Health assessment mean collection of data from client

1. HEALTH ASSESSMENT
OBJECTIVE DATA

2. OBJECTIVES
• Describe objective data collection
• Describe the techniques for collecting
objective data
• Describe the procedure for physical
examination of a patient

3. DEFINITION
• This is the information that you collect by
observing instead of the patient telling
you
• Can be seen, heard, felt, or smelled
• Obtained by observation or systematic
head to toe physical examination and
• Labolatory data which includes

4. • Testing of:
• Blood
• Urine
• Stool
• xrays

5. TECHNIQUES FOR PHYSICAL
EXAMINATION
• Inspection
• Palpation
• Percussion
• Auscultation
• Always in this order except in abdominal
assessment

6. INSPECTION
• This is the visual examination of the patient. It
begins at the nurse’s first contact with the patient
• It is the first step in the physical examination
• The nurse inspects the patient, underlying
anatomical structures are considered and
abnormalities identified
• Things such as colour, shape, symmetry,
movement, pulsations and texture of the
involved body part are noted

7. PALPATION
• This technique uses the sense of touch. It
helps to determine the size, shape, and
configuration of the underlying body
structures
• Superficial palpation assesses the
structures just under the skin
• Be careful with deep palpation, if it is
painful, STOP!!!!

8. PALPATION cont.
• The pulsation of blood vessels, the outline
of organs such as the thyroid, spleen, or
liver, mobility of masses, the temperature
of the skin, vibration or movement of blood
vessels can all be felt on palpation

9. PERCUSSION
• The art of striking one object against the
other for the purpose of producing a sound
• Percussion notes indicates the density or
hollowness of an area
• Percussion may be used to discover the
location and level of organs, the
consistency of body structures ( fluid ,air
or solid filled), the presence of tenderness
and identification of tumours or masses

10. AUSCULTATION
• The technique of listening to body sounds
with a stethoscope.
• The stethoscope is used to detect low and
high pitched sounds.( bowel sounds,
breath sounds, heart sounds)

11. REMEMBER
• YOU MUST KNOW WHAT THE NORMAL
IS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

12. OBJECTIVE DATA
• GENERAL SURVEY
• Look at: general body build( note
height/weight)
• Hygiene, grooming
• Dressing
• Skin colour
• Affect, attitude, mood, speech, facial
expression

13. GENERAL SURVEY cont.
• Eye contact, ability to relax
• Cognitive processes( note speech
patterns, content, orientation, appropriate
verbal responses)
• Vital signs- gives you a ‘snapshot in time’
when they are all taken at once, they tell
you a lot about the status of the patient.
When taken separately they don’t say
much

14. • So ALWAYS TAKE VITAL SIGNS TOGETHER
• Height and weight
• SKIN
– Inspect for colour, vascularity and lesions
– Palpate for temperature, moisture, turgor and texture
of skin
NAILS
– Inspect for shape, texture, colour and capillary refill.
Normal shape is convex.

15. • HEAD AND NECK
– Skull-assess for size and shape
– Face-examine for colour, symetry, oedema
– Eyes-assess for movement, vision and visual
disturbance, or pain which may indicate
factors such as high blood pressure or
diebetis. Size, shape and size of pupils.
Reaction to light

16. HEAD AND NECK cont.
• eyelids
– Colour, edema, and equal coverage of the
eyeball
– Check conjunctiva for paleness
• Ear
– Use autoscope to assess ear canal
– Inspect for shape, size and lesions
– Palpate for pain and edema

17. HEAD AND NECK cont.
• Ear
– Note any redness, discharge, wax plugs
– Assess for hearing acuity
• Nose
– Test for nose patency by occluding one nostril
at a time and ask patient to inhale through the
other
– Note any swelling, bleeding, discharge,
perforations or polyps

18. HAED AND NECK cont.
• Sinuses
– Examine by palpating the front of the face for
pain and edema
• Mouth and pharynx
– Inspect the lips, gums, and teeth, tongue,
hard and soft palate
– Assess the mucous membrane for colour,
lesions and swelling

19. ARMS
• Presence of arms, number, size, deformity
• Colour of palms- pink, pale
• Number of fingers
• Finger clubbing, capillary refill
• Nail colour
• Range of motion of arms
• Check radial, brachial pulses

20. HEAD AND NECK cont.
• The neck
– Assess for size and position of the trachea and
thyroid gland
– Range of motion, lymph nodes, and venous distention
• Trachea
– Palpate for allignment and position
• Thyroid
– Palpate for size, shape, symetry, tenderness and
precense of any nodules

21. HEAD AND NECK cont.
• Lymph nodes
– Palpate with finger pads for enlargement,
tenderness and mobility
• Jugular vein
– Assess for distension
• Carotid pulsation