Complete Health Assessment: Adult

Chapter 28: The Complete Health Assessment: Adult

Overview

  • The health assessment is a comprehensive process involving systematic evaluation and collection of data from adult patients.

  • The assessment includes both subjective (health history) and objective (physical examination) data.

Complete Health Assessment Adult I

  • Importance of arranging all learned steps in a coherent manner.

    • Requires pauses for thought and memory of procedures.

    • Continuous practice leads to natural flow during assessments.

    • Ability to gracefully integrate forgotten steps into procedural flow.

  • Suggested sequence aims to minimize position changes for both patient and examiner.

Complete Health Assessment Adult II

  • Importance of performing all listed steps for a comprehensive examination.

    • With experience, balance thoroughness and efficiency can be achieved.

    • Preparation of all necessary equipment beforehand is crucial.

Assessment Sequence: Detailed Steps

Sequence (1 of 4)

  • Patient enters room, takes a seat, and examiner sits facing the patient (patient in street clothes).

  • Steps:

    • Obtain health history.

    • Observe general appearance.

    • Obtain measurements:

    • Height and weight.

    • Examine skin:

    • Hands and nails.

    • Obtain vital signs:

    • Temperature, blood pressure, pulse, and respirations.

Sequence (2 of 4)

  • Assess:

    • Inspect and palpate:

    • Head and face.

    • Eyes and ears:

      • Test relevant cranial nerves; use of ophthalmoscope and otoscope.

    • Nose, mouth, and throat, and neck:

      • Test relevant cranial nerves.

    • Chest:

      • Inspect posterior, lateral, and anterior.

      • Add auscultation and percussion for heart and lungs.

Sequence (3 of 4)

  • Assess:

    • Inspect and palpate:

    • Upper extremities:

      • Test range of motion (ROM), temperature, and pulses.

    • Breasts and neck vessels:

      • Assess symmetry, teach self-breast exam.

    • Abdomen and inguinal area:

      • Incorporate auscultation and percussion.

    • Lower extremities:

      • Identify varicosities and check for edema.

Sequence (4 of 4)

  • Assess:

    • Inspect and palpate:

    • Musculoskeletal system:

      • Assess muscle strength, observe gait.

    • Neurologic system:

      • Include neurovascular assessments, cranial nerves, reflexes.

    • Genitalia and rectum:

      • Appropriate examination method based on gender.

Documentation and Critical Thinking

  • Record findings promptly to ensure accuracy.

  • Document both pertinent negative and positive findings.

  • Use concise phrases to enhance clarity, avoiding repetition.

  • Incorporate simple line drawings to assist in health education.

  • Clearly note the source of information gathered during assessment.

The Health History

(1 of 2)

  • Biographic Data:

    • Source and reason for seeking care, history of present illness.

  • Past Health:

    • Includes childhood illnesses, accidents, chronic illnesses, hospitalizations, obstetric history, immunizations, last examination, allergies, current medications.

(2 of 2)

  • Family History:

    • Genogram representation for maternal and paternal relatives.

  • Review of Systems:

    • General health focused on:

    • Skin, head, eyes, ears, nose, mouth & throat, neck, breasts, respiratory, cardiovascular, peripheral vascular, gastrointestinal, urinary, genitalia, sexual health, neurologic, hematologic, and endocrine.

  • Functional Assessment:

    • Self-concept, activity & exercise, sleep & rest, nutrition, alcohol and cigarette use, interpersonal relationships, coping & stress management, and personal perception of health.

Physical Examination

  • **Measurements: **

    • Height, weight, waist circumference, body mass index (BMI).

    • Vital signs including blood pressure and temperature.

  • General Survey:

    • Provide a brief statement about overall impression correlated with age/growth & development.

General Appearance

  • Observing:

    • Stated age, level of consciousness (LOC), skin color, nutritional status, personal hygiene, posture, mobility, facial expressions, mood, affect, hearing, and speech characteristics (articulation, pattern, and content).

Specific Measurements and Skin Examination

  • Measurements:

    • Height, weight, compute BMI, vision assessment using the Snellen eye chart.

  • Skin Examination:

    • Assess both hands and inspect nails during corresponding regional examination throughout.

Vital Signs and Head & Face Assessment

  • Vital Signs:

    • Radial pulse, respiratory rate, blood pressure (measured in arms or lower legs, ankle/brachial index if indicated), and temperature.

  • Head and Face Inspection:

    • Inspect and palpate scalp, hair, cranium; observe facial symmetry, expression, and cranial nerve VII functionality; palpate temporal artery and temporomandibular joint (TMJ).

Eye Assessment

  • Test Vision:

    • Visual fields by confrontation, cranial nerve II.

  • Assess Extraocular Muscles:

    • Corneal light reflex, six cardinal positions of gaze, cranial nerves III, IV, and VI.

