HEALTH ASSESSMENT & PHYSICAL ASSESSMENT

Introduction
The health assessment and physical examination are the irst steps to!ard pro"idin# sae and competent nursin#
care$
The nurse is in a uni%ue position to determine each patient&s current health status' distin#uish "ariations rom
the norm' and reco#ni(e impro"ements or deterioration in his or her condition$
As a nurse' you must )e a)le to reco#ni(e and interpret each patient&s )eha"ioral and physical presentation$ *y
perormin# health assessments and physical examinations' you !ill identiy health patterns and e"aluate each
patient&s response to treatments and therapies$
Definition
Health
Health is a state o complete physical' mental' social !ell )ein# and not merely the a)sence o disease or
inirmity$
assessment
accordin# to ANA Asessment is deined as a systematic' dynamic process )y !hich the nurse throu#h
interaction !ith client' si#niicant others & health care pro"iders' collects & analy(es data a)out client$
Purpose of health assessment
+$ To collect data a)out physical' mental' & social !ell,)ein# o client
-$ To identiy the pro)lem in early sta#e
.$ To determine the cause & extent o disease
/$ To e"aluate0monitor the chan#es in client&s health status
1$ To determine the nature o treatment re%uired or client
2$ To alle"iate the complications
3$ To certiy !hether client is medically it to resume duties
4$ To contri)ute in medical research
5$ To collect data systematically
+6$ To identiy clients stren#th' !ea7ness' 7no!led#e' moti"ation' support system & copin# a)ilities
HEALTH HISTORY
The purpose o the health history is to collect
Subjective ata 8 !hat the person says a)out himsel or hersel$
Objective ata 8 physical examination' la)oratory studies to orm the data )ase$
The data )ase is used to ma7e a 9ud#ement or a dia#nosis a)out the health status o the indi"idual$
Health history pro"ides a complete picture o the person past & present health$ It descri)es the indi"idual as a
!hole& ho! the person interacts !ith the en"ironment$
!actors affectin" the collection of histor#
+$ Physical settin#0en"ironment
-$ Client&s personality & )eha"ior
.$ Communication s7ill
/$ Pro)lem
1$ Nurses personality & )eha"ior
2$ Nurses 7no!led#e & s7ill
Althou"h histor# forms var#$ most contain information in this se%uence of cate"ories&
+$ *io#raphical data
-$ Chie complaints
.$ Present health or history o present illness
/$ Past history
1$ :amily history
2$ ;e"ie! o systems
3$ :unctional assessment o acti"ities o daily li"in# <A=Ls>
'io"raphic ata
Name' address & phone num)er' a#e & )irth date' )irth place' #ender' marital status' race' ethnic ori#in'
occupation' usual & present$
The person&s primary lan#ua#e & authori(ed representati"e' should )e recorded here$ This is in response to
research sho!in# dierences in lan#ua#e & culture may ha"e an impact on the %uality & saety o care$
Source of histor#
+$ ;ecord !ho urnishes the inormation 8 usually the person )y themsel"es$ Althou#h the source may )e a
relati"e or riend
-$ ?ud#e ho! relia)le the inormant seems & ho! !illin# he or she is to communicate$
.$ Note any special circumstances' such as the use o an interpreter$ Sample statements include@
Patient himsel' !ho seems relia)le
Patient&s son' !ho seems relia)le
Mrs$ A' interpreter or ; !ho does not spea7 En#lish
(hief complaints
this is a )rie spontaneous statement in the person&s o!n !ords that descri)es the reason or the "isit$ It states
one <possi)ly t!o> symptoms or si#ns & their duration$
A symptom is a su)9ecti"e sensation that the person eels rom the disorder$
A si#n is an o)9ecti"e a)normality that the examiner could detect on physical examination or in la)oratory
reports$
Present health or histor# of present illness
It is the chronolo#ical record o the reason or see7in# care' rom the time the symptom irst started until no!$
