Health Assessment

by
Dr. Hala Yehia
 Objectives
At the end of this lecture the
student will be able to:
Define health assessment
List purpose of H.E.
Identify types of HE.
Describe methods of data collection.
Explain component of nursing history.
 Objectives
Define physical assessment
Discuss principles of Physical
assessment.
Discuss preparation for physical
examination.
Identify physical assessment methods
Apply physical examination from head
to toe.
 Health Assessment
Systematic and continuous collection,
organization, validation and documentation
of data.

The first step in the nursing process

It is focus on a client’s response to a
health problem.
 Purposes of Assessment
To create a data base of the client’s
response to health and illness
To determine the nursing care needs of the
patient.
To evaluate physiologic outcomes of health
care and thus client progress
To screen for presence of risk factors
FOUR TYPES OF ASSESSMENT
Initial Assessment

Focus Assessment or On-going Assessment

Emergency Assessment

Time-Lapsed Assessment
FOUR TYPES OF ASSESSMENT

1. Initial Assessment
When performed:
At specified time after admission

Where done:
Done at the ward

Purpose of Initial Assessment:

•To create a data base for problem identification
• For reference and future comparison
FOUR TYPES OF ASSESSMENT
2. Focus Assessment or On-going Assessment
When performed:
Integrated throughout the nursing process

Purpose of On-going Assessment:

•To identify problems overlooked earlier

•To determine the status of a health problem

(i.e. hypertension status every fifteen minutes
FOUR TYPES OF ASSESSMENT
3.Emergency Assessment
When done:
During acute physiologic and psychological crisis

Where done:
Emergency Room Comfort Room
Anywhere!!! On site!!!

Purpose of Emergency Assessment

To identify life-threatening condition
 TYPES OF ASSESSMENT

4. Time-Lapsed Assessment
When done:
Several months after initial assessment
Purpose of Time-Lapsed Assessment
To compare current status of patient
with base line data (initial assessment)
 What is the initial output of the
Assessment Phase?
Data or Recorded Data:

process of gathering information about

the client’s health status
 TYPES OF DATA

1. Subjective or Covert Data:

Information (data) apparent only to the

person affected that can be described or
verified only by that person.

During the recording of data, this should be

stated using the patient’s own words
These are the symptoms felt by the patient.
Fever “ I felt of hotness
 TYPES OF DATA
2. Objective or Overt Data
signs or overt data; detectable
by an observer or can be tested
against an accepted standard
These are the signs which are
observable
Fever skin is warm to touch; temp. is
38.9.
 SOURCES OF DATA

1. Primary Source
Patient himself except when:
•He is unconscious
•Patient is a baby
•Patient is insane
 SOURCES OF DATA

2. Secondary
Support people
Clients records
Health care professionals
Literature
Results of laboratory and diagnostic tests
Medical history and physical examination
 Assessment

Observation +Interview +Examination =

Assessment (Data Collection)

 METHODS OF DATA
COLLECTION

Observing

Interviewing

Examining
 METHODS OF DATA COLLECTION

1-Observation – to gather data by:

using the five senses; a conscious

deliberate skill that is developed only
through effort and with an organized
approach.
METHODS OF DATA COLLECTION

2-Interview – a planned communication or

conversation with a purpose.
Preparation:
1. review the client’s medical records
2. conversations with other health team
members
3. research of the presenting medical diagnosis
METHODS OF DATA COLLECTION:
INTERVIEWING

Two types of Interview

Directive Type of Interview

Non-directive Type of Interview or
Rapport building Interview.
 DIRECTIVE TYPE OF INTERVIEW

Structured
Uses closed-ended questions calling for
specific data
• When used:
When you need to elicit specific data
When there is little time available
often begin with when, where, who,
what, do, does, did
NON-DIRECTIVE TYPE OR
RAPPORT-BUILDING INTERVIEW

Uses more open-ended questions

Advantage is that it allows the patient
to volunteer information
 TYPES OF INTERVIEW QUESTIONS

Open-Ended Questions
e.g. Explain ----
Closed-Ended Questions
e.g. did --------
 Stages of Interview

1. Introduction/Opening
2. Working/Body
3. Closure/Closing
 B- Nursing Health History
Is a data collected about the client’s
level of wellness.

