ASSESSING BODY

STRUCTURES AND
SYSTEMS
➢ a systematic assessment of the
patient’s body structure and
system is a vital responsibility of a
nurse.
1. Be Systematic
 Always start at the top of the head
and work your way down the body.
 This helps you from skipping any
areas.
 When questioning an elderly patient,
remember that he may have
difficulty hearing or communicating.
2. Assessing the Elderly
 An elderly patient might have a sensory,
memory impairment, or a decreased
attention span.
 If your patient is confused of has trouble
communicating, you may need to rely
on a family member for some of all of
the health history.
3. Ask specific questions
 Information gained from a health history
forms the basis for your care plan and
enables you to distinguish physical
changes and devise a holistic approach to
treatment.

 As with other nursing skills, the only way you

can improve your interviewing techniques
is with practice, practice and more practice.
4. Evaluating Symptoms
 Sometimes your patient is vague in describing his chief complaint.
For example, using you interviewing skills, you discover his
problem is related to abdominal distension.

Now what?
Ask the patient to identify the symptom that is
bothering him. If he tells you, “My stomach gets
bloated” form a first impression.

Does the patient’s condition alert you to an emergency?

For example, does he say the bloating developed suddenly?

Does he mention that other signs or symptoms occur with
it, such as sweating and light-headedness?
(both are indicators of hypovolemia)
 If the answer to the question is yes, take a brief
of history to gather more clues.
For example, ask the patient if he has severe
abdominal injury. Perform a focused physical
examination to determine the severity of the
patient’s condition quickly. Check for bruising,
lacerations, changes in bowel sounds, or
abdominal rigidity.
 However, if he answered “No” take a thorough
history to get an overview of the patient’s
condition.
 Ask him about associated signs or symptoms.
Especially note GI disorders that can lead to
abdominal distention.
 Now, thoroughly examine the patient to evaluate
the chief sign or symptom and to detect
additional signs and symptoms. Place the
patient in a recumbent position and observe for
abdominal asymmetry.
 Inspect the skin, auscultate for vowel sounds,
percuss and palpate the abdomen, and measure
abdominal girth.
Cephalo-caudal
Assessment
1. The Head- headaches, past or present head
injury.

✓ Do you get headaches?

✓ If so, where are they and how painful are they?
✓ How often do they occur, and how long do they
last?
✓ Does anything trigger them, and how do you
relieve them?
✓ Have you ever had a head injury?
✓ Do you have lumps or bumps on your head?
2. Eyes and Vision- vision, uses of eye glasses or
contact lens, history of glaucoma, cataracts, color
blindness, tearing, blurred vision, , double vision, dry,
itchy, burning sensation, or inflamed eyes.
✓When was your last eye examination?
✓Do you wear glasses?
✓Do you have Glaucoma, cataracts, or
color blindness?
✓Does light bother your eyes?
✓Do you have excessive tearing; blurred
vision; double vision; or dry; itchy,
burning, inflamed, or swollen eyes?
3. Ears and Hearing- hearing and balance,
history of ear surgery, use of hearing aid, ear
pain, or swelling, discharge from ears.
✓Do you have loss of balance, ringing your
ears, deafness, or poring hearing?
✓Have you ever had ear surgery?
✓If so, why and when?
✓Do you wear hearing aid?
✓Are you having pain, swelling, or
discharge from your ears? If so, has this
problem occurred before and how
frequently?
4. Nose and Smell- History of nasal surgery,
breathing or smelling difficulties, history of
sinusitis, or nosebleeds.
✓ Have you ever had nasal surgery?
✓ If so, why and when?
✓ Have you ever had sinusitis or
nosebleeds?
✓ Do you have nasal problem that impair
your ability to smell or that cause
breathing difficulties, frequent
sneezing, or discharge?
5. Mouth and Taste- Dentures, mouth sores
and dryness, loss of taste, toothache or
bleeding gums, throat soreness, or difficulty
swallowing.
✓ Do you have mouth sores, a dry mouth,
loss of taste, a toothache, or
bleeding gums?
✓Do you wear dentures?
✓If so, do they fit?
✓Do you have a sore throat fever, or chills?
✓How often do you get a sore throat, and
have you seen a doctor for this?
✓Do you have difficulty swallowing?
✓If so, is the problem with solids or
liquids?
✓Is it constant problem or does it
accompany a sore throat or another
problem?
✓What, if anything, makes it go away?
6. Neck- Swelling, soreness, stiffness or
pain
✓Do you have swelling, soreness, lack of
movement, stiffness, or pain in your
neck?
✓If so, did something specific cause it to
happen, such as to much exercise?
✓How long have you had this symptom?
✓Does anything relieve it or aggravate it?
7. Respiratory system- Shortness of breath,
pain or wheezing in breathing, cough
(productive or non productive), history of
pneumonia, asthma, emphysema, or frequent
respiratory, tract infection, tuberculin screen
test or chest x ray results.
✓ Do you have shortness of breath on
exertion or while lying in bed?
✓ How many pillows do you use at
night?
✓Does breathing cause pain or
wheezing?
✓Do you have night sweats?
✓Have you ever been treated for
pneumonia, asthma, emphysema, or
frequent respiratory tract infections?
✓Have you ever had a chest X-ray or
tuberculin skin test?
✓If so, when and what were the results?
8. Chest and the Heart
✓ Do you have chest pain, palpitations,
irregular heartbeat, fast heartbeat,
shortness of breath, or persistent
cough?
✓Have you ever had an electrocardiogram?
✓If so, when?
✓Do you have high blood pressure,
peripheral vascular disease, swelling of
the ankles and hands, varicose veins,
cold extremities, or intermittent pain in
your legs?
9. The breast
Ask women these questions:
✓Do you perform monthly breast self-
examinations?
✓Have you noticed a lump, a change in
breast contour, breast pain, or
discharge from your nipples?
✓Have you ever had breast cancer?
✓If not, has anyone else in your family had
it?
✓Have you ever had a mammogram?
✓When and what were the results?

