KRISHNA INSTITUTE OF NURSING SCIENCE, KARAD

SUBJECT :Medical Surgical Nursing

TOPIC :Health assessment

YEAR :2nd year GNM Nursing

VENUE : Ward No.15 (Male Medical Ward)

DATE : 16/05/2017

TIME : 2 to 4 Pm

SUBMITTED TO SUBMITTED BY

MR. SHREYAS SHRIPAD WALVEKAR

MRS.SUSHAMA SHETE 1ST YEAR M.SC NURSING
MSC NURSING KINS, KARAD
KINS KARAD
NAME OF STUDENT TEACHER :Mr. Shreyas Shripad Walvekar

SUBJECT :Medical Surgical Nursing

TOPIC :health assessment

GROUP :2nd year GNM Nursing

VENUE :KINS, Karad.

DATE :16 /06/2017

TIME : 2 to 4 Pm

A.V.AIDS : Demonstration

MEDIUM OF TEACHING :English

GENERAL OBJECTIVES:
At the end of demonstration student will know about health assessment

SPECIFICOBJECTIVES :
At the end of Demonstration student will know about ,
Define health assessment
Enlist steps of health assessment
Explain preparation of patient for procedure.
Discuss articles required for health assessment
Describe the procedure with rationale.
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INTRODUCTION
0.1
Assessment of physical findings should confirm data conclusion. Baseline information mind
for making accurate inspections: is obtained on admission. The proper examination
proceeds logically from head to be starting with general appearance, blood pressure (BP),
pulse, hands, head and neck, heart, lungs, abdomen, feet and legs
Teacher D
0.3 Define 1. DEFINITION explains E Students
health students M define
Physical examination is defined as a complete assessment of patient's physical and mental
assessment listens O physical
status. examination

Teacher list
0.6 Teacher PURPOSES out purposes Students list
enlists students out purposes
1.To understand the physical and mental well-being-' of the patient.
purposes of recall. of procedure
the 2.To detect disease in its early stage.
procedure
3.To determine the cause and the extent of disease.
4.To understand any changes in the condition of diseases, any improvement or regression.
5.To determine the nature of the treatment or nursing care needed for the patient.
6.To safeguard the patient and his/her family by noting the early signs especially in case of
a communicable disease.
7.To contribute to the medical research.
8.To find out whether the person is medically fit or not for a particular task.
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METHODS OF EXAMINATION
0.10 Teacher Teacher
explain Inspection explains D Students are
methods of students E able state the
Visual lamination of_the body is called 'inspection'. It is the observation with the naked
examination listens M methods of
eyes to determine the structure and functions of the body. It means looking with eyes. It O examination
reveals any rash, scar, color, size, shape, contour or symmetry of body parts. The quality of
inspection depends on the time spent by the nurse to be thorough and systematic
observation. In a hurry, we may overlook significant findings and make an incorrect.
conclusion.

The following principles should be kept in mind for making accurate inspections:

1.Good lighting and exposure are essential.

2.Inspect each area for size, shape, color, symmetry and proposition and find out any
deviations from normal.
3.Use additional lights for examining body cavities, e.g. oral.
4.Use sense of olfaction along with visual to detect abnormalities, e.g. bad breath indicates
unhygienic mouth condition, acidotic smell is significant of diabetic acidosis.
Palpation
Palpation is the feeling of the body or a part with the hands to note the size and positions of
the organs. In palpation, the finger pads (not the finger tips), are used. Palpation is an
assessment technique in which the examiner feels with his/her fingers and one or both
hands. Skill and gentleness are important. The degree of pressure applied during palpation
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varies, depending on age tenderness of the area and the depth of palpation required. It
reveals any swelling, coldness, hotness, stiffness, hardness, smoothness, roughness, pain,
vibration, firmness and flaccidity.
The following points are to be kept in mind, while doing palpation:
1.The client should be relaxed and comfortable. Observe non-verbal signs of discomfort
during palpation.
2.Palpation to be done with warm hands, short fingernails and a gentle approach.
3.Palpation to be done slowly and gently.
4.For light palpation the hand is depressed about 1 cm (1 /2 inch) and for deeper palpation it
should be approximately 2.5 cm (1 inch).
D
5.Use appropriate parts of the hands for doing various palpations. E
M
O
Percussion
Percussion is the examination by tapping with the fingers on the body to determine the
condition of the internal organs by the sounds that are produced. It is done by placing a
finger of the left hand firmly against a part to be examined and tapping with the finger tips
of the right hand. It means striking tapping with fingers.
It elicits sounds, which indicate whether the underlying tissues are solid or filled with air or
fluid.
The sound may be:
1.Resonance: A low-pitched and loud sound heard over the normal lung tissues.
2.Hyper resonance: Very loud, very low pitch sound longer than resonance and is of
booming quality signifies emphysema.
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3.Tympany: A drum-like sound heard over the air- filled tissues such as gastric air bubble.
4.Dull: A medium-pitched sound with a medium duration without resonance heard over
solid tissues such as heart, liver.
5.Flat: A high-pitched sound with a short duration without resonance heard over complete
solid tissues such as hand, thigh.
D
Methods of Percussion
E
The percussion can be done by two methods. Teacher M
discusses and O
These are:
students
Direct Percussion: responds
Striking the body surface directly with one or two fingers, e.g. ascitic thrill.
Indirect Percussion:
Placing the middle finger of the non-dominant hand firmly against the body surface and
striking the distal joint of non-dominant finger with the middle fingers of the dominant
hand.
Auscultation
Auscultation means listening with stethoscope/placing ear against the body. It reveals
sounds produced within the body and the blood vessels such as heart beats, bowel sounds,
while auscultation frequency loud, quality and duration of the sound to be noted.
Manipulations
Manipulations is the moving of a part of the body to note its flexibility. Limitation of
movements is discovered by this method.
Testing of Reflexes
The response of the tissues to external stimuli is tested by means of percussion hammer,
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safety pin, wisp of cotton, hot and cold water, etc.

