Health Assessment by Dr. Hala Yehia

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Health Assessmentby Dr. Hala Yehia
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Objectives

• At the end of this lecture the student will be
  able to
• Define health assessment
• List purpose of H.E.
• Identify types of HE.
• Describe methods of data collection.
• Explain component of nursing history.

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Objectives

• Define physical assessment
• Discuss principles of Physical assessment.
• Discuss preparation for physical examination.
• Identify physical assessment methods
• Apply physical examination from head to toe.

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Health Assessment

• ? Systematic and continuous collection,
• organization, validation and documentation of
  data.
• ? The first step in the nursing process
• ? It is focus on a clients response to a health
  problem.

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Purposes of Assessment

• To create a data base of the clients response to
  health and illness
• To determine the nursing care needs of the
  patient.
• To evaluate physiologic outcomes of health care
  and thus client progress
• To screen for presence of risk factors

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FOUR TYPES OF ASSESSMENT
?Initial Assessment ?Focus Assessment or
On-going Assessment ?Emergency
Assessment ?Time-Lapsed Assessment
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FOUR TYPES OF ASSESSMENT

• 1. Initial Assessment
• ?When performed
• At specified time after admission
• ?Where done
• Done at the ward
• ?Purpose of Initial Assessment
• To create a data base for problem identification
• For reference and future comparison

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FOUR TYPES OF ASSESSMENT

• 2. Focus Assessment or On-going Assessment
• ?When performed
• Integrated throughout the nursing process
• ?Purpose of On-going Assessment
• To identify problems overlooked earlier
• To determine the status of a health problem
• (i.e. hypertension status every fifteen minutes

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FOUR TYPES OF ASSESSMENT
3.Emergency Assessment ?When done During acute
physiologic and psychological crisis ?Where
done Emergency Room Comfort
Room Anywhere!!! On
site!!! ?Purpose of Emergency Assessment To
identify life-threatening condition
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TYPES OF ASSESSMENT

• 4. Time-Lapsed Assessment
• ?When done
• Several months after initial assessment
• ?Purpose of Time-Lapsed Assessment
• To compare current status of patient with base
  line data (initial assessment)

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• What is the initial output of the Assessment
  Phase?
• ?Data or Recorded Data
• process of gathering information about the
  clients health status

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TYPES OF DATA

• ?1. Subjective or Covert Data
• Information (data) apparent only to the person
  affected that can be described or verified only
  by that person.
• During the recording of data, this should be
  stated using the patients own words
• These are the symptoms felt by the patient.
• Fever I felt of hotness

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TYPES OF DATA

• 2. Objective or Overt Data
• signs or overt data detectable by an observer or
  can be tested against an accepted standard
• These are the signs which are observable
• Fever skin is warm to touch temp. is 38.9.

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SOURCES OF DATA

• 1. Primary Source
• ?Patient himself except when
• He is unconscious
• Patient is a baby
• Patient is insane

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SOURCES OF DATA

• 2. Secondary
• Support people
• Clients records
• Health care professionals
• Literature
• Results of laboratory and diagnostic tests
• Medical history and physical examination

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• Assessment
• Observation Interview Examination
• Assessment (Data Collection)

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METHODS OF DATA COLLECTION

• ?Observing
• ?Interviewing
• ?Examining

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METHODS OF DATA COLLECTION

• 1-Observation to gather data by
• using the five senses a conscious deliberate
  skill that is developed only through effort and
  with an organized approach.

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METHODS OF DATA COLLECTION

• 2-Interview a planned communication or
• conversation with a purpose.
• Preparation
• 1. review the clients medical records
• 2. conversations with other health team members
• 3. research of the presenting medical diagnosis

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METHODS OF DATA COLLECTION INTERVIEWING

• Two types of Interview
• ?Directive Type of Interview
• ?Non-directive Type of Interview or Rapport
  building Interview.

