Health AssessmentChapter 25

Competencies for Ch 25, Health Assessment By the end of this unit, the student will:

Demonstrate techniques to obtain patient information

Describe the components of a health assessment Describe how to prepare the patient for the exam List the equipment needed for an examination Demonstrate a brief head to toe physical

assessment

Health Assessment

Two components of the health assessment Health History Physical Assessment

What happens during a health assessment between a patient and nurse? Establish the nurse-

patient relationship Gather data-

physiological, psychological,cognitive, sociocultural, developmental, spiritual

Identify patient strengths

Identify actual and potential health problems

Establish a base for the nursing process (Assessment)

General Guidelines for Physical Assessment Instrumentation Positioning Draping Preparation of the environment Patient preparation Techniques of physical assessment

Positioning Sitting –used in an

upright chair or dangling off exam table

Supine-lie flat on your back

Dorsal recumbent-lie back with knees bent

Sims’s-lies on either right or left side lower arm behind the body and the upper arm is bent at the shoulder and elbow and knees are both bent

•Prone-Pt. Lies on abdomen

•Lithotomy- patient is in a dorsal recumbent position with buttock at the edge of the examining table and feet support in stirrups.

•Knee to Chest-using the knees and chest to bear the weight of body.

•Standing

Draping, preparing the environment Draping prevents

unnecessary exposure, provides privacy, and keeps the patient warm during the physical exam (P.E.).

Prepare examination table Place a gown and drape on

the table Set up any supplies that

are needed.

-Example: otoscope, tuning fork, ophthalmoscope.

Pull curtain around or close door to exam room

Techniques for examination Inspection- observing, listening or smelling to

gather data Palpation-assessment that uses sense of touch Percussion-act of striking on e object against

another to produce a sound Auscultation-act of listening with a stethoscope to

sounds produced with in the body.

Inspection

Deliberate, purposeful, observations in a systematic manner

Nurse use the physical senses: visualizing, hearing, and smelling

Instrumentation or Equipment used for inspecting Ophalmoscope-

Exam the eyes Otoscope- examine the

ears, mouth and nostrils Tuning fork - hearing Nasal speculum-visualized

the turbinates of the nose Stethoscope

Instrumentation or Equipment used for vision screening

Snellen chart- used to check eye sight

Palpationtechnique using the sense of touch

The hands and fingers are sensitive tools and assess: Temperature- use the dorsum of the hand Turgor Texture Moisture Vibrations Shape

Use the palmer (front side) of the hand

Percussion-the act of striking one object against another to produce a sound

Percussion tones are used to assess location, shape, size and density of tissue

Percussion Tones Flat Dull Resonance Hyper resonance Tympany

Auscultation-act of listening with a stethoscope to sounds produced with in the body

Four characteristics assessed by auscultation Pitch- ranging from high to low Loudness- ranging from soft to loud Quality- gurgling or swishing Duration (short, medium, long)

General Survey

Gather information regarding Patient's appearance,

behavior Measuring vitals signs Height, and weight

General appearance Gender and race Body build, posture and

gait

General appearance Hygiene, grooming

(note body odor, cleanliness).

Signs of illness Affect, mood, attitude

(speech and facial expressions)

Cognitive process (speech content, patterns, orientation, appropriate verbal responses)

Vital Signs, Height and Weight Take Vital signs (VS)

and determine normal or abnormal -document

Height and weight- document

(Check the height and weight table to determine if a patient is under, normal or over weight.)

Physical Assessment Head to Neck General survey Height and weight Vital Signs

Neck Skin Lymph nodes Muscles Thyroid Trachea Carotid arteries Neck veins

•Head –Skin

–Face, skull, scalp, hair

–Eyes

–Nose and sinuses

–Mouth and or pharynx

–Cranial nerves

Integument structures

Skin Nails Hair Scalp

Obtain history of rashes, lesions, changes of color or itching

History of bruising or bleeding

Exposure to sun Note presence of wounds,

abrasions Changes in mole size,

shape or color

SKIN

Inspect for color, vascularity, lesions and body odors

Color-pinkish white to various shades of brown.

