Health Assessment
part - 1
By:-
Mrs. Babitha K Devu
Asstt. Professor
SMVDCoN

• Define Health Assessment
• Discuss the purpose
• Describe the techniques used
• Describe proper positioning for the patient
• Make environmental preparations
• List the articles needed
• Perform systemic assessment

Introduction
While working in a variety of settings, nurses
seek information about patient’s health status.
Health screenings focus on a specific physical
problem. A complete health assessment
involves a nursing history and behavioural and
physical examination. Continuity in health care
improves when you make ongoing, objective,
and comprehensive assessment.

DEFINITION
• Health assessment
Health assessment is an organized
systematic assessment of human body which
involves the use of one’s senses to determine
the general physical and mental conditions of
the body by collecting both subjective and
objective data.

Indication of health assessment
• On admission
• On discharge
• On follow up
• Health camps
• Before and after diagnostic and therapeutic
procedure.

Purpose
• Gather baseline data about the patient’s
health status
• Supplement, confirm, or refute data obtained
in the history
• Confirm and identify nursing diagnoses
• Make clinical judgement about a patient’s
changing health status and management
• Evaluate the outcomes of care

Principles of Health Assessment
• An accurate and timely health assessment provides
foundation for nursing care & intervention.
• Go for comprehensive assessment.
• The health assessment process should include data
collection, documentation and evaluation of the client’s
health status.
• All documents should be objective, accurate, clear,
concise, specific and current.
• It should be practiced in all settings whenever there is
nurse-client interaction.
• Information gathered should be communicated to other
health care professional.
• Keep the confidentiality.

Legal Issues
• In today’s litigious society, you must be ever vigilant when engaging
in nursing practice. Documentation issues have previously been
addressed. Equally important is how you execute the nursing
assessment. Establishing a trusting and caring relationship is the
primary element in avoiding malpractice claims.
• While performing each step in the physical assessment process, you
need to inform the patient of what to expect, where to expect it,
and how it will feel. Protests by the patient need to be addressed
prior to continuing the examination. Otherwise, the patient may
claim insufficient informed consent, sexual abuse, or physical
harassment.
• All assessments and procedures, including any injury that was
caused during the physical assessment, must be completely
documented. The institutional policy regarding patient injury in the
workplace must be followed.

TYPES OF HEALTH ASSESSMENT
The type of health assessment dependents on several
factors like context of care, the patient’s needs and the
nurse’s experience.
o Comprehensive assessment:
This involves a detailed history or physical examination
performed at the onset of care in a primary care setting
or an admission to a hospital or long term carte facility.
o Problem- based / focused assessment:
It involves a history and examination that are limited to a
specific problem or complaint. This type of assessment is
most commonly used in a walk in clinic or emergency
department and out patient departments.

Contin..
o Episodic/ Follow-up assessment:
This type of assessment is usually done when a patient is
following up with a health care provider for previously
identified problem.
o Shift assessment:
When individuals are hospitalized, nurses conduct
assessment each shift. The purpose is to identify changes
in a patient’s condition from baseline .
o Screening assessment:
It is a short examination focused on disease detection. It
may be performed in a health care provider’s office or at
a health fair.

TECHNIQUE/ SKILLS OF PHYSICAL
ASSESSMENT

CONTIN..
 Inspection
 Palpation
 Percussion
 Auscultation
Olfaction
Other techniques are:
Manipulation
 Reflex Testing

INSPECTION
It is the use of vision and hearing
to distinguish normal from abnormal
findings. Inspection is a simple
technique, and the quality of an
inspection depends upon your
willingness to be thorough and
systematic.
PRINCIPLES:
1. Adequate lighting
2. Position & expose body parts
3. Inspect each areas
4. When possible, compare each area
with opposite side of the body
5. Use additional light to inspect cavities
6. Do not hurry, pay attention to detail

GENERAL INSPECTION OF A CLIENT
FOCUSES ON
• Overall appearance of health or illness
• Signs of distress
• Facial expression and mood
• Body size
• Grooming and personal hygiene
• Colour, texture, symmetry,
movement

PALPATION
Palpation, which is the act of touching a patient in a
therapeutic manner to elicit specific information.

PRINCIPLES OF PALPATION
• Perform slowly, gently, and deliberately.
• Encourage the patient to continue to breathe
normally throughout the palpation.
• If pain is experienced during the palpation.
discontinue the palpation immediately.
• Inform the patient where, when, and how the
touch will occur, especially when the patient
cannot see what you are doing.

• Light palpation Deep palpation

Ulnar Surface
(Vibration)

Caution to be taken
• To avoid injuring a patient.
• Do not try deep palpation without clinical
supervision.
• Do not palpate without considering the
patient’s condition.
• Do not palpate a vital artery with pressure
that obstructs blood flow.

