles to assist with breathing.

Slide 30: Assessing Cardiovascular and Peripheral Vascular Systems

• Identify Risk Factors: History of hypertension, chest pain, smoking, diabetes, and family history of heart disease.

• Inspection and Palpation: Assess for jugular venous distention, edema, and capillary refill.

• Auscultation: Listen for heart sounds (S1, S2) and note any murmurs or abnormal rhythms.

• Peripheral Pulses: Palpate pulses in the carotid, radial, femoral, popliteal, posterior tibial, and dorsalis pedis arteries.

Slide 31: Characteristics of Sound Heard When Using Auscultation

• Pitch: Ranges from high to low.

• Loudness: Can be soft or loud.

• Quality: For example, gurgling or swishing.

• Duration: Short, medium, or long.

• Importance of understanding sound characteristics for accurate assessment.

Slide 32: Cardiovascular and Peripheral Vascular Variations in Infants and Children

• Visible Cardiac Pulsation: May be seen if the chest wall is thin.

• Sinus Dysrhythmia: Normal variation where the heart rate increases with inspiration and decreases with expiration.

• Presence of S3: Common in children and young adults.

• Rapid Heart Rate: Faster heart rate compared to adults.

Slide 33: Common Cardiovascular and Peripheral Vascular Variations in Older Adults

• Difficult-to-Palpate Apical Pulse: Due to increased chest wall thickness.

• Dilated Proximal Arteries: Often seen in older adults.

• Varicosities: More prominent and tortuous veins.

• Increased Blood Pressure: Both systolic and diastolic pressures may be elevated.

Slide 34: Abdominal Assessment

• Identify Risk Factors: History of abdominal pain, surgeries, bowel habits, and diet.

• Inspection: Observe for contour, symmetry, and skin condition.

• Auscultation: Listen for bowel sounds in all four quadrants.

• Percussion: Assess for tympany and dullness.

• Palpation: Light and deep palpation to assess for masses or tenderness.

Slide 35: Abdominal Quadrants and Underlying Organs

• Right Upper Quadrant (RUQ): Liver, gallbladder, part of the pancreas.

• Left Upper Quadrant (LUQ): Stomach, spleen, part of the pancreas.

• Right Lower Quadrant (RLQ): Appendix, cecum.

• Left Lower Quadrant (LLQ): Sigmoid colon.

• Importance of understanding organ location for targeted assessments.

Slide 36: Common Abdominal Variations in Different Age Groups

• Newborns: Umbilical cord present, falls off within weeks.

• Children: “Pot-belly” appearance is normal in toddlers.

• Older Adults: Decreased bowel sounds, decreased abdominal tone, fat accumulation on abdomen and hips.

Slide 37: Characteristics of Masses Determined by Palpation

• Shape: Round, irregular.

• Size: Measure in centimeters.

• Consistency: Soft, firm, hard.

• Surface: Smooth or nodular.

• Mobility: Fixed or mobile.

• Tenderness: Painful or non-painful.

Slide 38: Question #6

• Place the steps of abdominal assessment in their appropriate order:

  • Options:

    • A. Auscultation

    • B. Palpation

    • C. Percussion

    • D. Inspection

Slide 39: Answer to Question #6

• Correct order: D. Inspection, A. Auscultation, C. Percussion, B. Palpation.

• Rationale: This order prevents altering bowel sounds by palpation or percussion before auscultation.

Slide 40: Assessing the Musculoskeletal System

• Identify Risk Factors: History of trauma, arthritis, neurologic disorders.

• Inspection: Assess posture, gait, and joint symmetry.

• Palpation: Assess muscle tone, joint tenderness, and crepitus.

• Range of Motion (ROM): Evaluate active and passive ROM in all joints.

Slide 41: Assessing the Neurologic System

• Identify Risk Factors: History of seizures, head trauma, dizziness, numbness, or tingling.

• Mental Status: Assess level of consciousness, orientation to person, place, time, and situation.

• Cranial Nerve Assessment: Evaluate function of cranial nerves I-XII.

• Motor and Sensory Function: Assess muscle strength, sensation, and reflexes.

Slide 42: Assessing the Neurologic System #2

• Health History Interview: Ask about headaches, vision changes, and coordination issues.

• Mental Status Examination: Assess memory, cognitive abilities, and emotional status.

• Cerebellar Function: Test motor skills, balance, and coordination (e.g., finger-to-nose test).

• Reflexes: Test deep tendon reflexes (e.g., patellar reflex).

Slide 43: Assessing Mental Status

• Level of Consciousness (LOC): Determine if the patient is awake, alert, lethargic, stuporous, or comatose.

• Glasgow Coma Scale (GCS): Used to assess LOC in patients with head injuries.

• Level of Awareness: Assess orientation to time, place, person.

• Memory and Language: Assess short-term and long-term memory, ability to understand and use language.

Slide 44: Purposes of Documentation

• Identify Actual and Potential Health Problems: Use documentation to track patient progress and identify issues.

• Plan Appropriate Care: Documentation helps in planning individualized patient care.

• Evaluate Patient Responses: Track responses to interventions and modify care as needed.

• Legal Record: Provides a legal record of care provided and protects both patient and healthcare provider.