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Health Assessment
Fundamentals Of Nursing Practice (NURS 202)
Pace University
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Chapter 26: Health Assessment
- Purposes of the Health Assessment
● Establish the nurse–patient relationship. ● Identify patient strengths. ● Establish a base for the nursing process.
- Types of Health Assessment
● Comprehensive ○ Conducted upon admission to health care facility ● Ongoing partial ○ Conducted at regular intervals ● Focused ○ Conducted to assess a specific problem ● Emergency ○ Conducted to determine life-threatening or unstable conditions
- Two Components of a Health Assessment
● Health history ○ Focus on interviewing skills ● Physical assessment ○ Head-to-toe sequence, system sequence
- Considerations When Performing Health Assessment
● Lifespan considerations ● Cultural considerations and sensitivity ● Patient preparation ● Environmental preparations
- Data Collection
● Subjective data ● Objective data
- The Interview
● An organized conversation with the client ○ Stages ■ Orientation ■ Working ■ Termination ○ Gathering information ○ Questioning ■ Closed-short answer ■ Open ○ Restatement (Paraphrasing) ○ Clarification
- Factors of Assess During a Health History
● Biographical data ● Reason for seeking health care ● History of present illness ● Past health history ● Family history
● Functional health ● Psychosocial and lifestyle factors ● Review of systems
- Document Findings
● No symptoms ○ Denies ● Significant Positive Finding ○ Attributes of a symptom (PQRST Mnemonic): ■ Provocative or palliative (What causes the symptoms? What makes it better or worse?) ■ Quality or quantity (How does the symptom feel, look or sound? How much of it are you experiencing now?) ■ Region or radiation (Where is the symptom located? Does it spread?) ■ Severity (How does the symptom rate on a scale of 1 to 10, with 10 being the most severe?) ■ Timing (When did the symptoms begin? Did it occur suddenly or gradually? How often does it occur?) ● Purposes of Documentation ○ Identify actual and potential health problems ○ Make nursing diagnoses ○ Plan appropriate care ○ Evaluate patient’s responses to treatment
- Preparing the Patient for Physical Assessment
● Consider the physiologic and psychological needs of the patient. ● Explain the process to the patient. ● Explain that physical assessments will not be painful (decrease patient fear and anxiety). ● Explain each procedure in detail as it is conducted. ● Ask the patient to change into a gown and empty bladder. ● Answer patient questions directly and honestly.
- Preparing the Environment for Physical Assessment
● Agree on a time for the assessment. ○ The time should not interfere with meals, daily routines, or visiting hours. ● Make sure patient is as free of pain as possible. ● Prepare the examination table. ● Provide a gown and drape for the patient. ● Gather the supplies and instruments needed. ● Provide a curtain or screen if the area is open to others.
Equipment Used During a Physical Examination ● Scale ● Metric tape measure and ruler ● Eye chart ● Tuning fork
Positions Used During a Physical Assessment
● Standing ○ Assessment of posture, balance, and gait ● Sitting ○ Allows visualization of upper body ● Supine
■ Inspecting Skin Vascularity & Lesions ● Ecchymosis
● Petechiae
● Lesions ○ Primary-arise from normal skin ○ Secondary-arise from a change in a primary lesion ● Characteristics of Masses Determined By Palpation ○ Shape ○ Size ○ Consistency ○ Surface ○ Mobility ○ Tenderness ○ Pulsatile ■ Assessing and documenting skin ● Lesions, wounds and rashes ○ Size ○ Shape ○ Depth ○ Location ○ Drainage ○ Odor ■ Skin Lesions ● Macule ○ Flat lesion up to 1 cm ○ Circumscribed ○ Nonpalpable Change in Skin Color
● Patch ○ Flat lions 1 cm or larger ○ Circumscribed ○ Nonpalpable change in skin color
● Papule ○ Elevated lesion up to 0 cm ○ Palpable
● Plaque ○ Elevated superficial lesion larger than 0 cm ○ Palpable
● Nodule ○ 0-2cm ○ Firmer than a papule ○ Palpable ○ Elevated solid masses
● Tumor ○ Elevated