As the client tal7s' do not 9ump to conclusions & )ias the story )y addin# opinions$
Te inal summary o any symptom the person has should include the 4 critical characteristics
)* Location
*e speciicB as7 the client to point the location$ I the pro)lem is pain' note the precise site$ Chead painD
is "a#ue' !hereas' descriptions such as Cpain )ehind the eyesD' C9a! pain & occipital painare more
precise & are dia#nostically si#niicant$ Is the pain locali(ed to this site or radiatin#E Is the pain
supericial or deepE
+* (haracter or %ualit#
It includes terms li7e )urin#' sharp' dull' achin#' #na!in#' thro))in#' shootin#' "iseli7e$ Fse similes,
does )lood in the stool loo7 li7e stic7y tarE =oes )loo in "omitus loo7 li7e coee #roundsE
,* -uantit# or severit#
Attempt to %uantiy the si#n or symptom such as Cprouse menstrual lo! soa7in# i"e pads per hourD'
the symptom o pain is diicult to %uantiy )ecause o indi"idual perception$
Gith pain' a"oid ad9ecti"es & ho! it aects daily acti"ities$
.* Timin"
<onset' duration' re%uency>$ Ghen did the symptom irst appearE Hi"e the speciic date & time' or state
speciically ho! lon# a#o the symptom started prior to arri"al <PTA>$
/* Settin"
Ghere !as the person or !hat !as the person doin# !hen the symptom startedE Ghat )rin#s it onE
:or example@ did you notice the chest pain ater sho"elin# sno!' or did the pain start )y itselE
0* A""ravatin" or relievin" factors
Ghat ma7es the pain !orseE Is it a##ra"ated )y !eather' acti"ity' ood' medication' standin# )ent o"er'
ati#ue' time o day' season' & so onE Ghat relie"es <E$#$ rest' medication' or ice pac7>E Ghat is the
eect o any treatmentE As7' C!hat ha"e you triedE Ir C!hat seems t helpED$
1* Associate factors
Is this primary symptom associated !ith any others <e$#$' urinary re%uency & )urnin# associated !ith
e"er & chills>E ;e"ie! the )ody system related to this symptom no! rather than !ait or the re"ie! o
systems$
2* Patient3s perception
:ind out the meanin# o the symptom )y as7in# ho! it aects daily acti"ities$ Also as7 directly$ D!hat
do you thin7 it meansED this is crucial )ecause it alerts you to potential anxiety i the person thin7s the
symptom may )e omnius$
The %uestion se%uence coul be arran"e in P-RST
P& Provocative or Palliative
Ghat )rin#s it onE Ghat !ere you irst noticed itE Ghat ma7es it )etterE GorseE
-& -ualit# or -uantit#
Ho! does it loo7' eel' soundE Ho! intense0se"ere is itE
R& Re"ion or Raiation
Ghere is itE =oes it spread any!here$
S& Severit# Scale
Ho! )ad is it <on scale o + to +6>E Is it #ettin# )etter' !orse' stayin# the sameE
T& Timin"
Inset 8 exactly !hen did it irst occurE
=uration,ho! lon# did it lastE
:re%uency,ho! oten does it occurE
4& 4nerstan Patient3s Perception
Fnderstand patients perception o the pro)lem$ Ghat do you thin7 it meansE
Past health
Past health e"ents may ha"e residual eects on the current health state$
(hilhoo illness
Measles' mumps' ru)ella' chic7en pox' pertusis' & strep throat$ A"oid recordin# Cusual childhood illness'D
)ecause an illness common in the person&s childhood <e$#$' measles> may )e unusual today$ As7 a)out serious
illnesses that may ha"e se%uelae or the person in later years <e$#$' rheumatic e"er' scarlet e"er' &
poliomyelitis>$
Accients or injuries
Auto accidents' ractures' penetratin# !ounds' head in9uries <especially i associated !ith unconsciousness> &
)urns$
Serious or chronic illnesses
=ia)etes' hypertension' heart disease' sic7le,cell anemia' cancer' & sei(ure disorder$
Hospitali5ation
Cause' name o the sur#eon' name o hospital' & ho! the person reco"ered$
Operations
Type o sur#ery' date ' name o the sur#eon' name o hospital' & ho! the person reco"ered$
Obstetric histor#
No$o pre#nancies <#ra"idity>' no$o deli"eries in !hich the etus reached ull term' no$o preterm pre#nancies
