Health Assessment and Physical Assessment - Quick Reference

Components of Health Assessment

• Health history (subjective data: what client says)

• Physical examination (objective data: what nurse observes)

• Documentation of data

• Data collection terms:

  • Symptom = subjective data (what client feels)

  • Sign = objective clinical findings (observed during exam)

  • Clinical manifestations = signs and/or symptoms gathered via inspection, palpation, percussion, auscultation

Types of Assessments

• Comprehensive health assessment

• Problem-based (focused) health assessment

• Shift assessment

• Screening assessment

Interviewing Techniques

• Core nursing competency: obtain information and listen carefully

• Questions should be clearly spoken and understood

• Define words; avoid unnecessary slang; adapt to client understanding

• Encourage specificity; ask one question at a time; pause for reply

• Be attentive to client feelings; may indicate need for more data

• Sensitive topics require tact; seek clarification when needed

Types of Questions

• Open-ended: free-flowing responses; focus on health topics

• Close-ended: precise data; provide response options

• Directive: focuses client on one area; used in systems review and functional assessment

Challenges to the Interview

• Others in the room: clarify relationships; interview adolescent directly; assistants for adults if needed

• Language barriers: use an objective interpreter (same gender, not a family member); takes more time

Health History Types & Components

• Types: Comprehensive (full database) vs Focused/problem-based (scope limited to problem)

• Components:

  • Demographic information

  • Source of history

  • Chief concern

  • History of present illness

  • Past health history and current status

  • Family history

  • Psychosocial history

  • Health promotion behaviors

Review of Systems

• Extensive questioning to ascertain functioning of all body systems and problems

Purposes of Physical Examination

• Gather baseline data about client health

• Aid clinical decisions about changing health status and management

Physical Examination (Overview)

• May be focused or comprehensive depending on situation

• In hospital: general bed every $8\,\text{hours}$; IMC/ICU every $4\,\text{hours}$

Cultural Sensitivity

• Culture influences behavior, beliefs, therapies, nutrition, family relationships

• Avoid stereotyping and gender bias

Preparation for Examination

• Infection control: hand hygiene

• Equipment readiness

• Physical preparation and positioning of client

Organization of the Examination

• Systematic head-to-toe assessment

• Compare sides for symmetry

• Focus on systems at risk for abnormal findings

• Allow rest periods; record findings precisely

Physical Assessment Techniques

• Inspection, Palpation, Auscultation, Percussion (not routinely performed by RN)

Inspection

• Use adequate lighting; inspect body cavities with direct light as needed

• Assess size, shape, color, symmetry, position; expose surfaces while maintaining privacy

• Validate findings with client

Palpation

• Uses touch to gather data

• Use different parts of hands for different findings:

  • Dorsal surface: temperature

  • Fingertips: pulsation, position, texture, turgor, size, consistency

  • Palmar surface/base of fingers: vibration

• Hands warm; nails short

• Start with light palpation; end with deep palpation

Auscultation

• Listening to internal sounds; stethoscope blocks extraneous noise

• Use in quiet room; place stethoscope on skin (clothes can muffle sounds)

• Focus on transient or subtle sounds; selective listening

Percussion

• Not routinely performed by RN

General Survey

• Components: Physical appearance, Body structure, Mobility, Behavior, Vital signs, Mental status

Physical Appearance

• Age, Sex, Race/ethnicity; skin color; facial features

• Distress indicators: pallor, labored breathing, guarding, anxiety

Body Structure

• Body build, stature, height, weight; nutritional status

• Symmetry, posture; gross abnormalities; skin lesions; amputations

Mobility

• Gait, movement, range of motion, motor activity

Behavior

• Facial expressions, mood/affect, speech, dress, hygiene, odors

Mental Status

• Determine alertness and orientation; assess through questions/interactions

• Example orientations: name, time, place, event/situation

Vital Signs

• Baseline indicators: $T,<br>HR,<br>RR,<br>BP,<br>SpO_2$

• Nurse interprets trends and abnormal findings

Oral Temperature

• Range: $36-38^\circ\mathrm{C}$

• Oral route is safe and relatively accurate

• Wait $ext{minutes} \, 10$ after hot/cold liquids or smoking

• Used for clients $\ge 4\ \text{years}$

Temperature Sites

• Temporal, Tympanic, Oral, Rectal

Fever

• Illness/injury may elevate temperature; fever is the body’s response to infection/inflammation