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DIRECTIVE TYPE OF INTERVIEW

• Structured
• ?Uses closed-ended questions calling for specific
  data
• When used
• When you need to elicit specific data
• When there is little time available
• often begin with when, where, who, what, do,
  does, did

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NON-DIRECTIVE TYPE ORRAPPORT-BUILDING INTERVIEW

• Uses more open-ended questions
• Advantage is that it allows the patient to
  volunteer information

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TYPES OF INTERVIEW QUESTIONS

• Open-Ended Questions
• e.g. Explain ----
• Closed-Ended Questions
• e.g. did --------

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Stages of Interview

• 1. Introduction/Opening
• 2. Working/Body
• 3. Closure/Closing

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B- Nursing Health History Is a data collected
about the clients level of wellness.
Objectives Identify pattern of health and
illness. Risk factors for physical and
behavioural health problems .
Deviations from normal .
Available resources for adaptation.
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Components of Nursing Health History
Biographic Data Clients name ,age , sex ,
occupation, health care
financing. Chief Complain or Reason for
Visit The answer given to the question,, What
is troubling you?,, It should be recorded in the
client own words.
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History of the Present Illness - When the
symptoms started. - Whether the onset of the
symptoms was sudden or gradual. -
How often the problem occurs. - Exact location
of the distress. - Character of complain. -
Activity in which the client was involved when
the problem occurred. - Factors
that aggravate or alleviate the problem.
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Past History - Childhood illness (
chickenpox, measles) - Childhood
immunizations. - Allergies to drugs, animal,
insect. - Accidents and injuries how, when ,
type of injury. - Hospitalization
for serious illnesses. - Medications all
currently used prescription.
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Family History of Illness - If they are
diseased, The cause of death. Lifestyle -
Personal habits ( smoking, alcohol, tea ) -
Diet description of a typical diet on a normal
day or any special diet , who cooks and
shops for the food. - Sleep rest
pattern Usual daily sleep, wake time -
Activities of daily living(eating, grooming,
dressing, elimination)
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• Social data
• Family relationship
• Educational history
• Occupational history
• Economic status

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Psychological Data - Major stressors
experienced and clients perception of
them. - Usual coping pattern with a serious
problem. Pattern of Health Care. All
health care resources the client is currently
using and has in the past.
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Physical Examinations

• Is the process which investigate the body of a
  patient for sign of disease.
• It generally follows the taking of the medical
  history.

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Purposes of Physical Assessment

• Gather baseline data about the clients current
  health status.
• Supplement, confirm or refute data obtained from
  history taking.
• Confirm and identify health problems.
• Make clinical judgment about the clients
  changing health status.
• Decide on an intervention based on data obtained.
• Evaluate The Physiologic Outcome Of Care.

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Principles in Performing Physical Assessment

• Order of examination
• Preparation of environment
• Preparation of equipments
• Physical preparation of the client
• Psychological preparation of the client

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How You Prepare the Environment for Physical
Assessment The environment needs to be
well lighted and the equipment should
be organized. Family and friends should not
be present unless the client ask for
someone Provide a curtain or screen if the
area is open to others.
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Maintain appropriate room temperature.
e.g., warm temperature not cold to prevent
client discomfort. maintain safe
environment.
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-- Client should be free of pain as
possible. -- Client should be comfortable (
wearing comfortable gown). --
Explain the assessment process to the patient.
-- Explain that physical assessments will not be
painful (decrease patient fear and
anxiety). -- Answer patient questions
directly and honestly. -- Client should
empty their bladder before examination.
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How You Prepare the Equipment for physical
assessment All equipment required for the
health assessmentshould be - clean - In
good working order. - Readily accessible. -
Set up on tray ready for use.
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The equipment of the physical examination
Stethoscopeeye examination chart
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Flashing or penlight purpose of use To
assist viewing of the pharynx or to determine
the reactions of the pupils of the
eye. Nasal speculum Purpose of use To
permit visualization of the lower and middle
turbinates, usually , a penlight is used for
illumination.
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Ophthalmoscope Purpose of use Alighted
instrument to visualize the interior of the
eye. Otoscope Purpose of use Lighted
instrument to visualize the eardrum and
external auditory canal. Percussion hammer
Purpose of use An instrument with a rubber
head to test reflexes
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Tuning fork Purpose of use A two-
pronged metal instrument used to test hearing
acuity and vibratory sense. Vaginal Speculum
Purpose of use To assess the cervix and the
vagina. Cotton applicator Purpose of use
To obtain Specimens.
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Gloves Purpose of use To protect the
nurse. Lubricant Purpose of use To ease
insertion of instrument (e.g., vaginal speculum)
Tongue blades (depressor) To depress the
tongue during assessment of the mouth
pharynx.
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Draping Draping should be arranged so the
area to be assessed is exposed and other area are
covered for privacy and warmth. Positioning
Several positions are frequently required during
the physical assessment.
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Physical Assessment Methods