  • External Eye Structures Inspection:

    • Conjunctivae, sclerae, corneas, irides; test pupil size for light and accommodation in a darkened room.

  • Ophthalmoscopic Examination:

    • Inspect ocular fundus, red reflex, disc, vessels, and retinal background.

Ear Inspection

  • External Ear Examination:

    • Inspect position, alignment, skin condition, and auditory meatus; check for tenderness by moving the auricle.

    • Use otoscope to inspect the ear canal and tympanic membrane for condition and landmarks; conduct hearing tests (e.g., whispered voice test).

Nose Assessment

  • Inspect External Nose:

    • Look for symmetry and lesions; assess facial symmetry (cranial nerve VII functionality).

  • Nasal Examination:

    • Test patency of each nostril; using a speculum, inspect nares, nasal mucosa, septum, and turbinates.

Mouth and Throat Examination

  • Inspection:

    • Using light, inspect the mouth, including buccal mucosa, teeth, gums, tongue, floor of the mouth, palate, and uvula; grade tonsils if present.

  • Functionality Tests:

    • Note mobility of the uvula while phonating "ahh," assess gag reflex (cranial nerves IX & X), and check cranial nerve XII function with tongue protrusion; bimanually palpate the mouth with gloved hands if indicated.

Neck Assessment

  • Inspection and Palpation:

    • Inspect neck for symmetry, lumps, pulsations; palpate cervical lymph nodes, carotid pulse (one side at a time); listen for any carotid bruits if indicated.

    • Test range of motion and muscle strength against resistance: head forward, backward, side-to-side, and shoulder shrug (cranial nerve XI).

Chest Inspection: Posterior and Lateral

  • Inspection:

    • Inspect posterior chest for thoracic cage configuration, skin characteristics, symmetry of shoulders/muscles.

  • Palpation:

    • Symmetric expansion, tactile fremitus checking for lumps/tenderness.

  • Percussion:

    • Assess all lung fields and costovertebral angle for tenderness.

  • Auscultation:

    • Breath sounds compared side-to-side and upper-to-lower.

Chest Inspection: Anterior

  • Inspection of Anterior Chest:

    • Monitor respirations and skin characteristics.

  • Evaluation:

    • Palpate for tactile fremitus, lumps/tenderness, percuss anterior lung fields, and auscultate comparing both sides/regions.

Heart and Upper Extremities Assessment

  • Heart Examination:

    • Patient leans forward to exhale briefly; auscultate cardiac base for murmurs.

  • Upper Extremity Examination:

    • Test ROM, muscle strength of hands and arms; palpate epitrochlear nodes; assess temperature/capillary refill; compare radial and brachial pulses bilaterally.

Female Breast Examination

  • Inspection:

    • Assess for symmetry, mobility, and dimpling; palpate each breast while lifting the same side arm over head; assess nipple discharge.

  • Supportive Actions:

    • Teach breast self-examination, and palpate axilla and regional lymph nodes.

Male Breast and Neck Vessels Examination

  • Male Breast Assessment:

    • Inspect and palpate while assessing anterior chest wall; palpate axilla/regional nodes.

  • Neck Vessels:

    • Inspect for jugular venous pulse, estimating jugular venous pressure if indicated.

Heart Assessment

  • Precordial Inspection:

    • Inspect for any pulsations or heave; palpate apical impulse and assess for thrills.

  • Auscultation:

    • Measure apical rate and rhythm; assess heart sounds using diaphragm and bell of the stethoscope.

Abdomen Assessment

  • Inspection:

    • Assess contour, symmetry, skin characteristics, umbilicus, and any pulsations.

  • Auscultation:

    • Check bowel sounds and vascular sounds over aorta/renal arteries.

  • Percussion and Palpation:

    • Percuss all quadrants, palpate lightly and deeply for liver, spleen, kidneys, and detect pulsations if indicated.

Inguinal Area and Lower Extremities Assessment

  • Inguinal Assessment:

    • Palpate each groin for femoral pulse and inguinal nodes; expose legs as necessary.

  • Lower Extremities Examination:

    • Inspect for symmetry, skin characteristics, and hair distribution; palpate pulses (popliteal, posterior tibial, dorsalis pedis); inspect between toes; assess ROM and muscle strength in hips, knees, ankles, and feet.

Musculoskeletal System Examination

  • Assessment:

    • Note muscle strength while seated.

Neurologic Assessment

  • Tests:

    • Sensation in face, arms, hands, legs, and feet (superficial pain, light touch, vibration).

    • Test position sense of fingers; stereognosis; cerebellar functions with finger-to-nose test and rapid-alternating movements for upper extremities; assess lower extremities via heel-to-shin test.

  • Reflex Testing:

    • Elicit deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles); perform Babinski reflex test.