Health assessment:

• Introduction:The ability to assess patients in holistic manner is a skill

integral to nursing, regardless of the practice setting.

• As the first step in the nursing process, patient assessment is necessary to

obtain data that enable the nurse to make an accurate nursing diagnosis,
identify and implement appropriate interventions, and assess their
effectiveness.

• Purpose & objectives:

• This session will provide the nurse with the knowledge needed to provide a
complete health assessment for a patient. And the nurse will be able to

• Ask appropriate questions to elicit data that will be used to guide a

physical examination.

• List the components of the comprehensive physical examination and

review of systems based on the data identified in the patient history.

• Determine when to perform four different types of health assessments:

• Complete or comprehensive

• Interval or abbreviated

• Focused

• Special populations

Definition:
A health assessment is a plan of care that identifies the specific needs of a person
and how those needs will be addressed by the healthcare system or skilled nursing
facility. Health assessment is the evaluation of the health status by performing
a physical exam after taking a health history.

It is done to detect diseases early in people that may look and feel well.

Health history:
• A thorough and skilled assessment allows you, the nurse, to obtain descriptions
about your patient’s symptoms, how the symptoms developed,

• Assessment uses both subjective and objective data

• Subjective :- reported by the patient

 • Objective :- observable & measurable

Type of health assessment:

There are 4 types of health assessment;

1. A comprehensive or complete health assessment

2. An interval or abbreviated assessment

3. A problem-focused assessment

4. An assessment for special populations

.Purposes:

.The purpose of obtaining a health history is to provide you with a description of

your patient’s symptoms and how they developed.

.A complete history will serve as a guide to help identify potential or underlying

illnesses or disease states.

.Obtaining data about the patient’s physical status,

.Obtain information about many other factors that impact your patient’s physical
status including spiritual needs, cultural idiosyncrasies, and functional living status.

components of the complete health history:

• Biographical data

• Chief complaint

• Present health status

• Past health history

• Current lifestyle

• Psychosocial status

• Family history

• Review of systems

Biographical data:
• This includes;

• Name
 • Address

• Age

• Gender

• Marital status

• Occupation

• Ethnic origin

Past Health History:

• It is important to ask questions about your patient’s past health history.

• This includes patient’s

• childhood illnesses and immunizations,

• accidents or traumatic injuries,

• Hospitalizations

• Surgeries

• psychiatric or mental illnesses

• allergies, and chronic illnesses.

• For women-history of menstrual cycle, how many pregnancies and how many
births

Family History:
• To identify diseases that may be genetic, communicable, or possibly environmental
in origin.

• asks about the age and health status, or the age and cause of death, of first-order
relatives and second-order relatives.

• In general,

• the following conditions are included:

• Cancer

• Hypertension
 • heart disease

• Diabetes

• Epilepsy

• mental illness

• Tuberculosis

• kidney disease

• Arthritis

• Allergies

• Asthma

• alcoholism, and obesity.

• One of the easiest methods of recording such data is by using the family tree,
genogram, or pedigree.

Environment:
• Physical Environment:

• living arrangement

• housing

• Neighborhood

• and the presence of environmental hazards (eg, isolation, potential fire risks,
inadequate sanitation).

Spiritual:
• Spiritual :

• Spirituality may be expressed through identification with a particular religion.

• Spiritual values and beliefs often direct a person’s behavior and approach to
health problems and can influence responses to sickness.

• Illness may create a spiritual crisis and can place considerable stress on a
person’s internal resources and beliefs.
Assessment Techniques:
• Inspection:
• INSPECTIONis the most frequently used assessment technique. When you are using
inspection, you are looking for conditions you can observe with your eyes, ears, or
nose.

• You can inspect

• skin color

• location of lesions

• bruises or rash

• Symmetry

• size of body parts and abnormal findings

• Auscultation:
• AUSCULTATIONis usually performed following inspection, especially with
abdominal assessment.

• The abdomen should be auscultated before percussion or palpation to

prevent production of false bowel sounds

• ensure the exam room is quiet and auscultate over bare skin, listening to one
sound at a time.

• should never be performed over patient clothing or a gown, as it can produce

false sounds or diminish true sounds.