<preterm>' no$o incomplete pre#nancies <a)ortions>' & no$o children li"in#$
:or any incomplete pre#nancies' record the duration & !hether the pre#nancy resulted in spontaneous <S> or
induced <I> a)ortion$
Immuni(ation
Measles,mumps,ru)ella' polio' diphtheria,pertussis,tetanus' hepatitis *' human papiloma "irus' haemophilus
inluen(a type )' pneumococcal "accine$
Last e6amination ate
Physical' dental' "ision' hearin#' electrocardio#ram' chest x,ray examinations
Aller#ies
Note )oth the aller#en <medication' ood' or contact a#ent' such as a)ric or en"ironmental a#ent> & the raction
<rash' itchin#' runny nose' !atery eyes' diiculty )reathin#>$ Gith a dru#' this symptom should not )e a side
eect )ut a true aller#ic reaction$
Current medications
Note all prescription & o"er,the,counter medications$ As7 speciically a)out "itamins' )irth control pills'
aspirin' & antacids' )ecause many people do not consider these to )e medications$
!amil#histor#
As7 a)out the a#e & health or the a#e & cause o death o )lood relati"es' such as parents' #rand parents' &
si)lin#s$
Speciically as7 or any amily history o heart disease' hi#h )lood pressure' stro7e' dia)etes' )lood disorders'
cancer' sic7le,cell anemia' arthritis' aller#ies' o)esity' alcoholism' mental illness' sei(ure disorder' 7idney
disease' & tu)erculosis$ Construct an accurate amily tree or #eno#ram$
7OR8AL RA79E O! !I7DI79S A'7OR8AL !I7DI79S
APPEARA7(E
Posture@ Posture is erect & position is relaxed Sittin# on ed#e o chair or curled in )ed' tense
muscles' ro!nin#' dartin# !atchul eyes' rstless
pacin# occur !ith anxiety & !ith hyperthyroidism$
Sitin# slumped in chair' slo! !al7' dra##in# that
occur !ith depression & some or#anic )rain diseases$
'o# movements& *ody mo"ements are "oluntary'
deli)erate' coordinated' & smooth & e"en$
;estless' id#ety mo"ements' or hyper7inetic
appearance occur !ith anxiety$
Apathy & psychomotor slo!in# occur !ith depression
& or#anic )rain disease$
A)normal posturin# & )i(arre #estures occur !ith
schi(ophrenia$
:acial #rimaces
Dress* =ress is appropriate or settin#' season' a#e'
#ender' & social #roup$ Clothin# its & is put on
Inappropriate dress can occur !ith or#anic )rain
syndrome
appropriately Eccentric dress com)ination & )i(arre ma7e,up !ith
schi(ophrenia or manic syndrome
9roomin" : h#"iene*
The person is clean #roomedB hair is neat & cleanB
!omen ha"e moderate or no ma7e,upB men are sha"ed
or )eard or mustache are !ell #roomed$ Nails are
clean$
Fnilateral ne#lect occurs ollo!in# some
cere)ro"ascular accidents$
Inappropriate dress' poor hy#iene' & lac7 o concern
!ith appearance occur !ith depression & se"ere
Al(heimer&s disease$
'EHA;IOR
Level of consciousness*
The person is a!a7e' alert' a!are o stimuli rom the
en"ironment & !ithin the sel' & responds
appropriately to stimuli$
Lethar#ic' o)tunded' stupor or semi coma' coma$
Acute conusional state
!acial e6pression*
The loo7 is appropriate to the situation & chan#es
appropriately !ith the topic$
:lat' mashli7e expression occurs !ith par7insonism &
depression
Speech
?ud#e the %uality o speech )y notin# that the person
ma7es laryn#eal sounds eortlessly & shares
con"ersation appropriately$
=ysphonia is a)normal "olume' pitch
8oo : effect
?ud#e this )y )ody lan#ua#e & acial expression
(O97ITI;E !47(TIO7S
Orientation*
Time@ day o !ee7' date' year' season
Place@ !here person li"es' present location' type o
)uildin#' name o city
Person@ o!n name' a#e' !ho examiner is' type o
!or7er
=isorientation occurs !ith or#anic )rain disorders'
such as delirium & dementia
Attention Span
Chec7 the person&s a)ility to concentrate )y notin#
!hether he or she completes a thou#ht !ithout
!anderin#
Recent memor#
Assess recent memory in the context o the inter"ie!