Pulse

• Rate: $60-100/\min$ at rest

• Rhythm: regular vs irregular

• Strength: reflects volume ejected; arterial condition

• Equality: bilateral pulses should be similar

• Common site: Radial artery; also apical (mitral) via auscultation

How to Take Pulse

• Use index/middle fingers; press gently over pulse

• Regular rhythm: count for $30\text{ s} \times 2$

• Irregular rhythm: count for $1\text{ minute}$

• Document irregular rhythm

Apical Pulse

• Located at 5^{\text{th}}\text{ ICS},\; midclavicular line}

• Use stethoscope

Respirations

• Count ventilatory cycles per minute

• Do when client is unaware to avoid altered breathing

• Normal adult: $12-20/\min$

• Regular vs irregular; note rhythm and depth

Blood Pressure

• Measured in $\mathrm{mmHg}$

• Systolic: maximum arterial pressure during systole; normal <120\,mmHg

• Diastolic: minimum pressure during diastole; normal <80\,mmHg

• Direct vs indirect measurement

Direct and Indirect Blood Pressure Measurement

• Direct: arterial catheter for continuous monitoring (critical care)

• Indirect: auscultation with sphygmomanometer or automated cuff

Auscultation Method (Traditional BP)

• Sphygmomanometer components: gauge, cuff with inflatable bladder, bulb

• Stethoscope; listen for Korotkoff sounds

Automated Blood Pressure Monitoring

• Noninvasive electronic cuff (NIBP)

• Provides BP, mean arterial pressure, and pulse rate

• Cannot assess pulse quality (rhythm/strength)

Factors Affecting Blood Pressure

• Age, gender, race

• Diurnal variation: lower in morning, higher late afternoon/evening

• Emotions, pain, caffeine, smoking, weight

Oxygen Saturation

• Measured by pulse oximeter; $95\%-100\%$ expected

• Probe on finger, toe, earlobe, or nose; readout in seconds

Pain

• Routine assessment in all settings

• Often assessed with vital signs as part of overall comfort

Examination for Pain

• Observe posture and behaviors; facial expressions

• Listen for sounds; inspect skin; measure BP and pulse; assess respirations

Head-to-Toe Assessment

• Systematic approach; shift assessment often mirrors this process

Head & Neck

• Examines skull, face, hair, neck; jugular veins; shoulders

Skull

• Normocephalic; no deformities or tenderness; symmetry

Face

• Symmetry of features; facial expressions; no involuntary movements

Eyes

• External & internal anatomy; visual acuity; EOM; visual fields; external structures

External Eye Structures

• Lashes, eyebrows, iris, lacrimal caruncle, pupil, upper/lower lids, conjunctiva, lateral/medial canthi

Sclerae Color

• White (normal); yellow (jaundice); red (irritation)

Eyes (EOM & PERRLA)

• EOM tested by 6 cardinal positions; CN III, IV, VI

• PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation

Ears

• External ear: alignment, color, lesions, tenderness; cerumen

Nose

• Midline, symmetrical; nares patent; septum intact; mucous membranes moist with no discharge

Mouth

• Lips: moist, symmetric; Gums: pink, tight; Mucous membranes pink/moist

• Teeth: intact; note missing/loose teeth; discolored teeth

• Tongue: midline, moist, moves freely

Neck

• ROM: flexion (chin to chest); lateral flexion (ear to shoulder); hyperextension (chin up)

• Jugular veins distention assessment

Thorax, Heart, and Abdomen

• Breast inspection: size, symmetry, lesions

• Thorax/lungs: inspect shape, symmetry; respiratory support; cough; sputum

Thorax & Lungs - Inspection & Auscultation

• Inspect: respiratory effort, rate, pattern, use of accessory muscles, chest expansion, depth

• Auscultation sites: posterior thorax between scapulae; anterior/midaxillary lines; ensure side-to-side comparison

