HEALTH ASSESSMENT

in NURSING

N 295 Spring 2012

Week 2Revised January 2012 1

Preparing for a Physical Exam

Setting

Oneself

Client

Revised January 2012 2

General Assessment

General Survey

Vital Signs

Anthropometric Measures

Revised January 2012 3

General Survey1. Apparent State of Health2. Appear Stated Age3. LOC4. Behavior / Speech Pattern5. Height / Build / Weight6. Skin Color7. Dress / Grooming / Hygiene 8. Facial Expression / Behavior9. Posture & Gait

Revised January 2012 4

Vital Signs

• Temperature (T)

• Pulse (P)

• Respirations (R)

• Blood Pressure (B/P)

TPR &

B/P

Revised January 2012 5

Temperature

Core Temperature

Anatomic Sites

Normal Fluctuation

Revised January 2012 6

Celsius vs Fahrenheit

Degrees Celsius = 5/9 (F – 32)

Degrees Fahrenheit = (9/5 x C) + 32

Revised January 2012 7

Pulse

Normal variations– Rest or exercise– Oxygen needs– Cardiac output– Bradycardia (<60)– Tachycardia (>100)

Abnormal variations– Tachycardia (>100)– Bradycardia (<60)– Bounding– Thready, weak– Pulse deficit– Asystole

Revised January 2012 8

Respirations

• Abnormal Variations– Tachypnea – Bradypnea – Cheyne-Stokes– Biot’s– Kussmaul’s– Hyperpnea

Revised January 2012 9

Normal B/P Fluctuations

• Time of Day• Activity• Age• Gender• Race• Weight• Exercise• Emotions/Stress

Revised January 2012 10

Revised January 2012 11

Sample Question• Knowledge

– A nurse knows that blood pressure is….• Comprehension:

– A nurse interprets a client’s BP of 140/80 to mean:• Application:

– A client reports dizziness and fainting episodes that started a week ago. Which vital sign should the nurse assess first ?...

• Analysis:– A nurse assesses a client’s vital signs and note a BP of 180/90, heart

rate 72, respirations of 26/min, temp 98 degrees F. What is the next best action by the nurse?...

Revised January 2012 12

Types of Anthropometric Measures

• Height/Weight• Body Mass Index• Abdominal Fat• Triceps Skin Fold Thickness

(TSF)• Mid-Arm Circumference

(MAC)• Head/Chest Circumference

(infant)

BMI

Revised January 2012 13

Weight in pounds * 703

____________________

Height in inches2

BMI Categories:

• Underweight = <18.5 <18.5 or < 19 ( varies with source )

• Normal weight = 18.5-24.9 18.5-24.9

• Overweight = 25 -29.925 -29.9 • Obesity = ≥30

Revised January 2012 14

Ectomorph Mesomorph Endomorph

Revised January 2012 15

Parts of the Hand

• 1.• 2.• 3.• 4.

Revised January 2012 16

Types of Palpation

• Light • Deep *

Revised January 2012 17

Percussion

Direct (immediate)

Indirect (mediate)

Blunt - Direct

Blunt - IndirectRevised January 2012 18

Percussion NotesFlatness * Dullness

Resonance

Hyper-resonance

TympanyRevised January 2012 19

STETHOSCOPE

Revised January 2012 20

*

Documentation

Purpose

Guidelines

Types of Assessment Forms

Revised January 2012 21

Types of Documentation

• SOAPIE

• PIE

• DAR

Revised January 2012 22

Revised January 2012 23