Objectives
* Identify pattern of health and illness.
* Risk factors for physical and
behavioural
health problems .
* Deviations from normal .
* Available resources for adaptation.
Components of Nursing Health
History
* Biographic Data
Client’s name ,age , sex , occupation,
health care financing.

* Chief Complain or Reason for Visit

The answer given to the question,, What
is troubling you?,, It should be recorded in
the client own words.
 - When the symptoms started.
- Whether the onset of the symptoms was
sudden
or gradual.
- How often the problem occurs.
- Exact location of the distress.
- Character of complain.
- Activity in which the client was involved
when the
problem occurred.
- Factors that aggravate or alleviate the
problem.
* Past History
- Childhood illness ( chickenpox,
measles)
- Childhood immunizations.
- Allergies to drugs, animal, insect.
- Accidents and injuries: how, when ,
type of
injury.
- Hospitalization for serious illnesses.
- Medications: all currently used
prescription.
 - If they are diseased, The cause of death.
* Lifestyle
- Personal habits ( smoking, alcohol, tea )
- Diet: description of a typical diet on a
normal
day or any special diet , who cooks and
shops
for the food.
- Sleep & rest pattern :Usual daily sleep, wake
time
- Activities of daily living:(eating, grooming,
dressing, elimination)
Social data
Family relationship
Educational history
Occupational history
Economic status
 * Psychological Data
- Major stressors experienced and client’s
perception of them.
- Usual coping pattern with a serious problem.

* Pattern of Health Care.

All health care resources the client is
currently
using and has in the past.
 Physical Examinations

Is the process which investigate the

body of a patient for sign of disease.
It generally follows the taking of the
medical history.
Purposes of Physical Assessment
Gather baseline data about the client’s
current health status.
Supplement, confirm or refute data obtained
from history taking.
Confirm and identify health problems.
Make clinical judgment about the client’s
changing health status.
Decide on an intervention based on data
obtained.
Evaluate The Physiologic Outcome Of Care.
 Principles in Performing
Physical Assessment

Order of examination
Preparation of environment
Preparation of equipments
Physical preparation of the client
Psychological preparation of the client
 How You Prepare the Environment for
Physical Assessment

* The environment needs to be well lighted and

the equipment should be organized.
* Family and friends should not be present unless
the client ask for someone
* Provide a curtain or screen if the area
is open to others.
* Maintain appropriate room temperature.
e.g., warm temperature not cold to
prevent client discomfort.

* maintain safe environment.

-- Client should be free of pain as possible.

-- Client should be comfortable ( wearing comfortable

gown).
-- Explain the assessment process to the patient.

-- Explain that physical assessments will not be painful

(decrease patient fear and anxiety).

-- Answer patient questions directly and honestly.

-- Client should empty their bladder before examination.

How You Prepare the Equipment for
physical assessment:

* All equipment required for the health assessment

should be:
- clean
- In good working order.
- Readily accessible.
- Set up on tray ready for use.
The equipment of the physical examination

Stethoscope

eye examination chart

 Flashing or penlight
purpose of use :
To assist viewing of the pharynx or to
determine the reactions of the pupils of
the eye.
Nasal speculum
Purpose of use :
To permit visualization of the lower and
middle
turbinates, usually , a penlight is used for
illumination.
 Ophthalmoscope
Purpose of use :
Alighted instrument to visualize the interior
of the eye.
Otoscope
Purpose of use:
Lighted instrument to visualize the eardrum
and external auditory canal.