■ Danger signs of skin cancer/melanoma ● A – Asymmetry ● B – Boarder irregular ● C – Color variegated ● D - Diameter > 6 mm ● E - Enlarging ■ Palpation ● Temperature ● Texture ● Turgor-elasticity of the skin ● Edema ○ Graded as 0 (none), +1 (trace, 2 mm), +2 (moderate, 4 mm), +3 (deep, 6 mm), or +4 (very deep, 8 mm) ○ Nails ■ Shape ■ Angle ■ Texture ■ Color ○ Hair and Scalp ■ Color ■ Texture ■ Distribution ● Alopecia/hirsutism ○ No hair on any part of the body ● Male pattern baldness ■ Dryness, sclainess, lumps, lesions, lice ○ Vascular Lesions ■ Petechiae ■ Purpura ■ Hematoma
● Head and neck ○ Health history ■ Changes in vision or hearing with aging ■ History of use of corrective lenses or hearing aids ■ Loss of an eye (use of artificial eye) ■ History of allergies, disturbances in vision or hearing or chronic illnesses ■ Exposure to harmful substances or loud noises or ultraviolet light ■ History of smoking ,chewing tobacco, or cocaine use ■ Presence of body piercings and/or tattoos ■ History of eye or ear infections, head trauma or persistent hoarseness ■ Oral and dental care practices ○ Inspect the head and neck ■ Inspect & palpate skull for size and shape ■ Lack of symmetry, unusual size, contour ■ Inspect face for color, symmetry, distribution of facial hair. ■ Edema of the face (periorbital edema), involuntary facial movements (e.,tics, fasciculations, tremors) ■ Facial expression ○ Inspecting External Eye Structure ■ Color, edema, symmetry alignment
● Eyes ● Eyebrows ● Eyelids ● Eyelashes ● Lacrimal glands ● Pupils ● Iris ● Cornea ● Sclera ● Conjunctiva ■ Abnormalities of external eye ● Eyes ○ Asymmetry, misalignment, inability to converge, drainage, redness ● Eyebrows ○ Asymmetry ● Eyelids ○ Ptosis ● Eyelashes ○ Entropion, Ectropion ● Lacrimal glands ○ Swelling ● Pupils ○ Pale, cloudy, inability to react and accommodate (mydriasis & miosis) ○ Pupils ○ Equal ○ Round ○ Reactive ○ Light ○ Accommodation
● Iris ○ Cloudy ● Cornea ○ Cloudy ● Sclera ○ Discolored ● Conjunctiva ○ Redness ■ Vision ● Visual Acuity ○ Snellen Chart ○ 20/20 vision (20/30 or 20/ ● Extraocular Movement ○ Both eyes are coordinated, parallel ● Peripheral Vision ○ Equal on both sides ○ The Ears ■ Inspection and palpation ■ Otoscope, tuning fork, ticking watch ■ The ear assessment ● Normal ○ Ear canal: smooth and pink, No wax, discharge, or foreign
■ Mucous Membranes ● Pink, moist, and free of swelling or lesions. ● Abnormal ○ Pallor, cyanosis, redness ,swelling, lesions ■ Teeth ● Regular, free of cavities or have dental restoration ● Abnormal ○ Poorly aligned, missing, or carious teeth ■ Gums ● Pink and smooth ● Abnormal ○ Swollen, red, bleeding (from nutritional deficits, inflammation, infection, poorly fitted dentures, poor oral hygiene) ■ Tonsils ● Small, pink, and symmetric in size ● Abnormal ○ Red, swollen (infection) ■ Uvula ● Centered and freely movable ○ Neck, trachea and lymph nodes ■ Neck ● Symmetrical, no neck vein distention, full ROM ■ Trachea ● Midline at suprasternal notch ■ Lymph Nodes ● Small, smooth, mobile, nontender ● Abnormal ○ Lymphadenopathy (infection, autoimmune disorder, metastasis of cancer) ○ Palpating the thyroid gland ■ Palpate for size, shape, symmetry, tenderness, presence of nodules. ■ Normal ● Soft but elastic, nontender, ■ Abnormal ● Enlargement, masses, nodules (thyroid gland disease, infection of the thyroid, cancer)
● Thorax and lungs ○ Health history ■ History of trauma to the ribs or lung surgery ■ Number of pillows used when sleeping ■ History of chest pain with deep breathing and persistent cough with or without producing sputum ■ Environmental exposure to chemicals, asbestos, or smoke ■ History of smoking, lung disease or respiratory infections and allergies ○ Inspection ■ Color ● Even and consistent with color of patient’s face ■ Shape & Contour ● Downward equal slope at the rib cage ● The chest should be symmetric, with the transverse diameter
greater than the anteroposterior diameter. ■ Breathing patterns ● Smooth and even, 12 to 20 breaths/min ■ Muscle development ■ Abnormal Findings ● Increase in chest size and contour (ie, Barrel chest) ● Abnormal breathing patterns with use of accessory muscles (respiratory disease, COPD or asthma), nasal flaring ● Unequal chest expansion (chest trauma or pneumonia)