• Inspection
• Palpation
• Auscultation
• Percussion

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Inspection

• Assessment process during which the nurse
  observes the client

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Inspection

• Is the visual examination, that is assessing by
  using the sense of sight. It should be
  deliberate, purposeful, and symmetric.
• Done By
• Naked eye.
• Otoescope.
• To assess
• Moisture, color, and texture of body surface as
  well as shape, position, size, and symmetry of
  the body parts.

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Palpation

• The use of the hands and the sense of touch to
  gather data

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• Different parts of the hand are best suited for
  specific purposes For example, the dorsal aspect
  of the hand is best for assessing temperature
  changes , the ball of the hand on the palm and
  ulnar surface is best for detecting vibration,
  and the finger pads and tips are the most
  discriminating for detecting fine sensations,
  such as pulsations

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Palpation

• Is the examination of the body using the sense of
  touch. The pads of the fingers are used.
• Types of palpation
• Light palpation.
• Deep palpation.
• Bimanual Palpation
• To assess
• Texture, temperature, and size.
• Distention, pulsation, and mobility of organs
  or masses.

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• Guidelines for palpation
• The nurses hands should be clean and warm, and
  finger nail short.
• Area of tenderness should be palpated last.
• Deep palpation should be done after superficial
  palpation.
• .

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Percussion

• Tapping of various body organs and structures to
  produce vibration and sound.

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• Percussion
• Is the act of striking the body surface to elicit
  sounds that can be heard or vibration that can be
  felt.
• Types of percussion
• Direct percussion.
• Indirect percussion.
• It is indicate
• tissue is fluid filled, air filled or solid.

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Auscultation

• The act of listening to sounds within the body to
  evaluate the condition of body organs
• (stethoscope)

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Auscultation

• Quiet environment
• Know landmarks
• Know normal
• PRACTICE! PRACTICE! PRACTICE!
• Requires concentration, practice, and application
  of knowledge

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• Auscultation of the sounds described according to
  their
• Pitch is the frequency of the vibrations(
  ranging from high to low)
• Intensity the loudness or softness of a
  sound.
• Duration the sound length( short, medium, or
  long)
• Quality a subjective description of a
  sounds( gurgling, swishing)

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Organization of Physical Assessment

• 1- General appearance
• Mood and affect
• Signs of distress
• Posture
• Body movement
• Hygiene and grooming
• Type of clothing
• 2- Measurements
• Height and weight
• Vital signs

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3- Head to toe examination

• Head Neck
  
• Skull Anterior thorax
• Scalp Breast
• Hair Abdomen
• Face Posterior thorax
• Eyes Upper extremities
• Ears Lower extremities
  
• Nose
• Mouth

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General Appearance

• Affect is the persons feelings as they appear
  to others
• Mood or emotional state is expressed verbally and
  non verbally
• Sign of distress is signs and symptoms of pain,
  difficulty in breathing or anxiety
• Hygiene and grooming observe the appearance of
  hair, skin or fingernails and clothes
• Type of clothing observe if the type of clothing
  worn is appropriate for temperature and weather
  conditions

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Skin

• Method of assessment
• Inspection
• palpation
• Normal skin is
• varies from light to deep brown, from ruddy
  pink to light pink and from yellow overtones to
  olive.
• Intact surfaces.