Skin Color variations

Assessment areas Possible causes

Redness (erythema, flushing

Facial area Blushing, ETOH intake, fever, injury or infection

Bluish (cyanosis) Exposed areas, ears,lips, inside of mouth, hands feet, nail beds

Cold environment, cardiac or respiratory

Yellowish (jaundice) Overall skin areas, mucus membranes, sclera

Liver disease (increased bilirubin)

Vitiligo Whitish patchy areas De-pigmentation (autoimmune)

Tanned or brown Sun-exposed Melanin production Pregnancy brown spots?

Head and Neck

Assessment includes Skull Face Eyes Ears Nose Sinuses Mouth

•Pharynx •Trachea •Thyroid glands•Lymph nodes

Skull and face

Inspect size and shape Symmetry

Face- examine color Symmetry Distribution of facial

hair Assess facial nerve and

facial muscles-

                                                                                                                                                                                                                                                                                                                                                                                

  

cellulitis

Eye and Ears

EYE Inspect external

structures Pupils and Iris Internal structures Vision Extra ocular movement Peripheral vision

EAR Inspect external ear for

shape, size, location bilaterally, ear should be smooth Gently palpate ear for

pain, edema, or presence of lesions

Check hearing Inspect internal ear

Bacteria Conjunctivitis

Acute Glaucoma

Healthy Ear

Acute otitis media

Chronic otitis media, stapes extruding

Cerumen in ear

Nose and Sinuses

Nose Inspect size, shape and

location Check for patency

(open air passageways.)

Inspect using otoscope nares and turbinates

Sinuses Inspect the sinuses

and gently palpate maxillary bone and frontal sinus

Normally the sinuses are not painful.

Hematoma

Polyp

MOUTH AND PHARYNX

Composed of many structures Lips, tongue, teeth, gums

hard and soft palate,salivary gland, tonsillary pillars, and tonsils

Equipment needed: Penlight, tongue blade,

4X4 gauze sponge, and gloves

Tonsillitis

Hairy tongue

Neck

Trachea- note location Midline at the

suprasternal notch Thyroid- thyroid is

normally not palpable. Palpate for size shape, symmetry tenderness and presence of any nodules

Lymph nodes Generally not palpable If palpated, should be

small mobile, smooth non-tender

Abnormal- enlarged, indicate infection, autoimmune, or metastasis of cancer

ASSESSMENTPart I

COURSE OBJECTIVES

Students will learn: Components of a health assessment To prepare the patient for the exam What equipment is needed for the exam A variety of techniques to obtain patient

information How to examine the patient head to toe

HEALTH ASSESSMENT

Two components of the health assessment Health History Physical Assessment

WHAT HAPPENS DURING THE ASSESSMENT Establish the nurse patient relationship Gather data in the following areas

Physiological Psychological Cognitive Sociocultural Developmental Spiritual

Identify patient strengths Identify actual and potential health problems Establish base for nursing process

GENERAL GUIDELINES

Instrumentation Positioning Draping Preparation of the environment Patient preparation Assessment techniques

POSITIONING

Sitting – use upright chairor dangle of exam table.

Supine – flat on the back Dorsal Recumbant – on

back with knees bent Sim’s – lie on side, lower

arm behind back, upper arm bent at the shoulder and elbow, knees both bent

ASSESSMENT part 2

PULMONARY

HISTORY INSPECTION PALPATION PERCUSSION AUSCULTATION BREATH SOUNDS

PULMONARY

CARDIOVASCULAR

History Inspection Palpation Auscultation Heart sounds Peripheral vascular system

CARDIOVASCULAR

BREAST/AXILLA

History Inspection Palpation

ABDOMEN

History Inspection Auscultation Percussion Palpation

GENITALIA

Female History Inspection

Male History Inspection

MUSCULOSKELETAL

History Inspection Palpation Testing

Tone Strength

Bones and Joints

NEUROLOGICAL

History Mental Status

Orientation Level of Consciousness Memory Abstract Reasoning Language

CRAINIAL NERVES

Olfactory (I) Optic(II) Oculmotor (III),

Trochlear(IV), Abducens(V)

Trigeminal(VI) Hypoclosseal (VII)

Facial (VIII) Acuoustic (IX) Glossopharyngeal (X) Vagus (XI) Accessory (XII)

SENSORY MOTOR FUNCTION

Motor Balance and gait Coordination Sensory

REFLEXES

Abdominal Babinskis Bicepts Triceps Patellar Achilles Tendon