■ Palpation ● Use palmar surface of the hands to palpate the anterior and posterior thoracic landmarks ● Assess temperature, moisture, muscular development, tenderness, masses ● Normal ○ Skin should be warm and dry, with symmetric muscular development, no tenderness, masses, or vibrations. ● Abnormal ○ Cool or excessively dry or moist skin, muscle asymmetry, tenderness, masses, and vibrations ○ Chest landmarks nad sequence of assessment
○ Normal breath sounds ■ Bronchial ● High-pitched, harsh “blowing” sounds ● Heard over trachea and larynx ● Sound on expiration being longer than inspiration ■ Bronchovesicular ● Moderate blowing sounds ● Heard over the mainstem bronchus ● Sound on inspiration equal to expiration ■ Vesicular ● Soft, low-pitched, whispering sounds ● Heard over most of the lung fields ● Sound on inspiration being longer than expiration ○ Productive cough ■ Assess sputum for ● Color ● Consistency ● amount ● Cardiovascular and peripheral vascular systems
posterior tibial pulses ■ Arms ● Temperature ● Capillary refill (normal < 2-3 seconds) ● Pulses- Rate, regularity, amplitude ■ Legs ● Temperature ● Legs for edema (If noted, measure circumference) ● Pulses ● Capillary refill (normal < 2-3 sec) ○ Cardiac assessment ■ Percussion ● None with vascular assessment ■ Auscultation ● Neck ○ Carotids for bruit ● Chest ○ Be systematic ○ Breathe normally ○ Use diaphragm (high-pitched sounds) then bell (low- pitched sounds) of stethoscope ● Apical-Radial pulse ● Assessment for Pulse Deficit ○ Heart and cardiovascular sounds ■ Normal Heart Sounds ● S1 (Lub) ● S2 (Dub) ● Lub Dub ■ Abnormal Heart Sounds ● S3 (Dee) ○ Lub Dub Dee ● S4 (Dee) ○ Dee Lub Dub ● Murmur ■ Abnormal Cardiovascular Sound ● Bruit ○ Neurovascular status ■ Pain ■ Pallor (perfusion) ■ Peripheral Pulses ■ Paresthesia (sensation) ■ Paralysis (movement) ■ Pressure ○ Abnormal Findings ■ Neck Vein Distention ■ Perioral Cyanosis ■ Peripheral Cyanosis of Nail Bed
■ Capillary refill ■ Skin lesion on dorsal surface of left foot, note skin mottling ■ Edema left leg and foot
■ Nail – thick and irregular ■ Varicosities – Varicose Veins – Spider ■ Varicosities – Varicose Vein - palpable
■ Rubor and irregular coloring of feet ■ Bilateral loss of hair of both lower extremities
● Breasts and axillae ○ Health history ■ History of pain in one or both breasts, including relation-ship to menstrual period, lumps or swelling, redness, change in size, or dimpling in the breasts ■ History of discharge from the breast and breast disease, biopsy, or surgery ■ Family history of ovarian or breast cancer ■ Menstrual and pregnancy history ■ Use of hormones, oral contraceptives ■ Exposure to radiation, benzene, or asbestos ■ Usual dietary intake and alcohol consumption ■ Knowledge and practice of breast self-examination ■ Most recent clinical breast examination and mammogram ○ Inspecting the breast ■ Inspect breasts for size (varies), shape (round), symmetry (relatively), color (consistent with rest of skin), texture (soft & smooth), skin lesions (none & no dimpling or retractions) ■ Inspect the areola and nipples for size (equal, smooth) shape (round or oval), Montgomery’s tubercles, eversion ■ Inspect the nipples for discharge, crusting, and inversion ○ Palpate the breasts and axillae ■ Palpate (Circular, Wedge, Vertical Strip Methods) the breasts in each of the four quadrants to detect any abnormal lumps ■ Palpate the nipple and areola and gently compress the nipple between the thumb and forefinger to assess for discharge ■ Palpate the axillary areas for lymph nodes (nonpalpable and nontender)
discharge (clear or whitish). ● Palpate the labia for masses (none) and the Bartholin’s glands (located slightly below and to the left and right of the opening of the vagina) for swelling, pain, and discharge ● Nurses assist with internal exams - Abnormal findings include redness, swelling of glands, discharge, lesions, and pain, which may indicate infection, an abscess, a polyp, or cancer ○ Male genitalia ■ History ● Frequency of digital rectal examinations ● Frequency of testicular self-examination ● Use of contraceptives ● Occupational exposure to chemicals (tire and rubber manufacturing, farming, mechanics) ● History of sexually