Percussion hammer
Purpose of use:
An instrument with a rubber head to test
reflexes
 Tuning fork
Purpose of use :
A two- pronged metal instrument used to test
hearing acuity and vibratory sense.
Vaginal Speculum
Purpose of use :
To assess the cervix and the vagina.
Cotton applicator
Purpose of use :
To obtain Specimens.
 Gloves
Purpose of use :
To protect the nurse.
Lubricant
Purpose of use :
To ease insertion of instrument (e.g., vaginal
speculum)
Tongue blades (depressor)
To depress the tongue during assessment of the
mouth
pharynx.
 Draping
Draping should be arranged so the area to be
assessed is exposed and other area are covered
for privacy and warmth.

Positioning
Several positions are frequently required
during the physical assessment.
Physical Assessment Methods

Inspection
Palpation
Auscultation
Percussion
 Inspection
Assessment
process during
which the nurse
observes the
client
 Inspection
Is the visual examination, that is assessing by
using the sense of sight. It should be
deliberate, purposeful, and symmetric.
Done By:
Naked eye.
Otoescope.
To assess:
Moisture, color, and texture of body surface
as well as shape, position, size, and symmetry
of the body parts.
 Palpation

The use of the hands and the

sense of touch to gather data
Different parts of the hand
are best suited for specific
purposes For example, the
dorsal aspect of the hand
is best for assessing
temperature changes , the
ball of the hand on the
palm and ulnar surface is
best for detecting
vibration, and the finger
pads and tips are the most
discriminating for detecting
fine sensations, such as
pulsations
 Palpation
Is the examination of the body using the sense of
touch. The pads of the fingers are used.

Types of palpation:
Light palpation.
Deep palpation.
Bimanual Palpation
To assess:
Texture, temperature, and size.
Distention, pulsation, and mobility of organs or
masses.
 Guidelines for palpation

 The nurse’s hands should be clean and warm,

and finger nail short.
 Area of tenderness should be palpated last.
 Deep palpation should be done after
superficial palpation.

.
 Percussion
Tapping of
various body
organs and
structures to
produce
vibration and
sound.
Percussion
Is the act of striking the body surface to elicit
sounds that can be heard or vibration that can
be felt.
Types of percussion:
Direct percussion.
Indirect percussion.

It is indicate:
tissue is fluid filled, air filled or solid.
 Auscultation
The act of listening
to sounds within the
body to evaluate
the condition of
body organs
(stethoscope)
 Auscultation
Quiet environment
Know landmarks
Know “normal”
PRACTICE! PRACTICE! PRACTICE!
Requires concentration, practice,
and application of knowledge
Auscultation of the sounds described
according to their:

 Pitch: is the frequency of the vibrations(

ranging from high to low)

 Intensity: the loudness or softness of a

sound.

 Duration: the sound length( short,

medium, or long)

 Quality: a subjective description of a

sounds( gurgling, swishing)
Organization of Physical Assessment
1- General appearance
Mood and affect
Signs of distress
Posture
Body movement
Hygiene and grooming
Type of clothing
2- Measurements
Height and weight
Vital signs
 3- Head to toe examination
Head Neck
Skull Anterior thorax
Scalp Breast
Hair Abdomen
Face Posterior thorax
Eyes Upper extremities
Ears Lower extremities
Nose
Mouth
 General Appearance
Affect is the person’s feelings as they appear
to others
Mood or emotional state is expressed verbally
and non verbally
Sign of distress is signs and symptoms of
pain, difficulty in breathing or anxiety
Hygiene and grooming observe the
appearance of hair, skin or fingernails and
clothes
Type of clothing observe if the type of
clothing worn is appropriate for
temperature and weather conditions
 Skin
Method of assessment:

Inspection
palpation

Normal skin is:

varies from light to deep brown, from ruddy

pink to light pink and from yellow overtones
to olive.
Intact surfaces.
 Abnormal findings

Pallor: is the result of inadequate circulating blood

or hemoglobin and subsequent reduction in tissue
oxygenation.
Cyanosis: a bluish color is most evident in the nail
beds, and lips.
Jaundice: a yellowish color observed in the sclera
of the eyes, mucosa membrane and the skin.
Erythema: is a redness associated a Varity of
rashes.
Vitiligo: patches of hypo pigmented skin.
 Assessment of the hair
Method:
Inspection palpation
Normal hair is:
well distributed, thick hair, silky, resilient hair.

