Health Assessment Chapter 25

1
Health AssessmentChapter 25

2
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

3
Health Assessment

• Two components of the health assessment
• Health History
• Physical Assessment

4
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)

5
General Guidelines for Physical Assessment

• Instrumentation
• Positioning
• Draping
• Preparation of the environment
• Patient preparation
• Techniques of physical assessment

6
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
• Simss-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

7
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

8
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.

9
Inspection

• Deliberate, purposeful, observations in a
  systematic manner

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

10
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

11
Instrumentation or Equipment used for vision
screening

• Snellen chart- used to check eye sight

12
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
13
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

14
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)

15
General Survey

• 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)

• Gather information regarding
• Patient's appearance, behavior
• Measuring vitals signs
• Height, and weight
• General appearance
• Gender and race
• Body build, posture and gait

16
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.)

17
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

18
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

19
SKIN

• Inspect for color, vascularity, lesions and body
  odors

• Color-pinkish white to various shades of brown.

20
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?
21
Head and Neck

• Assessment includes
• Skull
• Face
• Eyes
• Ears
• Nose
• Sinuses
• Mouth

• Pharynx
• Trachea
• Thyroid glands
• Lymph nodes

22
Skull and face

• Inspect size and shape
• Symmetry

• Face- examine color
• Symmetry
• Distribution of facial hair
• Assess facial nerve and facial muscles-

23
cellulitis
24
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

25
Bacteria Conjunctivitis
26
Acute Glaucoma
27
Healthy Ear
28
Acute otitis media
29
Chronic otitis media, stapes extruding
30
Cerumen in ear
31
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.

32
Hematoma
33
Polyp
34
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

35
Tonsillitis
36
Hairy tongue
37
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

38
ASSESSMENTPart I
39
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

40
HEALTH ASSESSMENT

• Two components of the health assessment
• Health History
• Physical Assessment

41
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

42
GENERAL GUIDELINES

• Instrumentation
• Positioning
• Draping
• Preparation of the environment
• Patient preparation
• Assessment techniques

43
POSITIONING

• Sitting use upright chairor dangle of exam
  table.
• Supine flat on the back
• Dorsal Recumbant on back with knees bent
• Sims lie on side, lower arm behind back, upper
  arm bent at the shoulder and elbow, knees both
  bent

44
ASSESSMENT part 2
45
PULMONARY

• HISTORY
• INSPECTION
• PALPATION
• PERCUSSION
• AUSCULTATION
• BREATH SOUNDS

46
PULMONARY
47
CARDIOVASCULAR

• History
• Inspection
• Palpation
• Auscultation
• Heart sounds
• Peripheral vascular system

48
CARDIOVASCULAR
49
BREAST/AXILLA

• History
• Inspection
• Palpation

50
ABDOMEN

• History
• Inspection
• Auscultation
• Percussion
• Palpation

51
GENITALIA

• Female
• History
• Inspection
• Male
• History
• Inspection

52
MUSCULOSKELETAL

• History
• Inspection
• Palpation
• Testing
• Tone
• Strength
• Bones and Joints

53
NEUROLOGICAL

• History
• Mental Status
• Orientation
• Level of Consciousness
• Memory
• Abstract Reasoning
• Language

54
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)

55
SENSORY MOTOR FUNCTION

• Motor
• Balance and gait
• Coordination
• Sensory

56
REFLEXES

• Abdominal
• Babinskis
• Bicepts
• Triceps
• Patellar
• Achilles Tendon