• The bell or diaphragm of your stethoscope should be placed on your

patient’s skin firmly enough to leave a slight ring on the skin when removed.

• Palpation:
• PALPATION, another commonly used physical exam technique, requires you
to touch your patient with different parts of your hand using different
strength pressures.

• During light palpation, you press the skin about ½ inch to ¾ inch with the
pads of your fingers.

• When using deep palpation, use your finger pads and compress the skin
approximately 1½ inches to 2 inches.
 • Light palpation allows you to assess for texture, tenderness, temperature,
moisture, pulsations, and masses.

• Deep palpation is performed to assess for masses and internal organs

• Percussion:
• Press the distal part of the middle finger of your non dominant hand firmly on
the body part.

• Keep the rest of your hand off the body surface. Flex the wrist, but not the
foreman, of your dominant hand.

• Using the middle finger of your dominant hand, tap quickly and directly over
the point where your other middle finger contacts the patient’s skin, keeping
the fingers perpendicular. Listen to the sounds produced

• These sounds may include;

• Tympanysounds like a drum and is heard over air pockets.

• Resonance is a hollow sound heard over areas where there is a solid

structure and some air (like the lungs).

• Hyperressonanceis a booming sound heard over air such as in emphysema.

• Dullness is heard over solid organs or masses.

• Flatness is heard over dense tissues including muscle and bone

PHYSICAL EXAMINATION:
• The physical examination can be performed in a “head-to-toe” manner,

• The components of a physical examination include general observations and then a

more focused assessment of the pertinent body systems.

• The physical exam include

• Patients biographic data

• Vital signs:- temp. pulse, respiration, B.P

• General appearance:- alert/responsive, listless/acute or chronically ill

• Skin assessment:-normally Smooth, good color, moist/

• When assessing the skin, EXAMINE the following
 • General pigmentation (evenness, appropriate for heritage)

• Systemic color changes (pallor, erythema, cyanosis, jaundice)

• Freckles and moles (symmetry, size, border, pigmentation)

• Temperature (hypothermia, hyperthermia)

• Moisture and texture (diaphoresis, dehydration, firm smooth texture)

• Edema (location and degree)

• Bruising (location, pattern, consistent with history – especially in at risk populations)

• Lesions (color, elevation, pattern or shape, size, location, exudates)

• Hair :-

• normal-shiny, healthy scalp,equally distributed.

• Abnormalae-Dull and dry, brittle, depigmented, easily plucked; thin and

sparse

• Nails :-

• Normal-Firm, pink,

• Abnormal- Spoon-shaped, ridged, brittle

• Face:-

• Normal- Skin color uniform; healthy appearance

• Abnormal - Skin dark over cheeks and under eyes, skin flaky, face swollen or
hollow/sunken cheeks

• Eyes :-

• Normal- Bright, clear, moist

• Abnormal -Eye membranes pale, dry (xerophthalmia); increased vascularity,

cornea soft (keratomalacia)

• Conjunctiva and sclera (redness, irritation)

• Pupil (shape, symmetry, light reflexes, accommodation

• Ears

• Size, shape, skin condition, and tenderness

 • External canal (redness, swelling, discharge)

• Tympanic membrane [color & characteristics (amber, redness), air/fluid

levels]

• Hearing acuity (also examined as you collect the patient’s history)

• Nose

• Nasal cavity (discharge, rhinorrhea, swollen, boggy, mucosa)

• Lips:-

• Normal- Good color (pink), smooth

• Abnormal - Swollen and puffy; angular lesion at corners of mouth (cheilosis)

• Tongue

• Normal - Deep red in appearance; surface Smooth appearance,

• Abnormal - swollen, beefy-red, sores, atrophic papillae present papillae

• Teeth

• Normal - Straight, no crowding, no dental caries,

• Abnormal - Dental caries, mottled appearance (fluorosis),

malpositionedbright

• Gums

• Normal- Firm, good color (pink)

• Abnormal - Spongy, bleed easily, marginal redness, recession

• Thyroid

• Normal - No enlargement of the thyroid

• Abnormal - Thyroid enlargement (simple goiter)

• Cardiovascular Assessment
• Palpate and auscultate the carotid artery (strength of pulsation, bruits,
murmurs)

• Auscultate heart sounds

• Listen for murmurs- note timing, loudness, pitch, quality,

 • Palpate peripheral pulses: brachial, radial, femoral, popliteal, dorsalispedis,
posterior tibial (strength and symmetry)

• Inspect extremities (color, capillary refill, edema, ulcerations)

• Pulmonary Assessment
• Inspect the thoracic cage (symmetry of expansion)

• Percuss the thoracic cage (hyperressonance, dullness, diaphragmatic

excursion)

• Auscultate the anterior and posterior chest.

