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Miss.M.N PriyadarshanieBSc.Special in Nursing

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Session 2

Health Assessment

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Components of a Health Assessment

Health history — focus on interviewing skills Physical assessment: — head- to- toe sequence, — or systems sequence.

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Physical Assessment

Integument. Head and neck. Thorax and lungs. Cardiovascular and peripheral vascular systems. Breasts and axilla. Abdomen. Female and male genitalia. Musculoskeletal system. Neurological system.

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Purposes of Health Assessment

To evaluate the client’s current physical condition.

To detect early signs of developing health problems.

To establish a baseline for future comparisons. To evaluate the client’s responses to medical

and nursing interventions.

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Physical Assessment Environment

Adequate lighting. Facilities for handwashing. Easy access to a restroom. A door or curtain that ensure privacy. Adequate warmth for client comfort. A padded, adjustable table or bed. A lined receptacle for soiled articles. Sufficient room for moving to either side of the

client. A clean counter for placing examination

equipment.

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Preparing the Patient for Physical Assessment

Prepare equipment needed for assessment ( stethoscope, torch, disposable gloves, pin,…)

Have good lightening (daylight or artificial). Answer patient questions directly and honestly.

Screen the bed to provide privacy. Assure quite environment. Wash hands. Explain procedures for examination. Instruct for appropriate seating. Ask the patient to change into a gown and empty

bladder.

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Positions Used During a Physical Assessment

Sitting — used to take vital signs Supine — allows relaxation of abdominal muscles Dorsal recumbent — used for patients having

difficulty maintaining supine position Sim’s — assessment of rectum or vagina Prone — assessment of hip joint and posterior

thorax, Lithotomy — assessment of female rectum and

vagina; used for brief period only Knee-chest — assessment of the rectal area; used

for brief period only Standing — assessment of posture, gait, and

balance

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Factors to Assess During a Health History

Biographical data. Chief complaint . History of present illness . Past medical history . Family history . Life style .

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Components of the Health History• Biographical data• Present health–illness

• Past history• Family history• Psychosocial history

• Review of body systems

Biographical Data• Demographic data about the client– Name– Address– Age– Date of birth

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Biographical Data• Demographic data about the client– Birthplace– Gender– Marital status– Race– Occupation

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The Present Health or Illness History• Past and current health problems and concerns– Reason for seeking care– Health beliefs and practices– Health patterns– Medications

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Past History• Childhood diseases• Immunizations• Allergies• Blood transfusions• Major illnesses• Injuries

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Past History• Hospitalizations• Childbirths• Surgeries• Psychiatric problems• Use of alcohol, tobacco, and other substances

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Family History - Determines whether Genetic or Familial Patterns of Health Impact the Client’s Current or Future Health Status

Genogram - Pictorial Representation of Family Relationships and Medical History 16

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Psychosocial History• Occupation• Education• Finances• Roles and relationships• Ethnicity and culture• Family• Spirituality• Self-concept

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Review of Body Systems - Provides Subjective Information About Each Body System and Its Organs

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Sources of Information for the Health History• Primary source

– Client• Secondary sources

– Other individuals– Client records and charts

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Physical Assessment Techniques

Inspection. Palpation. Percussion. Auscultation.

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Inspection

Is the process of performing deliberate, purposeful observations in systematic manner, nurse observes visually and uses hearing and smelling to gather data.

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Palpation

Is an assessment technique that uses the sense of touch by hand and fingers which can assess temperature, shape , vital sign , tenderness , internal injury …. etc

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Auscultation Is the act of listening with a stethoscope to sounds

produced within the body. Auscultation is performed by placing the stethoscope diaphragm or bell against the body part being assessed.

This method uses the stethoscope to augment the sense of hearing.

The stethoscope must be constructed well and must fit the user. Earpieces should be comfortable, the length of the tubing should be 25 to 38 cm (10–15 inches), and the head should have a diaphragm and a bell.

The bell is used for low-pitched sounds such as certain heart murmurs.

The diaphragm screens out low-pitched sounds and is good for hearing high-frequency sounds such as breathe sounds.

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Auscultation (Cont’d)

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Percussion

Is the act of striking one object against another to produce sound , the sound waves produced by the striking action over body tissues are known as percussion tones , percussion used to assess the location , shape , size and density of tissues .

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Percussion (Cont’d)

Warm your hands Perform percussion as follows:a. Mediate percussion: Hyperextend the middle finger of the left hand Press the distal portion and joint firmly against the

surface to be percussed .(other fingers touching thesurface will damp the sound).

Cock the right hand at the wrist, flex the middle finger upwards, place the forearm close to the surface to bepercussed. (The right hand and forearm should be asrelaxed as possible)

Strike with the tip of the right middle finger behind the nailbed of the extended. left middle finger

Lift the right middle finger rapidly to avoid damping the vibrations.

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Percussion (Cont’d)

b- Identify percussion sounds as follows : Flatness : Percuss over the bone or thigh Dullness : Percuss over the liver Resonance : Percuss over the normal lung (intercostal

spaces) Tympani : Percuss over the stomach Hyperresonancc: Percuss over emphysema lung.c- Immediate percussion:- Use one or more fingers of one hand. Strike the body surface.d- Fist percussion:- Place one hand flat against body surface Strike the back of hand with the other hand clenched in

a fist

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Percussion (Cont’d)

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Equipment Used During a Physical Examination

Ophthalmoscope - visualizes the interior structures of the eye .

Otoscope - examines the external ear canal and tympanic membrane.

Laryngoscope- visualizes the trachea. Snell en's chart- screens for distant vision Nasal speculum - visualizes the lower and

middle turbinate's of nose . Vaginal speculum- examines the vaginal canal

and cervix. Tuning fork – tests auditory function and

vibratory perception.

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Equipments (Cont’d)

Percussion hammer - tests deep tendon reflexes and determine tissue density .

ECG. Glucometer Stethoscope. Sphygmomanometer.

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Nurse’s Role in Diagnostic Procedures

Assist before, during, and after diagnostic tests. Be responsible for other activities associated with

diagnostic tests. Witness the patient’s consent. Schedule the test. Prepare the patient physically and emotionally for

the test. Provide care after the test. Dispose of used equipment. Transport specimens.

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The End