)y the -/,hour diet recall or )y as7in# the time the
person arri"ed at the a#ency
Remote memor#
In the context o the inter"ie!' as7 the person
"eriia)le past e"ents
7e< learnin"=The four unrelate <ors test
Thus tests the person&s a)ility to lay do!n ne!
memories$ It is a hi#hly sensiti"e & "alid memory test$
It also a"oids the dan#er o un"eriia)le material
Pic7 our !ords !ith semantic & phonetic di"ersity
*ro!n un
Honesty carrot
Tulip an7le
Eyedropper loyality
Ater 1 minutes' as7 or the recall o the our !ords' to
test the duration o memory' as7 or a recall at +6
minutes & .6 minutes$
PHYSI(AL E>A8I7ATIO7
A physical examination is conducted as an initial e"aluation in tria#e or emer#ency careB or routine screenin#
to promote !ellness )eha"iors and pre"enti"e health care measuresB
The physical examination re%uires that the examiner de"elop technical s7ills & a 7no!led#e )ase$ The s7ills
re%uisite or the physical examination are inspection' palpation' percussion' auscultation$
Inspection
Inspection is concentrated !atchin#$ It is close' careul scrutiny' irst o the indi"iduala as a !hole & then o
each )ody system$
Inspection al!ays comes irst$ A ocused inspection ta7es time & yields a surprisin# amount o data$
Inspection re%uires #ood li#htin#' ade%uate exposure' occasional use o certain instruments <otoscope'
ophthalmoscope' penli#ht' nasal & "a#inal specula>$
Palpation
Palpation ollo!s & oten conirms points noted durin# inspection$ Palpation applies sense o touch to assess
these actors@ texture' temperature' moisture' or#an location & si(e' as !ell as any s!ellin#' "i)ration or
pulsation' ri#idity or spasticity' crepitation' presence o lumps or masses' & presence o tenderness or pain$
=ierent parts o the hands are)est suited or assessin# dierent actors@
:in#ertips,)est or ine tactile discrimination' as o s7in texture' s!ellin#' pulsation' & determinin#
presence o lumps$
A #raspin# action o the in#ers & thum),to detect the position' shape' & consistency o an or#an or
mass
The dorsa <)ac7s> o hands & in#ers,)est or determinin# temperature )ecause the s7in here is thinner
than on the palms$
*ase o in#ers <metacarpophalan#eal 9oints> or ulnar surace o the hand,)est or "i)ration$
Palpation techni%ue should )e slo! & systematic$ Startin# !ith li#ht palpation & then deep palpation$
Percussion
Percussion is tappin# the person&s s7in !ith short' sharp stro7es to assess underlyin# structures$ The stro7es
yield a palpa)le "i)ration & a characteristic sound that depicts the location' si(e & density o the underlyin#
or#an$
Percussion has the ollo!in# uses
Mappin# out the location & si(e o an or#an )y explorin# !here the percussion note chan#es )et!een
the )orders o an or#an & itsnei#h)ours
Si#nalin# the density <air' luid' or solid> o a structure )y a characteristic note
=etectin# an a)normal mass i it is airly supericialB the percussion "i)rations penetrate a)out 1 cm
deep,a deeper mass !ould #i"e no chan#e in percussion
Elicitin# pain i the underlyin# structure is inlamed' as !ith sinus areas or o"er the 7idney