• Identify any adventitious breath sounds, their location, and timing in relation
to the cardiac cycle (crackles, or rales and wheezes or rhonchi)

• Measuring body temperature:

• Definition: Measuring temperature of the body by using clinical thermometer.

• Common method :

Oral
Rectal
Axillary

Purposes:

. To assess the general health status of the patient.

. To assess for any alteration in health status.

Articles:

.A Clean tray containing.

.A bottle with disinfectant solution.

.A Bottle with water.

.Thermometer.

.Small bowl with cotton swab.

.Paperback.

.Pen
• Procedure:
• A certain method of taking temperature and explain procedure to the patient and
instruct him/ her to co-operate.
•
- prepare equipment.

- Wash the hand.

- check temperature:

. Oral method

. Rectal method

.Axillae

. Tympanic membrane

- remove thermometer

- read the temperature

- shakedown the Mercury level

- clean the thermometer by using soap and water.

- drive and store it in disinfectant solution.

- wash the hand.

- document temperature.

- replace articles.

. Special points: It is always best to use individual thermometer for each patient.

Normal temperature:

Age Centigrade

3-11 month 37.4

1-3 yr. 37.6
4-7 yr. 37
• Assessment of pulse:
. Definition: Checking pulse rate, rhythm, volume for assessing circulatory status.

Purpose:

- to establish baseline data.

- to check abnormalities in rate

- to monitor any changes in health status

- check peripheral circulation.

. Sites:

- radial

- temporal

- carotid

- apical

- brachial

- femoral

- posteriortibia

- brachial

-ulnar

-popliteal artery

• Articles:

-Wrist watch.

-pen

Procedure:

- explain procedure to the patient.

- wash the hand

- select the pulse site.

- assist the patient to comfortable position.

- palpate and check the pulse.

- document the data in the appropriate record

- wash the hand.

Normal pulse rate:

Age Normal pulse rate

1yr 100-170/m
3yr 80-170/m
6yr 80-130/m
8-15yr 80-86/m
Adult 70-80/m

Assessing respiration:
Definition: Monitoring inspiration and expiration in a patient.

. Purposes:

- to assess rate, rhythm, and volume of respiration.

- to assess for any changes in condition and health status.

- to monitor the effectiveness of therapy related to respiratory system.

. Articles:

- wrist watch.

- pen

- graphics sheet.

. Procedure:

- ensure that patient is relaxed.

- assist other vital sign such as pulse or temperature prior to continuing respiration.

- check the position of the patient.

 - keep your finger over the wrist as if checking pulse.

- observe one complete respiratory cycle.

- assess rate, depth, rhythm.

- count respiration for 1 whole minutes.

- wash the hand.

- record the findings.

Normal respiration rate:

Age Normal rate

New-born 36-40/m
1-2 month 28-32/m
2-4 yr. 22-26/m
5-10 yr. 18-24/m
11-18 yr. 16-24/m

Blood Pressure:
Definition:Blood pressure (BP) is the pressure of circulating blood on the
walls of blood vessels.

• Purposes:

- to monitor change in condition of the patient.

- to assess response to medical therapy.

- to determine patient hemodynamic status.

. Articles:

- blood pressure apparatus[sphygmomanometer]

- stethoscope

- patient chart for recording

- pen.
 • Procedure:

-Wash hands.

- apply deflated cuff evenly with rubber bladder over the brachial artery

- palpate the brachial artery with the finger tips.

- place the bell of the Stethoscope on the brachial pulse.

- the Stethoscope Must hang freely from the ears.