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• Abnormal findings
• Pallor is the result of inadequate
  circulating blood or hemoglobin and subsequent
  reduction in tissue oxygenation.
• Cyanosis a bluish color is most evident in
  the nail beds, and lips.
• Jaundice a yellowish color observed in the
  sclera of the eyes, mucosa membrane and the skin.
• Erythema is a redness associated a Varity of
  rashes.
• Vitiligo patches of hypo pigmented skin.

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Assessment of the hair

• Method
• Inspection palpation
• Normal hair is
• well distributed, thick hair, silky, resilient
  hair.
• Abnormal finding
• Alopecia hair loss.
• Protein deficiency the hair color is reddish
  or bleached.
• Hypothyroidism cause very thin and brittle
  hair.

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Assessment of the nails

• Method Inspection- Palpation.
• Assess the nails plate shape, angel between
  the nail and the nail bed, nail bed color, and
  the intactness of the tissue around the nail.
• Normal nail convex curvature, angel of nail
  plate about 160, smooth texture, highly vascular,
  and intact epidermis.

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The head

• Method inspection - palpation.
• Assess Skull- Face
• Normal skull rounded, smooth skull contour,
  absences of masses or nodules.
• Normal face symmetric facial features, equal
  in size, and symmetric facial movement.
• Abnormal finding
• Edema of the eyelids.
• Moon face round face with reddened cheeks

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Assessment of the eyes and vision

• Method inspection- palpation.
• Assess External eye structure, vision,
  lacrimal gland, lacrimal sac, nasolacrimal duct.
• Normal eyes
• Eye structure symmetrical eyes, eyebrows
  symmetrically aligned, equal movement, skin
  intact, with shiny smooth and pink or red
  conjunctiva, pupils equal in color, size and
  diameter.
• Lacrimal glands No edema or tenderness over
  lacrimal gland.

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Assessment of the ear and hearing

• Method inspection palpation
• Assess the external ear- internal ear canal-
  tympanic membrane.
• Normal ear and hearing
• Color of the ear as same of facial skin,
  symmetrical, and the auricle aligned with outer
  canthus of eye.
• Mobile, firm, and not tender.
• Normal tympanic membrane is grayish color.

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Pulling the ear pinna up and back
Inserting the otoscope
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Hearing Test

• Watch tick test.
• Tuning fork tests.

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A- Webers test
B1-(Rinne test) Place the tuning fork on the
mastoid process
B2-(Rinne test) Place the tuning fork in front of
the ear
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Assessment of the nose and sinuses

• Method inspection- palpation.
• Assess the nose, nasal cavity patency, sinuses.
• Normal nose symmetric and straight, no
  discharge and flaring, , no tender or lesions.
• Nasal cavity patency the air moves freely as the
  client breath, mucosa pink and watery discharge.
• Sinuses no tenderness in the maxillary and
  frontal sinuses.

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Assessment of the Mouth and pharynx

• Method inspection- palpation.
• Assess the lips and buccal mucosa, teeth, gum,
  tongue, floor of the mouth, salivary gland,
  palate, uvula, tonsils.
• Normal Mouth and pharynx
• Lips and buccal mucosa pink color, soft, moist,
  smooth texture, symmetry of contour, ability to
  purse lips.
• Teeth and gums 32 adult teeth, smooth, white,
  shiny tooth enamel, pink gums and intact.

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• Tongue/floor of the mouth central position for
  the tongue, moves freely, no tenderness, smooth
  with no palpable nodules in the tongue or in the
  floor.
• Silvery glands same color of the buccal mucosa,
  no nodules or tenderness, and secret the saliva
  in the oral cavity.
• Palates and uvula light pink, smooth, soft
  intact palate, the uvula positioned in the
  midline and mobile.

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• pharynx and tonsils pink and smooth posterior
  wall, pink and smooth tonsils within normal size
  and no discharge.
• Abnormal findings
• Dental caries cavities.
• Glossitis inflammation of the tongue.
• Stomatitis inflammation of the oral mucosa.

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Assessment of the neck

• Method inspection- palpation
• Assess the muscles, lymph nodes, trachea,
  thyroid gland, carotid arteries, and jugular
  vein.

