Health Assessment

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Health Assessment

• CHD 1 VN 230
• Presented by
• Cynthia Bartlau, RN, PHN, MSN

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Components of a Health History

• Chief Complaint
• Present Illness
• Past History
• Health Maintenance (immunizations)
• Family History
• Personal and Social History
• Review of Systems

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LVN Role in Health Assessment

• DATA COLLECTION
• REPORTING AND DOCUMENTATION
• ACUTE CARE - Assessment q shift
• LONG TERM CARE Assessment q weekly, monthly, prn

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Purpose for Physical Assessment

• Compare patient status
• Determine effects of interventions
• Early detection of changes

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Set the Setting

• Know your patient
• Know the Diagnosis/ Chief Complaint
• Lighting
• Gather equipment

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At the Beginning

• Introduction
• Explain what you are doing
• Ask permission to continue
• Provide privacy
• Ask before you touch
• Continue to explain what you are going to do
  ---BEFORE YOU DO IT!

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Continue throughout

• Ensure
• Patient Comfort
• Privacy
• Special needs
• Ask open ended questions
• YET, stay on focus
• Consider biases
• Be respectful and courteous
• Prevent discriminating care
• Explain your findings

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Body Parts and Areas

• Location and position
• Anatomical position
• Standing upright
• Facing forward
• Arms at sides with palms forward
• Feet slightly apart

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• Body cavities membranes
• Dorsal cavity
• Cranial cavity (skull contains brain)
• Spinal cavity (formed by the spine spinal cord)
• Meninges (line these cavities cover the organs
  of the CNS central nervous system

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• Ventral cavity
• Thoracic cavity (heart and lungs)
• pleural membranes line the chest wall (parietal
  pleura) and the lungs (visceral pleura)
• pericardial membranes line the heart

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• Abdominal cavity
• (liver, stomach, kidneys, intestines, pancreas,
  gallbladder, spleen)
• Peritoneum is the membrane that lines the
  abdominal wall
• Mesentery is the membrane that folds around and
  covers the outer surfaces of the abdominal organs
• Pelvic cavity
• (urinary bladder reproductive organs, uterus,
  prostate)

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• A plane is an imaginary flat surface that
  separates two sections of the body or organ
• Frontal plane
• Divides the body into 2 sections
• Front (ventral/anterior)
• Back (dorsal/posterior)

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• Transverse
• Divides the body into 2 sections
• Upper (superior)
• Lower (inferior)
• Sagittal plane
• Divides the body into 2 unequal sections from top
  (superior) to bottom (inferior)
• Midsagittal plane divides the body into 2 equal
  right and left halves
• Cross-section a plane perpendicular to the long
  axis of an organ
• Longitudinal a plane along the long axis of an
  organ

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Areas of the Abdomen

• Four (4) quadrants
• RUQ Right Upper Quadrant
• LUQ Left Upper Quadrant
• RLQ Right Lower Quadrant
• LLQ Left Lower Quadrant
• Quadrants are more frequently used for location

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• Nine area divisions
• Epigastric
• Umbilical
• Suprapubic (hypogastric)
• Right hypochondriac
• Left hypochondriac
• Right lumbar
• Left lumbar
• Right iliac
• Left iliac
• Most frequently used for more specific location

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Physical Assessment Techniques

• Inspect to see
• Use appropriate lighting
• Provide privacy for client
• Expose body areas adequately
• Use instruments when appropriate, i.e. otoscope,
  ophthalmoscope, penlight

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• Palpate to feel

• Light
• Depress area to 1 cm or less, slowly and gently
• Keep hand relaxed
• Use for palpating skin and superficial areas
• Deep
• Depress area to 4 cm or more
• Slowly, gently, and deliberately
• Rested hand during inspiration
• Increased depth of probe with expiration
• Instructed patient to breath deeply

• Light and Deep
• Warm hands
• Place client in a comfortable relaxed position
• Progress systematically
• Use bilateral and symmetrical pattern (right to
  left)
• Compare corresponding areas of each side of body
• Select a starting point and moved in a clockwise
  direction, i.e., abdomen, breasts, etc...
• Palpate potentially tender areas last