Elicitin# a deep tendon relex usin# the percussion hammer$
T!o methods o percussion can )e used,direct <immediate> & indirect<mediate>
In direct percussion the stri7in# hand directly contacts the !all
In indirect percussion is used more oten & in"ol"es )oth hands
Indirect percussion is used more oten & in"ol"es )oth hands$ The stri7in# hand contacts the stationary hand
ixed on the person&s s7in$
Production o sound
+$ Amplitude or intensity
A loud or sot sound' the louder the sound' the #reater the amplitude$ Loudness depends on the orce o
the )lo! & the structure&s a)ility to "i)rate
-$ Pitch or re%uency
The no$o "i)rations per second' !ritten as Jcps& or cycle per second$ More rapid "i)rations produce a
hi#h pitched toneB slo!er "i)rations yield a lo!,pitched tone
.$ Kuality or tim)re
A su)9ecti"e dierence due to sound&s distincti"e o"ertones$ A pure tone is a sound o one re%uency$
/$ =uration
The len#th o time the note lin#ers$
Amplitude Pitch Kuality =uration Sample location
;esonant Medium,
loud
Lo! Clear' hollo! Moderate I"er normal lun# tissue
Hyper
resonant
Louder Lo!er *oomin# Lon#er Normal o"er child&s lun#
A)normal in the adult' o"er lun#s !ith
increased amount o air' as in
emphysema
Tympany Loud Hi#h Musical &
drumli7e
Sustained
lon#est
I"er air,illed "iscus
E#$' the stomach' the intestine
=ull Sot Hi#h Muled thud Short ;elati"ely dense or#an' as li"er or
spleen
:lat Lery sot Hi#h A dead stop o
sound' a)solute
dullness
Lery short Ghen no air is present' o"er thi#h
muscles' )one' or o"er tumor
Auscultation
Auscultation is listenin# to sounds produced )y the )ody' such as the heart & )lood "essels & the lun#s &
a)domen$ Certain )ody sounds !ith ear alone or example' the harsh #ur#lin# o "ery con#ested )reathin#$
Ho!e"er' most )ody sounds are "ery sot & must )e channeled throu#h a stethoscope to e"aluate$
Settin"
The examination room should )e !arm & comorta)le' %uite' pri"ate' & !ell lit$
+$ Time o examinin# must )e con"enient to )oth client as !ell as nurse' and examination should not )e
done in a hurry
-$ Ade%uate li#ht 8 or "isuali(ation o )ody area
.$ E%uipment,)eore startin# examination all the e%uipment needed must ne in reach & in !or7in#
condition$ Client must )e relaxed & sit in comorta)ly on ta)le0chair
/$ Pri"acy@ as patient eels ema)arassed on exposin# there )ody pri"acy is a must
1$ Temperature, a !arm en"ironment 0 room temperature should )e pro"ided$ It should neither )e too hot0
too cold
2$ Positions
3$ =rapin#, means co"er the ad9acent )ody areas )ein# exposed$ =rapin# maintains pri"acy as !ell as
co"erin# )ody a"oids heat loss unnecessarily$
E%uipment
Platorm scale !ith hei#ht attachment
S7inold calipers
Sphy#momanometer
Stethoscope !ith )ell & diaphra#m endpieces
Thermometer
Pulse oximeter
:lashli#ht or penli#ht
Itosope0ophthalmoscope
Tunin# or7
Nasal speculum
Ton#ue depressor
Poc7et "ision screener
S7in,mar7in# pen
:lexi)le tape measure & ruler mar7ed in centimeters
;elex hammer
Sharp o)9ect
Cotton )alls
*i"al"e "a#inal speculum
Clean #lo"es
Materials or cytolo#ic study
Lu)ricant
:ecal occult )lood test materials