Health Assessment

Chapter 27: Health Assessment

Professionalism in Nursing

  • Be Prepared and On Time: Ensures respect for the patient and colleagues.

  • Appropriate Attire: Wear professional clothing appropriate for the healthcare setting to maintain a respectful environment.

  • Be Present: Avoid distractions including phone use during assessments.

Health Assessment

  • Types of Data:

    • Subjective: Information based on patient experiences and perceptions.

    • Objective: Measurable data that can be directly observed.

  • Data Collection:

    • Health History: Collection of subjective information about health status.

    • Physical Assessment: Collection of objective observations about body systems.

Types of Health Assessments

  1. Comprehensive Assessment: Conducted upon patient admission to a healthcare facility.

  2. Ongoing Partial Assessment: Conducted at regular intervals to monitor changes.

  3. Focused Assessment: Targeted evaluation of specific health problems.

  4. Emergency Assessment: Quick assessment to identify life-threatening or unstable conditions.

Preparing the Patient for Physical Assessment

  • Physiological and Psychological Needs: Consider these needs before beginning assessment.

  • Explanation: Clearly explain the assessment process and procedures to the patient.

  • Pain Management: Assure the patient that assessments will not be painful, easing fear and anxiety.

  • Privacy: Maintain privacy with drapes, and answer any questions honestly.

Considerations When Performing Health Assessment

  • Lifespan Considerations: Adapt assessments according to the age of the patient.

  • Cultural Considerations: Be respectful and sensitive towards cultural differences.

  • Patient Preparation: Properly prepare the patient for assessment to facilitate cooperation.

  • Environmental Preparation: Ensure the assessment environment is conducive to comfort and privacy.

Factors to Assess During a Health History

  • Biographical Data: Collect vital information about the patient.

  • Reason for Seeking Health Care: Understand the main concerns or symptoms.

  • History of Present Health Concern: Document relevant details of symptomatic concerns.

  • Past Health History: Review patient's medical history for context.

  • Family Health History: Assess hereditary conditions and risks.

  • Functional Health: Evaluate how well the patient can function in daily life.

Preparing the Environment for Physical Assessment

  • Hand Hygiene: Essential to prevent infection.

  • Examination Table Preparation: Ensure the table is clean and ready for use.

  • Patient Gown and Drape: Provide appropriate garments to maintain modesty.

  • Precautions: Confirm if there are specific precautions beyond standard ones.

  • Gather Supplies: Collect all necessary instruments and tools before the assessment begins.

  • Comfortable Room Temperature: Ensure that the environment is not too cold or hot.

Equipment Used During a Physical Examination

  • Thermometer and Sphygmomanometer: For measuring temperature and blood pressure, respectively.

  • Scale: To assess the weight of the patient.

  • Flashlight or Penlight: For detailed inspection of dark areas.

  • Stethoscope: Essential for auscultation of heart and lung sounds.

  • Metric Tape Measure and Ruler: For measuring body parts.

  • Eye Chart: For vision assessment.

  • Watch with a Second Hand: To time various assessments.

Positions Used During a Physical Assessment

  • Standing: Used for posture, balance, and gait assessment.

  • Sitting: Facilitates upper body visualization.

  • Supine: Allows relaxation of abdominal muscles.

  • Dorsal Recumbent: For patients having difficulty being supine.

  • Sim’s Position: Focused on rectal or vaginal assessment.

  • Prone: For assessment of hip joint and posterior thorax.

  • Lithotomy Position: Used for female genitalia assessment.

  • Knee-Chest Position: For rectal examination.

Techniques Used During a Physical Assessment

  • Inspection: Assessing size, color, shape, position, and symmetry of body parts.

  • Palpation: Touch to assess temperature, turgor, texture, and vibrations.

  • Percussion: Tapping to evaluate the characteristics of underlying tissues.

  • Auscultation: Listening to the sounds produced by organs and tissues.

General Survey

  • Includes assessment of:

    • General Appearance: Overall look and health of the patient.

    • Vital Signs: Heart rate, respiratory rate, blood pressure, and temperature.

    • Height, Weight, and Waist Circumference: Important for calculating BMI.

Physical Assessment Components

  • Integument: Skin health and evaluation.

  • Head and Neck: Comprehensive assessment including HEENT.

  • Thorax and Lungs: Respiratory assessment.

  • Cardiovascular System: Heart health evaluation.

  • Breast Assessment: Inquiry on breast conditions.