D
0.10 Teacher HEAD TO TOE EXAMINATION Teacher E Students ion
emphasizes discusses and M revise head
The examination is carried out in an orderly manner focusing upon one area of the body at a
on head to students O to toe
Toe time. The observation of the patient starts as the patient walks into the examination room, responds examination
examination of procedure
e.g. a limp may be noted as the patient walks in.
The following observations are made:

General Appearance
1.Nourishment: Well-nourished or under-nourished.
2.Bodv build: Thin or obese.
3.Health: Healthy or unhealthy.
4.Activity". Active or dull (tired).

Mental Status
1.Consciousness: Conscious, unconscious, delirious, talking incoherently.
2.Look: Anxious or worried, depressed, etc.
Posture
3.Body curves: Lordosis, kyphosis and scoliosis.
4.Movement Any limp.
Height and Weight
1.Ask to stand str-ght tile measuring foe height.
2.Check the v -i king condition of foe instrument even time before use.
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D
Skin Conditions E
M
1.Color: Pallor, jaundice cyanosis, flushing, etc.
O
2.Texture: Drones, baking, wrinkling or excessive moisture.
3.Temperature: Warm, cold and clammy.
4.Lesions. Macules, papules vesicles, wounds, etc.
Head and Face
1.Shape of foe skull and fontanel.
2.Skull circumference.
3.Scalp: Cleanliness, condition of foe hair, dandruff, pediculi, infections like ringworm.
4.Face: Pale, flushed, puffiness, fatigue, pain, fear, anxiety, enlargement of parotid glands,
etc.
Eye
1.Eyebrows: Normal or absent,
2.Eyelashes: Infection, sty.
3.Eyelids: Edema, lesions, ectropion, entropion,
4.Eyeballs: Sunken or protruded.
5.Conjunctiva: Pale, red, purulent.
6.Sclera: Jaundiced,
7.Cornea and iris: Irregularities and abrasions.
8.Pupils: Dilated, constricted reaction to light.
9. Lens: Opaque or transparent.
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10.Fundus: Congestion, hemorrhagic spots.
11. Eye muscles: Strabismus (squint).
12. Vision: Normal, myopia, hypermetropia.
D
Ears
E
1.External ear-discharges, cerumen obstructing the ear passage M
O
2.Tympanic membrane: Perforations, lesions, bulging
3.Hearing: Hearing acuity.
Nose
1.External nares: Crusts or discharges
2.Nostrils: Inflammation of the mucus membrane, septal deviations.
Mouth and Pharynx
1.Lips: Redness, swelling, crusts, cyanosis, angular stomatitis.
2.Odor of the mouth: Foul smelling.
3.Teeth: Discoloration and dental caries.
4.Mucus membrane and gums: Ulceration and bleeding, swelling, pus formation.
5.Tongue: Pale, dry, lesions, sords, furrows, tongue tie, etc.
6.Throat and pharynx: Enlarged tonsils, redness and pus.
Neck
1.Lymph nodes: Enlarged, palpable.
2.Thyroid gland: Enlarged.
3.Range of motion: Flexion, extension and rotation.
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Chest
1.Thorax: Shape, symmetry of expansion, posture.
2.Breath sounds: Sigh, swish, rustle, wheezing, rales, crepitations, pleural rub, etc.
3.Heart: Size and location, cardiac murmurs.
4.Breasts: Enlarged lymph nodes.
Abdomen
1.Observation: Skin rashes, scars, hernia, ascites distension, pregnancy, etc.
2.Auscultation: Bowel sounds, fetal heart sounds.
3.Palpation: Liver margin, palpable spleen, tenderness at the urea of appendix, inguinal
hernias.
4.Percussion: Presence of gas, fluid or masses.
Extremities
Movement of joints, tremors, clumbing of fingers, ankle edema, varicose veins, reflexes,
etc.
Back
Spina bifida curves.
Genital and Rectum
1.Inguinal lymph glands: Enlarged, palpable.
2.Patency of urinary meatus and rectum (in infants).
3.Descent of the testes.
4.Vaginal discharges.
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5.Presence of sexually transmitted diseases.
6.Hemorrhoids.
7.Enlargement of the prostate gland.
8.Pelvic masses.
Neurological Tests
1.Coordination tests.
2.Reflexes.
3.Equilibrium tests.
4.Tests for sensations.
5.Role of the nurse in the physical examination.
Students ion
0.5 Teachers Teacher D revise
PREPARATION OF THE ENVIRONMENT
describes discusses and E preparation
preparation 1.Maintenance of privacy. students M of
of responds O environmet
2.A separate examination room is needed.
environment
3.Keep the doors closed. The relatives are not allowed.
4.Drape the patient according to the parts that are exposed.
5.Lighting: As far as possible natural light should be available in the examination room,
because if a patient is jaundiced, it may not be detected in the artificial light. There should
be adequate lighting.
6.Comfortable bed or examination table: The patient should be placed comfortably
throughout the examination. There should be provision for the maintenance of a suitable
position, e.g. a lithotomy position may be maintained when examining the genitalia. To
maintain this position, a special examination table with stirrup rods is needed.
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7.The room should be warm and without draughts.