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Assessment of thorax and lungs

• Method inspection- Auscultation- percussion.
• Assess chest shape and size, Breathing sounds,
  chest sounds.
• Chest shape and size
• the thorax is oval.

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• Abnormal chest shape
• in older adult kyphosis and osteoporosis alter
  the size of the chest cavity as the ribs move
  downward and forward.
• Pigeon chest.
• Permanent deformity ( caused by rickets).
• Funnel chest.

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Funnel chest
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• Chest landmarks
• Front anterior axilla line, midclavicular
  line, midsternal line.
• Back Vertebral line, right scapular line

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• Assessing the thorax and lungs
• Anterior thorax
• Assess respiratory excursion .
• Percussion sounds on the anterior chest.
• Posterior thorax
• Assess respiratory excursion

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Assessment of cardiovascular and peripheral system
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Heart

• Auscultation is more meaningful method.
• Heart examination are usually performed when the
  client is a symmetrical position.

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• The normal heart sounds
• Systole Ventricles contract S1.
• Diastole Ventricles relax S2.
• S1 (Lub) .. occur when atrioventricular valves
  close (A-V), valve close when the ventricles have
  been filled.
• S2 ( Dub) . after the ventricles empty their
  blood into the aorta and pulmonary arteries, has
  a higher pitch than S1 and also Shorter.
• S1 and S2 are (Lub-Dub) sounds.

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• Abnormal heart sounds
• S3.. is normal in children and young adults,
  in older adults its indicate heart failure.
• S4. may be heard in many elderly clients and
  can be signs of hypertension.

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• CAROTID ARTERY
• Palpation Palpate carotid artery with extreme
  caution -auscultation
• JUGULAR VEIN
• Inspection Client is placed in a semi fowlers
  position

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BREAST AND AXILLAE

• Inspection
• Inspect the breast for size, symmetry, and
  contour or shape.
• Inspect the skin of the breast for localized
  discoloration

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• Normal
• Female rounded shape slightly unequal in size
  generally symmetric
• Male breast even with chest wall
• Abnormal
• Recent change in breast size swellings marked
  asymmetry.
• Localized discoloration

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Abdomen

• Inspection
• Inspect the abdomen for skin integrity.
• Inspect the abdomen for contour and symmetry.
• movements associated with respirations,
  peristalsis or aortic pulsations

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• Auscultation
• Auscultate the abdomen for bowel sounds
• Percussion
• Percuss several areas in each of the four
  quadrants to determine the presence of tympany
  (gas in the stomach and intestines) and dullness
  (decrease, absence or flatness of resonance over
  solid masses or fluid).

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Palpation

• Perform light palpation first to detect areas of
  tenderness and/or muscle guarding.
• Perform deep palpation over all four quadrants

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Musculoskeletal System

• Muscles, bones and joints
• Objective assessment of musculoskeletal system
• Purpose
• To assess function of ADL (activities of daily
  living)
• Screen for abnormalities
• Screening exams
• Inspection (look)
• Palpation (feel)
• ROM with movement active or passive
• Compare with the opposite

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Muscles

• Inspect for muscle size equal size on both
  sides of the body
• Inspect the muscles and tendons for contractures
  there should be no contractures
• Inspect the muscles for fasciculation and tremors
  there should be no fasciculation and tremors

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• Palpate muscles at rest to determine muscle
  tonicity normally firm
• Palpate muscles while the client is active and
  passive for flaccidity, plasticity smoothness
  of movement there should be smooth coordinated
  movements

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Bones

• Inspect the skeleton for normal structure and
  deformities there should be no deformities
• Palpate the bones to locate any areas of edema or
  tenderness no tenderness or swelling

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Joints

• Palpate each joint for tenderness, smoothness of
  movement, swelling, crepitating, and presence of
  nodule no tenderness, swelling, crepitating or
  nodules

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Types of joint movement

• Flexion bending
• Extension straightening
• Adduction toward further straightening
• Abduction the midline
• Rotation around its central axis
• Circumduction circular
• Eversion foot outward
• Inversion foot inward
• Pronation palm down
• Supination palm up

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THANK YOU