Abnormal finding:
Alopecia: hair loss.
Protein deficiency: the hair color is reddish
or bleached.
Hypothyroidism: cause very thin and brittle
hair.
 Assessment of the nails
Method: Inspection- Palpation.

Assess: the nails plate shape, angel

between the nail and the nail bed, nail
bed color, and the intactness of the
tissue around the nail.

Normal nail: convex curvature, angel

of nail plate about 160, smooth texture,
highly vascular, and intact epidermis.
 The head

Method: inspection - palpation.

Assess: Skull- Face

Normal skull: rounded, smooth skull contour,

absences of masses or nodules.

Normal face: symmetric facial features, equal in size,

and symmetric facial movement.

Abnormal finding:
Edema of the eyelids.
Moon face: round face with reddened cheeks
 Assessment of the eyes and vision
Method: inspection- palpation.

Assess: External eye structure, vision, lacrimal

gland, lacrimal sac, nasolacrimal duct.

Normal eyes:
Eye structure: symmetrical eyes, eyebrows
symmetrically aligned, equal movement, skin intact,
with shiny smooth and pink or red conjunctiva,
pupils equal in color, size and diameter.
Lacrimal glands: No edema or tenderness over
lacrimal gland.
Assessment of the ear and hearing

Method: inspection –palpation

Assess: the external ear- internal ear canal-
tympanic membrane.

Normal ear and hearing:

Color of the ear as same of facial skin,
symmetrical, and the auricle aligned with
outer canthus of eye.
Mobile, firm, and not tender.
Normal tympanic membrane is grayish color.
Pulling the ear pinna up and Inserting the otoscope
back
 Hearing Test

Watch tick test.

Tuning fork tests.

 A- Weber’s test

B1-(Rinne test) Place the

tuning fork on the mastoid
process

B2-(Rinne test) Place the

tuning fork in front of the ear
 Assessment of the nose and sinuses

Method: inspection- palpation.

Assess: the nose, nasal cavity patency, sinuses.

Normal nose : symmetric and straight, no

discharge and flaring, , no tender or lesions.

Nasal cavity patency: the air moves freely as

the client breath, mucosa pink and watery
discharge.

Sinuses: no tenderness in the maxillary and

frontal sinuses.
Assessment of the Mouth and
pharynx
Method: inspection- palpation.
Assess: the lips and buccal mucosa, teeth,
gum, tongue, floor of the mouth, salivary
gland, palate, uvula, tonsils.

Normal Mouth and pharynx:

Lips and buccal mucosa: pink color, soft, moist,
smooth texture, symmetry of contour, ability to
purse lips.
Teeth and gums: 32 adult teeth, smooth, white,
shiny tooth enamel, pink gums and intact.
Tongue/floor of the mouth: central
position for the tongue, moves freely, no
tenderness, smooth with no palpable nodules
in the tongue or in the floor.

Silvery glands: same color of the buccal

mucosa, no nodules or tenderness, and
secret the saliva in the oral cavity.

Palates and uvula: light pink, smooth, soft

intact palate, the uvula positioned in the
midline and mobile.
pharynx and tonsils: pink and smooth
posterior wall, pink and smooth tonsils within
normal size and no discharge.

Abnormal findings:
Dental caries: cavities.
Glossitis: inflammation of the tongue.
Stomatitis: inflammation of the oral mucosa.
 Assessment of the neck

Method: inspection- palpation

Assess : the muscles, lymph nodes,
trachea, thyroid gland, carotid arteries, and
jugular vein.
 Assessment of thorax and lungs

Method: inspection- Auscultation-

percussion.
Assess: chest shape and size,
Breathing sounds, chest sounds.