0.2 Teachers Students list

PREPARATION OF THE EQUIPMENTS
describes D out
preparation All the articles needed for the physical examination are kept ready for the examination at E preparation
of M of
hand.
equipments O equipments
Sphygmomanometer
Stethoscope
Fetoscope
TPR Tray (To check temperature, pulse, respiration)
Tongue depressor
Pharyngeal retractor
Laryngoscope
Tape measure
Flash light
Weighing machine
Opthalmoscope
Otoscope
Tuning fork
Nasal speculum
Percussion hammer, safety pins
Cotton wool, cold and hot water
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Test tubes
Vaginal speculum
Protoscope
Gloves
Sterile specimen bottles, slides
Cotton applicators.
Articles Appropriate for Specific Examination
D
1.Eye: Torch, ophthalmoscope, snellen chart, wisp of cotton. E
2.Ear: Head mirror, light bulb fixed on the wall or a table lamp and a torch, a timing fork. M
O
3.Nose: Nasal speculum, forceps, a head mirror and a light bulb.
4.Throat: Tongue depressor, a laryngeal mirror, a kidney tray, a paper bag, throat swabs in a
container. Torch gauze pieces in a bowl.
5.Chest and abdomen: Stethoscope, tape measure.
6.Vaginal: Sterile vaginal speculum, gloves, a kidney tray, a bowl with swabs (sterile), an
antiseptic lotion.
7.Rectal: Proctoscope, gloves, finger cots, a kidney tray, water-soluble jelly.
8.Neurological: A percussion hammer, safety pins, a wisp of cotton with hot or cold water.
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Teachers PREPARATION OF THE PATIENT Teachers Students

0.2 describes explains D understands
Physical Preparation
preparation students E preparations
of 1.Keep the patient clean. listens M of patient
equipments O
2.Shave the part if necessary.
3.Keep the patient in a comfortable position, which is convenient for the doctor to examine
the patient.
4.Empty the bladder prior to the examination Empty the bowels by an enema if required.
5.Loosen the garments and change into the hospital dress, if it is the custom.
6.Drape the patient with extra sheets and expose only the need areas.
7.Avoid unnecessary exposure.