transmitted infection, discharge from the penis and erectile dysfunction ● Difficulty with urination (incontinence, hesitancy, frequency, voiding at night) ■ Inspecting and palpating the external genitalia ● Inspect for size, placement, contour, appearance of the skin, redness, edema, and discharge. ● Retract foreskin & inspect glans penis ● Assess the location of urinary meatus ● Inspect the scrotum for symmetry (it is not unusual for the left testicle to lie lower in the scrotal sac than the right) ○ Size, shape, and consistency of scrotal contents (i., testes) should be similar bilaterally ● Normal findings ○ Skin that is free of lesions, foreskin that is intact, uniform in color, easily retracted. ○ Urinary meatus in the center of the glans penis and free of discharge ○ Scrotum and testes free of masses and nontender ● Abnormal findings ○ Lesions, redness, edema, pain, discharge, fluid-filled masses in the scrotum, displacement of the urinary meatus or difficulties with voiding ● Anus, rectum, prostate ○ History ■ Bowel patterns, including constipation, diarrhea, or pain ■ History of blood or mucus in the stool, hemorrhoid and anal intercourse ■ Family history of polyps, colon or rectal cancer, or prostate cancer ■ Frequency of digital rectal examinations (DREs) ○ Inspection and palpation ■ Techniques ● Inspection and palpation ■ Equipment ● Gloves and good lighting ■ Position-knee ● Chest or side-lying position ■ Normal Findings ● Increased pigmentation and some hair growth. ■ Abnormal findings ● Lesions, ulcers, fissures, inflammation, hemorrhoids, relaxed sphincter tone, nodules, or bleeding ● Musculoskeletal system ○ History ■ History of trauma, arthritis, or neurologic disorder
■ History of pain, swelling or surgery in the muscles and/or joints ■ Frequency and type of usual exercise ■ Dietary intake of calcium ■ History of smoking and alcohol intake ○ Physical exam ■ Posture, gait, bone size and structure, joint range of motion, muscle strength ■ Inspection and palpation ■ Can be integrated ○ Inspecting/palpating the muscles ■ Test muscle tone and strength ● Bilaterally symmetric ● Nontender ● Guideline 26- ○ Shoulder Flexion ○ Elbow Extension & Flexion ○ Wrist Extension ○ Grip ○ Hip Flexion ○ Knee Flexion & Extension ○ Ankle Plantar Flexion & Dorsiflexion ○ Abnormal muscle assessment ■ Atrophy ■ Tremors ■ Flaccidity ■ Loss of strength and tone ■ Decreased range of motion ■ Uncoordinated movements ■ Swelling ■ Pain ■ May indicate a musculoskeletal disease, trauma, neurologic disease ○ Palpating the bones ■ Contour ■ Prominence ■ Bilateral symmetry ■ Abnormal findings ● Pain ● Enlargement ● Asymmetry ● Changes in contour ■ Trauma, degenerative joint disease, musculoskeletal disease, neurologic disease ○ Inspecting and palpating the joints ■ Normal joints - bilaterally equal in size, shape, and color; free of swelling, pain, nodules, or crepitus, move through full ROM ■ Abnormal joints – have deformity, crepitus, pain, swelling, nodules, limited ROM ● Indicate injury, inflammation, arthritis of the affected joints ○ Inspecting spinal curves ■ Scoliosis ● Lateral curve ■ Kyphosis ● Thoracic
● Long-term – When is your birthday/anniversary? ■ Abstract Reasoning ● Describe an abstract thought (“The early bird catches the worm”) ■ Language ● Name items in the room, point to body parts ● Aphasia ○ Expressive or Receptive ○ Assessing motor and sensory function ■ Balance & Gait ● Walk across the room on toes, heel, heel to toe ● Abnormal ○ Loss of balance, shuffling, wide-based gait, abnormal gait ■ Coordination ● Touch each finger with thumb, pat-a-cake, finger to nose, heel down shin ■ Sensory Perception ● Response to pain, light touch, normal shapes, vibration ● Assess distal to proximal ○ Cranial nerve mnemonics ■ On Old Olympus' Towering Top A Finn And German Viewed Ancient Hills ■ Some Say Marry Money, But My Brother Says Big Brains Matter Most ○ Assessing deep tendon reflexes ■ Determine functional ability of specific spinal segment levels ■ Biceps, Triceps, Knee, Ankle, Babinski
Health Assessment
Course: Fundamentals Of Nursing Practice (NURS 202)
University: Pace University
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