Chest shape and size:

the thorax is oval.
Abnormal chest shape:
in older adult kyphosis and osteoporosis
alter the size of the chest cavity as the ribs
move downward and forward.
Pigeon chest.
Permanent deformity ( caused by rickets).
Funnel chest.
Funnel chest
Chest landmarks:
Front: anterior axilla line,
midclavicular line, midsternal line.

Back: Vertebral line, right scapular

line
Assessing the thorax and lungs:

Anterior thorax:
Assess respiratory excursion .

Percussion sounds on the anterior chest.

Posterior thorax
Assess respiratory excursion
Assessment of cardiovascular and
peripheral system

Heart

Central Vessels

Peripheral Vascular System

 Heart

Auscultation is more meaningful

method.
Heart examination are usually
performed when the client is a
symmetrical position.
The normal heart sounds:

Systole: Ventricles contract S1.

Diastole: Ventricles relax S2.
 S1 (Lub) ….. occur when atrioventricular valves
close (A-V), valve close when the ventricles have
been filled.

 S2 ( Dub) …. after the ventricles empty their blood

into the aorta and pulmonary arteries, has a higher
pitch than S1 and also Shorter.

S1 and S2 are (Lub-Dub) sounds.

Abnormal heart sounds:
 S3….. is normal in children and young adults,
in older adults its indicate heart failure.

 S4…. may be heard in many elderly clients and

can be signs of hypertension.
CAROTID ARTERY
Palpation Palpate carotid artery with
extreme caution -auscultation

JUGULAR VEIN
Inspection Client is placed in a semi
fowlers position
 BREAST AND AXILLAE
Inspection
Inspect the breast for size, symmetry,
and contour or shape.
Inspect the skin of the breast for
localized discoloration
Normal;
Female: rounded shape; slightly
unequal in size; generally symmetric
Male; breast even with chest wall
Abnormal:
Recent change in breast size; swellings;
marked asymmetry.
Localized discoloration
 Abdomen

Inspection
Inspect the abdomen for skin integrity.
Inspect the abdomen for contour and
symmetry.
movements associated with
respirations, peristalsis or aortic
pulsations
Auscultation
Auscultate the abdomen for bowel sounds
Percussion
Percuss several areas in each of the four
quadrants to determine the presence of
tympany (gas in the stomach and
intestines) and dullness (decrease,
absence or flatness of resonance over
solid masses or fluid).
 Palpation

Perform light palpation first to detect

areas of tenderness and/or muscle
guarding.
Perform deep palpation over all four
quadrants
 Musculoskeletal System
Muscles, bones and joints
Objective assessment of musculoskeletal system
Purpose
To assess function of ADL (activities of daily living)
Screen for abnormalities
Screening exams
Inspection (look)
Palpation (feel)
ROM with movement active or passive
Compare with the opposite
 Muscles
Inspect for muscle size – equal size on
both sides of the body
Inspect the muscles and tendons for
contractures – there should be no
contractures
Inspect the muscles for fasciculation and
tremors – there should be no fasciculation
and tremors
Palpate muscles at rest to
determine muscle tonicity –
normally firm
Palpate muscles while the client is
active and passive for flaccidity,
plasticity & smoothness of
movement – there should be
smooth coordinated movements
 Bones

Inspect the skeleton for normal

structure and deformities – there
should be no deformities
Palpate the bones to locate any
areas of edema or tenderness – no
tenderness or swelling
 Joints

Palpate each joint for tenderness,

smoothness of movement,
swelling, crepitating, and presence
of nodule – no tenderness, swelling,
crepitating or nodules
 Types of joint movement
Flexion – bending
Extension – straightening
Adduction – toward – further straightening
Abduction –the midline
Rotation – around its central axis
Circumduction – circular
Eversion – foot outward
Inversion – foot inward
Pronation – palm down
Supination – palm up