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

  • Genitalia: Assessment of male and female anatomy and health.

  • Musculoskeletal System: Evaluation of joint and muscle function.

  • Neurologic System: Assessment of nervous system capabilities and responses.

Integument (Skin) Assessment

  • Subjective: Includes history of rashes, lesions, allergies, or bruising, along with exposure histories.

  • Objective: Assess color, temperature, texture, turgor, and lesions of the skin.

Skin Language Terminology

  • Erythema: Redness.

  • Cyanosis: Bluish color.

  • Jaundice: Yellow discoloration.

  • Pallor: Paleness.

  • Petechiae: Small hemorrhagic spots.

  • Turgor: Skin elasticity.

  • Edema: Fluid accumulation.

  • Diaphoresis: Excessive sweating.

Skin Terminology for Lesions

  1. Primary Lesions:

    • Macule: Flat, circumscribed area.

    • Papule: Elevated, palpable area <5mm.

    • Vesicle: Fluid-filled blister <5mm.

    • Pustule: Similar to vesicle but filled with pus.

    • Bulla: Blister >5mm.

    • Cyst: Fluid-filled elevated area.

    • Nodule: Palpable area >5mm.

    • Plaque: Elevated, flat-topped area >2cm.

    • Wheal: Elevated, irregularly shaped lesions.

  2. Secondary Lesions:

    • Crust: Dried serum or exudate.

    • Excoriation: Linear scratches.

    • Lichenification: Thickened skin from rubbing.

    • Scale: Flaky, exfoliated skin.

Assessment of Skin, Hair, and Nails

  • Inspection:

    • Assess color, shape, lesions, and distribution.

    • Use ABCDE rule for skin cancer screening.

  • Palpation:

    • Evaluate temperature, texture, turgor, and capillary refill (normal <3 seconds).

ABCDE for Skin Cancer Screening

  • A: Asymmetry

  • B: Border irregularity

  • C: Color variation

  • D: Diameter >6mm

  • E: Evolving lesions

HEENT Assessment (Head, Ears, Eyes, Nose, Throat)

  • Subjective: Gather patient history on vision, hearing, and exposure to harmful substances.

  • Objective Inspection and Palpation:

    • Check for symmetry, size, shape of head and face.

    • Assess nasal patency and any frontal/maxillary sinus issues.

Ear Assessment

  • Inspection: Examine for shape, size, lesions, and cerumen.

  • Palpation: Check for pain in the ear and mastoid area.

  • Whisper Test: Evaluates hearing and CN VIII function.

Eye Assessment

  • Inspection: Evaluate eyelids, cornea, and conjunctiva for clarity and symmetry.

  • Evaluation: Check direct and consensual light reflex and extraocular movements.

Throat Assessment

  • Objective: Inspect the mouth and throat for lesions, color, and moisture. Check for movement of uvula to assess cranial nerves IX and X.

Thyroid Assessment

  • Technique: Inspect and palpate the thyroid gland for size and nodules.

Neck Assessment

  • Palpation: Assess lymph nodes, noting any enlargements or tenderness.

Thorax and Lung Assessment

  • Subjective and Objective Data:

    • Gather history of respiratory symptoms and conduct inspection, palpation, and auscultation for abnormalities.

Cardiovascular Assessment

  • History: Document any related pain, palpitations, and patient history.

  • Objective Inspection and Techniques: Assess neck vessels, precordium, and apical impulse systematically.

Peripheral Vascular System Assessment

  • Subjective: Look for swelling and perfusion issues.

  • Objective: Inspect extremities for lesions and check pulses across major arteries.

Abdominal Assessment

  • Subjective: Collect information on symptoms like pain and dietary habits.

  • Objective Sequence: Follow inspection, auscultation, percussion, and palpation for assessment.

Breast Assessment

  • Inquiry: Discuss any pain, lumps, or discharge with patients prior to examination.

  • Objective Inspection and Palpation: Assess breast and axillary areas systematically.

Male and Female Genitalia Assessments

  • Subjective: Document patient history relevant to sexual and reproductive health.

  • Objective: Inspect and assess for any abnormalities in both genders.

Musculoskeletal Assessment

  • Subjective: Gather history on trauma and exercise routines.

  • Objective: Inspect muscle symmetry, assess range of motion, and perform strength grading.

Neurologic Assessment

  • Subjective: Evaluate any neurological symptoms such as dizziness and numbness.

  • Objective: Assess mental status, cranial nerves, motor and sensory function, and reflexes.