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• Size of masses - tips of fingers
• Temperature changes - dorsa of hands and fingers
• Vibrations - lateral surface or ulnar aspect of
  hand
• Rebound tenderness - distal portion of fingers
  placed opposite suspected area, slowly and deeply
  palpated and rapidly released
• Bimanual palpation
• Using the palmar surfaces of both hands
• One hand on top of the other
• With one hand elevating the organ and the other
  palpating it

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Percuss to tap

• Percussion Sounds - elicits 4 percussion notes on
  selected body surfaces
• Flatness (thigh muscle) elicit and describe sound
• Dullness (liver) elicit and describe sound
• Resonance (normal lung) elicit and describe
  sound.
• Tympani (gastric air bubble) elicit and describe
  sound

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• Indirect
• Place distal portion of pleximeter finger firmly
  on skin, remaining fingers on hand not touching
  body surface
• Use top of plexor (finger) immediately
• Hold forearm stationary and used wrist movement
  in striking motion
• Strike a quick, sharp blow with plexor (finger)

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• Rebound plexor (finger) immediately
• Use lightest blow that would produce sound
• Deliver strikes with equal force
• Limit strikes to three or less in each area,
  returned to an area when necessary for further
  investigation

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Auscultate to listen

• Appropriate positioning of stethoscope on self
• Use diaphragm of stethoscope for high-pitched
  sounds - breath, bowel, and normal heart sounds
• Use bell of stethoscope for low-pitched sounds -
  extra heart sounds or murmurs

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Assessment Fundamentals

• General survey
• Complete vs Focus Assessment

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30 second Assessment

• LOC
• Sign of distress
• Skin color/obvious lesions
• Sexual development
• Weight
• Posture/gait/motor activity

• Dress/grooming/personal hygiene
• Odors of body/breath
• Facial Expressions

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Sequencing an Assessment

• Assess what is showing
• Always compare sides
• Assess least personal body parts 1st
• Gain rapport
• Explain before exposing, keep exposure minimal
• Ask questions for subjective data as you are
  assessing

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Head to Toe

• General survey
• Orientation
• Signs of distress
• Skin
• Build (ht wt)
• Sexual development
• Odors
• Vital Signs

• Head (eyes, ears, nose etc)
• Upper strength
• Chest (back then front)
• Abdomen
• Lower strength
• Peripheral pulses

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Physical Assessment

• Head-to-toe assessment (focused or general)
• Neurosensory
• Cardiovascular
• Respiratory
• Gastrointestinal
• Integumentary
• Musculoskeletal
• General information
• Height weight
• Vital signs

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Neurological Assessment

• A/A/Ox4
• Orientation person, place, time, situation
• Response to verbal command
• Hand grips leg pushes
• PERRLA
• Glasgow Coma scale
• Eye opening
• Verbal response
• Motor response

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Glasgow Coma Scale
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Cardiovascular

• Blood pressure
• Pulses (bilateral, characteristics rate, rhythm,
  quality)
• Capillary refill (lt3sec.)
• Skin color/temperature
• Edema (location, degree)
• Heart sounds (clear/distant)

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Classification of BP
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Respiratory

• Respirations (rate, characteristics, depth,
  regularity)
• Use of accessory muscles
• Lung sounds
• Wheezes
• Rales/crackles
• Rhonchi
• Cough/secretions (characteristics)
• Use of oxygen (amount) or room air O2 sat

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Gastrointestinal

• Abdomen (general contour)
• Circumference (if disease related)
• Bowel sounds (location, frequency, intensity)
• Appetite (gastric distress, N/V)
• Bowel movement (frequency, characteristics)

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Genitourinary

• Urine elimination (pattern, changes)
• Urine (amount, characteristics)

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Integumentary (Skin)

• Mucous membrane (color, moistness)
• Skin turgor (good, poor, tenting)
• Skin color/temperature
• Skin integrity (describe lesions)

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Musculoskeletal

• Range of motion
• Gait/stability/strength
• Contractures

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Questions???
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Practice

• Using appropriate equipment positioning,
  complete an organized head to toe assessment on
  one classmate or more
• Complete documentation on LBCC Care Plan
  Worksheet assessment section