- close the wall on the pump by turning the knob clockwise.

- open the valve slowly by turning the knob anticlockwise.

- permit dare to escape very slowly.

- note the number on the manometer where the sound first beings. This is systolic
pressure.

- continue to release the pressure slowly. The sound become a louder and clearer.

- not the point on the manometer where the sound cease. This is diastolic pressure.

- do not take blood pressure more than 3 times in succession on the same arm.

- watch the hand.

- document the reading.

- replace the article.

Assessing the Abdomen/Gastrointestinal System:

• Inspection:

• For bulges, masses, hernias, ascites, veins, pulsations or movements.

• Auscultation:

• Auscultate after inspection so you do not produce false bowel sound through
percussion or palpation;

• auscultate for bowel sounds (normal, hyper- or hypo-active) and bruits.

• Percussion:
 • Percuss for general tympanic, liver span, splenic dullness (dullness over the
spleen) tenderness, presence of fluid wave and shifting dullness with ascites

• Palpation:

• Palpate lightly then deeply noting any muscle guarding, masses or tenderness
(tender areas last)

• Palpate the spleen (enlargement occurs with mononucleosis and trauma)

• Palpate the kidneys (enlargement may indicate a mass)

• Assess for rebound tenderness (pain on release of pressure to the abdomen

usually indicates peritoneal irritation)

Musculoskeletal System:
• Inspect the size and shape of any problem joints (color, swelling, masses,
deformities)

• Palpate each joint for temperature and range of motion (heat, tenderness, swelling,
masses, limitation in range of motion)

• Test muscle strength and strength against resistance of the major muscle groups of
the body

• Assess the cervical spine (alignment of head and neck, symmetry of muscles,
tenderness, spasms, range of motion)

• Inspect and assess upper extremity strength and range of motion for the shoulders,
elbows, wrists, and hands

• Inspect and assess lower extremity strength and range of motion for the hips, knees,
ankles and feet

Male Reproductive System:

• Inspect and palpate the penis (inflammation, lesions, freely moveable foreskin in
uncircumcised male, location of urinary meatus, narrowed urethral opening)

• Inspect and palpate the scrotum (scrotal edema, lesions or inflammation, absent,
atrophied or fixed testes, tenderness of testicle or spermatic cord)

• Inspect and palpate for hernia

• Inspect and palpate inguinal lymph nodes

Female Reproductive System:
• In the lithotomy position examine the external genitalia:

• Skin colour

• Labia and clitoris (swelling, lesions)

• Urethral opening (stricture, inflammation)

• Vaginal opening (foul-smelling discharge, inflammation, lesions)

• Palpate the vagina (tenderness, swelling, discharge, Bartholdi’s glands)

Assessing the Female Breasts & Axilla:

• Inspect the breasts for size, symmetry, and nipple dimpling

• Palpate the breasts and axilla in a circular pattern, covering all areas (note
inconsistencies and tenderness)

• If you palpate a mass, note its size, shape, consistency, mobility, degree of
tenderness, and location

Nutritional Assessment:
• A thorough nutritional assessment will identify individuals at risk for malnutrition
and provide baseline information for nutritional assessments in the future.

• A nutritional screening is indicated for all patients.

• A complete nutritional assessment is indicated for only those individuals at risk for
malnutrition. A screening assessment includes:

• Biographical data

• Age

• Height

• Weight

• Lab Data

• Albumin

• Haemoglobin

• Haematocrit
 • Total lymphocytes

• Other abnormal labs?

• Nutritional Assessment
• When performing your physical exam, OBSERVE for the following signs and
symptoms of nutritional deficiency:

• Eyes dry

• Pale or red conjunctivae

• Blepharitis

• Cheilosis

• Cracks at the side of mouth

• Tongue pale

• Bleeding gums

• Dry, flaky skin

• Petechiae

• Bruising

• Dry, bumpy skin

• Cracked skin

• Eczema

• Xanthomas

• Dull, dry, thin hair

• Hair color changes

• Brittle nails

• Joint pain

• Muscle wasting

• Pain in calves

• Splinter hemorrhages of nails

• Peripheral neuropathy

• Hyporeflexia

• Confusion or irritability