✓Ask men these questions: do you have

pain in your breast tissue?
✓Have you noticed lumps or a change in
contour?
10. Digestive system
✓ Have you had nausea, vomiting, loss of
appetite, heartburn, abdominal pain, frequent
belching, or passing of gas?
✓Have you lost or gained weight recently?
✓How often do you have a bowel movement, and
what color, odor, and consistency are your
stools?
✓Do you use laxatives frequently?
✓Have you had hemorrhoids, rectal bleeding,
hernias, gallbladder disease, or liver disease?
11. Genitourinary System
✓ Do you have urinary problems, such as
burning sensation during urination,
incontinence, urgency, retention,
reduced urinary flow, and dribbling?
✓ Do you get up during the night to
urinate?
✓ If so, how many times?
✓What color is your urine?
✓ Have you ever noticed blood in it?
✓ Have you ever been treated for kidney
stones?
12. Reproductive System
Ask women these questions:
✓ How old are you when you started
menstruating?
✓How often do you get your period, and how
long does it usually last?
✓Do you have pain or pass blood clots?
✓If you are in the transitional stage, what
perimenopausal symptoms are you
experiencing?
✓ Have you ever been pregnant?
✓ If so, how many times?
✓ What was the method of delivery?
✓ How many pregnancies resulted in live
births? How many resulted in
miscarriages?
✓ Have you had an abortion?
✓ What is your method of birth control?
✓ Are you involved in a long-term
monogamous relationship?
✓ Have you had frequent vaginal infections
or a sexually transmitted disease (STD)?
✓ When was your last gynecologic
examination and Papanicolaou test?
✓ What were the results?
Ask men these questions:
✓ Do you perform monthly testicular self-
examinations?
✓ Have you ever had a prostate examination?
✓ If so, when?
✓ Have you noticed penile pain, discharge, or
lesions or testicular lumps?
✓ Which form of birth control do you use?
✓ Have you had vasectomy?
✓ Are you involved in a long term,
monogamous relationship?
✓ Have you ever had an STD?
13. Muscular System
✓ Do you have difficulty in walking, sitting, or
standing?
✓ Are you steady on your feet or do you lose
your balance easily?
✓Do you have arthritis, gout, a back injury,
muscle weakness, or paralysis?
14. Nervous System
✓ Have you ever had seizures?
✓Do you ever experience tremors,
twitching, numbness, tingling, or loss of
sensation in a part of your body?
✓Are you less able to get around than you
think you should be?
15. Endocrine System
✓ Have you been unusually tired lately?
✓Do you feel hungry or thirsty more often
than usual?
✓Have you lost weight for unexplained
reasons?
✓How well can you tolerate heat or cold?
✓Have you noticed changes in your hair
texture or color?
✓Have you been losing hair?
✓Do you take hormone medications?
16. Circulatory System
✓ Have you ever been diagnosed with
anemia or blood abnormalities?
✓Do you bruise easily or become fatigue
quickly?
✓Have you ever had a blood transfusion?
✓ If so, did you have any type of adverse
reaction?
17. Psychological Assessment
✓ Do you ever experience mood swings or
memory loss?
✓ Do you ever feel anxious, depressed, or
unable to concentrate?
✓ Are you feeling unusually stressed?
✓ Do you ever feel unable to cope?
✓ When the patient’s condition does not
allow a full assessment, get as
much information as possible from
other sources.
 With a severely ill patient, keep these
key points in mind:
1.Identify your self to the patient and his
family.
2.Stay calm to gain his confidence and
alleviate anxiety.
3.Stay on the look out for important
information.
For example, if the patient seeks help for
a ringing in his ears, don’t overlook his casual
mention of a periodic “racing heartbeat.”
4.Avoid jumping to conclusions.
Thank you!!!