Health Assessment

Health assessment contains health

history, vital signs, general survey and physical assessment

Preparing
Client and environment require special consideration Keep the client informed Be organized demonstrate respect for the clients apprehension Appear calm, organized and competent at the bedside Adjust environment according to the clients need (special accommodations), quiet, warm and well lit Gather equipment Positioning and draping

HEALTH HISTORY
Purpose of the Health History Health history is a review of the clients functional health patterns prior to the current contact with a health care agency,

focuses on: functional health patterns, responses to changes in

health status, and alterations in lifestyle. Used in developing the plan of care and formulating nursing interventions.

Purpose of physical health examination is to evaluate the physiologic outcomes of health care and thus the progress of a clients health problem

Subjective data Elements of health history

Demographic info: name, address, date of birth, gender,

religion, race, ethnic origin, occupation, insurance

Reason for seeking health care: this should be put in the patients own words, its pt actual report Clients perception of health status: clients opinion of his/her general health

Previous illnesses, hospitalizations, and surgeries

Health history cont

Family history of acute or chronic illnesses that tend to be familial Immunizations, exposure to communicable disease

Allergies
Current medications Psychosocial history Value and belief system

Health history cont

1. Sociocultural history Activities of daily living Nutrition

2.
3. 4.

Elimination
Rest/sleep Activity/exercise Review of systems(ROS)-pain assessment

Objective data
Physical assessment
Height , weight, v/s, (general survey) Physical exam can be head to toe exam, focused exam of a body part, or body system Conducted in an aseptic, systematic and efficient manner

Physical assessment
General survey; clients physical appearance, mood and
behavior, signs and symptoms of distress Document data in an organized format, use proper terminology and agency-approved abbreviations

Techniques

1. 2. 3. 4.

Inspection Palpation Percussion Auscultation (see hand-out)

Systems
1. Integumentary system (hair, scalp, skin and nails) 2. Head and Neck (skull, face, eyes, ears, nose, mouth, pharynx, and neck) 3. Thorax and Lungs 4. Heart and Vascular system 5. Lymphatic system 6. Abdomen

7. Genitalia
8. Musculoskeletal system 9. Neurologic system

Integumentary system

Skin Hair and Scalp Nails Skin assessment provides a noninvasive window to observe the bodys physiological functions.

SKIN

Color Lesions Moisture Temperature Texture Mobility and Turgor Edema

HEART AND LUNGS

Thorax and Lungs

Landmarks for inspection, auscultation, and percussion Anterior and posterior examination Shape and symmetry Thoracic expansion

Auscultation of Normal Breath Sounds

1. Vesicular sounds

2. Bronchovesicular sounds

3. Bronchial sounds

 Auscultation of Adventitious Breath Sounds

Crackles

Rhonchi
Wheezes

Pleural friction rub

Stridor

 Heart
Landmarks for inspection, palpation, auscultation Heart sounds Palpation for thrills and heaves Abnormal auscultatory findings
Murmurs Bruits

 Vascular System
Blood perfusion of peripheral vessels
Peripheral pulses compared bilaterally Skin temperature, color

Measurements
Capillary Refill: Push on the tip of the great toe or the nail bed until blanching occurs. Then release and note how long it takes for the red color to return, a reflection of blood inflow to the distal aspect of the lower extremity. Longer then 2-3 seconds is considered abnormal and consistent with arterial insufficiency.

Edema: There is a very subjective scale for rating edema which ranges from "trace at the ankles" to "4+ to the level of the knees." After examining many patients, you'll develop a sense of what is a lot and what is not.
Pulses: These are rated on a scale ranging from 0 (not palpable) to 2+ (normal). As with edema, this is very subjective and it will take you a while to develop a sense of relative values. In the event that the pulse is not palpable, the doppler signal generated is also rated, ranging again from 0 to 2+.

Abdomen

Inspection
Contour Symmetry Umbilicus Surface motion Scars

 Auscultation
All four quadrants in a systematic fashion Beginning with the RLQ
Tympany Dullness Bruits Hyperactive or hypoactive bowel sounds

Abdomen

Light palpation in all four quadrants beginning with the RLQ

Resistance Tenderness Rebound tenderness Organ enlargement

Musculoskeletal system

Inspection Palpation Range of Motion (ROM) Bilateral Comparison Joints

Arthritis Osteoarthritis Crepitus

Mental Status

Appearance Level of alertness Speech Behavior Awareness of environment, also referred to as orientation Mood Affect: flat ,excitable, appropriate. Thought Process Thought Content Memory Judgment Higher cortical functioning and reasoning

Wakefulness
Unresponsive, Sleepy, Drowsy, Awake, Alert (Eye Opening None to spontaneous in Glascow Coma Scale)

Confusion
Memory defects of all kinds, intermittent or constant (Delirium b/c illness or medication OR depression, or dementia)

Orientation
Identifies person, place, time typically, but circumstances may prevent those steps if medicated or unfamiliar with environment

Observations for Documentation

Skin Lesions
Color Associated pain, redness, heat, swelling Size and location Pattern of eruption (macular, papular, scaling, oozing, etc.) Distribution (linear, circular, symmetric Wound bed Wound edges and margins Wound size (in cm) Surrounding skin Condition of dressing removed Odor, exudate Careful documentation of findings of all wounds is essential for legally sensible practice

Wounds