• Normal vs abnormal breath sounds: crackles, rhonchi, wheezes, pleural rub; absent/diminished

Heart

• Heart rate; auscultate heart sounds; blood pressure

• S1, S2, S3 (ventricular gallop), S4 (atrial gallop)

• Dysrhythmias; murmurs (grade/pitch/quality)

• Auscultatory sites: Aortic (RSB 2nd ICS), Pulmonic (LSB 2nd ICS), Tricuspid (LSB 4th ICS), Mitral/APICAL (L MCL 5th ICS)

Abdomen (Subjective)

• Ask about swallowing, appetite, N/V, last BM, diarrhea/constipation, passing flatus, urination issues

Abdomen Inspection

• Color, skin lesions/incisions/scars; contour (flat, convex, concave, distended)

• Note guarding or splinting; silver striae

Abdomen Distention & Abnormal Findings

• Distention due to fat, fluid, gas, hernia; bulges; venous engorgement; abnormal contour

Abdominal Devices & Urinary Drainage

• GI devices: NG, G-tube, PEG; urinary devices; assess patency, urine color/clarity/amount/odor

Abdomen Auscultation

• Use diaphragm; listen in all 4 quadrants until sounds heard (usually 5-20 s per quadrant; if none, listen 5 minutes to confirm)

• Expected: bowel sounds in all quadrants; assess motility and borborygmi

Abdomen Palpation

• Performed last; assess tenderness, distention, masses

• Can be light or deep; normal=soft and nondistended

Integumentary System

• Skin: color, moisture, temperature, texture, turgor

• Skin Turgor: returns to original position; tenting = dehydration

Skin Color Abnormalities

• Pallor, Cyanosis, Jaundice, Erythema

Skin Lesions, Wounds, and Incisions

• Size, color, shape, consistency, elevation, location, distribution, tenderness, fluid, drainage

• Measure height, width, depth; note odor

Nails

• Inspect/palpate; reflect health, nutrition, occupation, self-care, age

• Clubbing: angle > $160^{\circ}$

Hair

• Distribution; alopecia; hirsutism

Peripheral Arteries (Vascular System)

• Assess perfusion: pulses, skin/nail condition, venous system integrity

• Compare right vs left sides

Peripheral Arteries Pulses & Grading

• 0: absent; 1+: diminished; 2+: normal; 3+: full; 4+: bounding

Capillary Refill

• Palpate fingers/toes; color return < $2\ \text{seconds}$

Vascular System Edema

• Edema: pitting edema graded 1+ to 4+ (depth in mm varies by grade)

Genitalia and Rectum

• Not routinely part of head-to-toe; culturally sensitive

• Female genitalia assessed on gynecologic/OB units; male during urologic procedures

• Rectum/anus: privacy; inspect and digital palpation when indicated

Musculoskeletal System

• Assessment: inspection & palpation; gait; alignment; symmetry; muscle tone; ROM; involuntary movements; inflammation signs; deformities

Abnormal Curvatures

• Kyphosis, Scoliosis, Lordosis

Neurological System

• Focus on mental status, motor function, gait, coordination

• Integration throughout data collection

• Cranial nerve assessment overview

Level of Consciousness (LOC)

• LOC changes are early/central indicators of cerebral function changes

• Examples of changes: alert to lethargic, calm to restless

Describing LOC: Standard definitions

• Alert: responsive; spontaneously answers questions

• Lethargic: arousable but sleeps with stimuli

• Stuporous: withdraws to painful stimuli

• Comatose: no response to stimuli

Glasgow Coma Scale (GCS)

• Score range: $3-15$; higher is better

• Components: E (eye opening), V (verbal), M (motor)

• PGCS is used for children 2 years and younger

• Interpretation: 13-15 mild, 9-12 moderate, ≤8 severe brain injury

After the Examination

• Ensure client comfort; document findings; verify accuracy

• Communicate significant findings to physician/NP/PA

Key Points

• Prepare environment/equipment and client physically/psychologically

• Keep client warm, comfortable, and informed throughout

• Use a systematic, head-to-toe approach; history guides focus

• Focus on essential data for quick recall