Mental Preparation
1.The patient may be quite new to the hospital situation and patient may be anxious about
his illness.
2.Patient may have false ideas about the medical examination.
3.It is the duty of the nurse to allay his patient's, anxieties and fears by proper explanations.
4.Explain the sequence of the procedure to gain his/ her confidence and cooperation.
5.As far as possible a nurse should remain with a female patient during the physical
examination.
ASSISTANCE IN THE EXAMINATION
Take height and weight
1.To measure the length of the baby who cannot stand, place the baby on a hard surface,
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with the soles of the feet supported in an upright position.
2.The knees are extended and the measurement is taken from the soles of the feet to the
vertex of the head.
3.The head should be in such a position that the eyes are facing the ceiling.
4.After a child can stand, the height can be measured, if the child with the heels back and
head against a wall.
5.A small flat board held from the top of the head to the wall, will give an accurate measure
of the height that is the distance from the floor to the board.
6.The weight of a person who can stand is generally measured by a standing scale.
7.The patient stands on the platform and the weight is noted on the dial.
8.Usually the weight is taken without shoes.
9.To take the weight of the baby, a baby weighing scale is used, in which there is a
container, where the baby can be laid.
10.It is important to weigh a baby unclothed. If weighed with cloth then weigh the clothes
separately and subtract this weight.
Measure the Skull Circumference
The skull is measured at its greatest diameter from
above the eyes to the occipital protuberance.
Examination of the Eyes
1.The examination is done in a lying or sitting position
2.The examiner frequently uses a head mirror that reflects light to the patient's face.
3.The first examination is one of inspection to determine the movements of the eyes,
reaction to light, accommodation to near and far objects.
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4.For detailed examination of the internal parts of the eye, an ophthalmoscope is used.

Examination of the Ears

1.The patient may be placed either in a lying or sitting position with the ear to be examined
turned towards the examiner.
D
2.Articles used for the examination are a head mirror, ear speculum of various sizes, cotton
E
tipped applicators and autoscope. M
O
3.Tuning fork is used to test the hearing ability.
4.A child needs to be carefully restrained.
5.Young children sit on their mother's lap with their legs restrained between the mother's
knees and their arms held against their back.
6.The mother then holds the child's head against the chest.
7.Very small infants can be laid on the examination table.

Examination of the Nose, Throat and Mouth

1.The patient is usually seated with the head resting against the back of the chair.
2.For the examination of the throat, a tongue depressor and a good light are needed.
3.For examination of the nose, a nasal speculum and a head mirror are used. Sometimes the
autoscope is also used.

Examination of the Neck

The neck needs to be palpated for lymph nodes. In order to assess the thyroid glands, the
patient is asked to swallow saliva.
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Examination of the Chest
1.While examining the anterior chest, the patient is placed in a horizontal recumbent
position.
2.The chest is examined in several ways.
3.It is percussed to determine the presence of fluid or congested areas.
4.The physician listens to the sound within the chest by means of a stethoscope.
5.To examine the posterior chest, the patient is placed in a sitting position.
6.The heart and lungs are examined by percussion and auscultation.
7.The breasts are examined by palpation for the presence of lumps or growths.
8.The axillae are palpated for enlarged lymph nodes.
9.During the examination, the patient's face is turned away from the doctor.
Examination of the Abdomen
1.Extremities are inspected, palpated and moved.
2.A fine tremor suggestive of hyperthyroidism can be observed, if the patient is asked to
hold the arms out in front of him for a few minutes.

Teachers CARE AFTER EXAMINATION Teacher D Students

0.2 mention discusses and E understands
1.Assist him to dress and help him to remain in a comfortable position in the bed.
after care & students M after care &
nurses 2.Aftercare of equipment: Wash the equipment with soap and water, rinse, dry and sterilize, Responds O nurses
responsibilit responsibilit
as needed.
y y
3.Replace the equipments in their usual places.
4.Label specimens properly and send them to the laboratory immediately.
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NURSES RESPONSIBILITIES DURING PHYSICAL EXAMINATION

0.3
1.A separate examination room is needed. Keep the doors closed, screen the patient and
provide privacy if he is not in a separate room. Relatives are not allowed.
2.Drape the patient according to the parts that are to be examined. Natural Ught-should be
available in the examination room.
3.There should be adequate lighting in the room. The patient should be comfortable
throughout the examination.
4.There must be provision for the maintenance of a suitable position, e.g. lithotomv
position. The room should be warm.
5.The nurse must stay in the room at all times, while the doctor examine a female patient.
6.During the examination of a male patient's genitals, the nurse leaves the room.
Take the patient's temperature, pulse, respiration and BP, if recent readings are not
avaliable
7.Give health teacher to the patient as need arises.

CONCLUSION
Health assessment is important to everyone. It includes physical examinations or other
procedures to detect disease early in people who look or feel well. This is different from
diagnostic tests which are done when someone is already showing signs and/or symptoms
of a disease.
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SUMMARY
Health assessment is the evaluation of the health status of an individual along the health
continuum. The purpose of the assessment is to establish where on the health continuum the
individual is because this guides how to approach and treat the individual. The health
continuum approaches range from preventative, to treatment, to palliative care in relation to
the individual's status on the health continuum. It is not the treatment or treatment plan.

BIBLIOGRAPHY .
1. Clinical Nursing Procedures: The Art of Nursing Practice (Paperback)
2. Annamma Jacob (author), R. Rekha (author), Jadhav Sonali Tarachand (author) 2nd
edition jaypee publications pg no.265-267.
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