PERCUSSION

Direct percussion is used to assess the sinus or infant thorax.
Indirect percussion is used to evaluate abdomen or thorax.
Another method of indirect percussion is tapping with the
rubber head of the reflex hammer.
Fist percussion to evaluate back and kidney for tenderness.
Or Plexor

TYPE OF PERCUSSION
• DIRECT PERCUSSION/ Immediate Percussion

INDIRECT PERCUSSION/ MEDIATE PERCUSSION

FIST PERCUSSION
Technique of Direct Fist
Percussion:Left Kidney
Technique of Indirect Fist
Percussion:Left Kidney

Percussion Sounds
SOUND INTENSITY DURATION PITCH QUALITY NORMAL
LOCATION
ABNORMAL
LOCATION
Flatness Soft Short High Flat Muscle
(thigh) or
Bone
Lungs (severe
pneumonia
Dullness Moderate Moderate High Thud Organs (liver) Lungs
(atelectasis)
Resonance Loud Moderate-
long
Low Hollow Normal lungs No abnormal
location
Hyper
resonance
Very loud Long Very
low
Boom No normal
location in
adults;normal
lungs in
children
Lungs
(emphysema)
Tympany Loud Long High Drum Gastric air
bubble
Lungs (large
pneumothorax)

AUSCULTATION

FOUR CHARACTERISTICS OF SOUND
• 1.Frequency/ Pitch (ranging from high and
low):frequency or number of oscillations generated
per second by vibrating object. The higher the
frequency, the higher the pitch of a sound and vice
versa.
• 2. Loudness (ranging from soft to loud): amplitude
of sound wave.
• 3. Quality (gurgling or blowing): sounds of similar
frequency and loudness from different sources.
• 4. Duration (short, medium or long): length of time
that sound vibrations last.

What you should know?
• Need good hearing acuity
• A good stethoscope & knowledge of how to use it
• Place stethoscope on patient skin directly
• Free from extraneous sound
• Requires concentration and practice

Normal Body Sounds
• Normal breath sounds are classified as tracheal,
bronchial, bronchovesicular, and vesicular sounds.
• Tracheal breath sounds are heard over the trachea.
These sounds are harsh and sound like air is being blown
through a pipe.
• Bronchial sounds are present over the large airways in
the anterior chest near the second and third intercostal
spaces; these sounds are more tubular and hollow-
sounding than vesicular sounds, but not as harsh as
tracheal breath sounds. Bronchial sounds are loud and
high in pitch with a short pause between inspiration and
expiration; expiratory sounds last longer than inspiratory
sounds.

Contin..
• Bronchovesicular sounds are heard in the posterior chest
between the scapulae and in the center part of the anterior
chest. Bronchovesicular sounds are softer than bronchial
sounds, but have a tubular quality. Bronchovesicular sounds are
about equal during inspiration and expiration; differences in
pitch and intensity are often more easily detected during
expiration.
• Vesicular sounds are soft, blowing, or rustling sounds normally
heard throughout most of the lung fields. Vesicular sounds are
normally heard throughout inspiration, continue without pause
through expiration, and then fade away about one third of the
way through expiration.
• In a normal air-filled lung, vesicular sounds are heard over most
of the lung fields.

Contin..
• Bowel sound consist of clicks and gurgles and
5-30 per minute.
• An occasional borborygmus (loud prolonged
gurgle) may be heard.
• Heart sound:
The first heart sound, or S1, forms the "lub“
The second heart sound, or S2, forms the "dub"

OLFACTION

Olfaction
• Olfaction is the action or capacity of smelling;
the sense of smell.
• The nurse’s olfactory sense provides vital
information about a patient’s health status.
• It helps to detect abnormalities not
recognized by other means.
• E.g., if a patient cast has a sweet, heavy, thick
odour, this indicate an underlying infection.

Manipulation
• It means moving with the body parts. It
reveals rigidity, difficulty or discomfort in
moving the body parts.

Reflex Testing
• Means automatic response to a given
stimulus. It reveals reflex is present or not,
strength and movement of hands and legs.

Nurse’s Responsibility
Has the responsibility to carry out health
assessment on every person.
Should perform focused assessments in
response to client’s need.
Obtain consent in prior.
Demonstrate a caring attitude, respect and
concern for client.
Keep confidential.
Draw inferences from collected data to make
appropriate clinical judgement.

Contin..
Acquire specialized skills and competencies in
collecting accurate data.
Document the result of health assessment.
Should continuously advance their
competence in health assessment.
Do all the relevant preparation prior.

PREPARATION FOR ASSESSMENT
Proper preparation of the environment,
equipment, and patient ensures a smooth
examination with few interruptions. A
disorganized approach when preparing for a
physical examination causes errors and
incomplete findings. It is necessary to wear
gloves during palpation and percussion when
there is possibility of coming in contact with body
fluids .

PREPARING THE ENVIRONMENT

Environment
 Requires privacy
 Well-equipped examination room is preferable
 Adequate lighting, sound proof
 Make sure the room is warm enough
 Special tables to assume positions
 Special needs of the client
 Surface for placement of equipment
Equipment
Perform hand hygiene before equipment preparation
Set up in a readily available manner and easy to use
Check the functioning
Maintenance
Isolation precautions
Adequate number of gloves

PHYSICAL PREPERATION OF THE
PATIENT

CONTIN..
Patient’s physical comfort is vital
It involves being sure the patient is dressed and
draped properly
Provide privacy
Make sure the patient stays warm
Routinely ask if the patient is comfortable
Positioning: during examination, ask the patient
to assume proper positions so body parts are
accessible and patient stays comfortable.

PREPARING THE PATIENT
• PSYCHOLOGICAL PREPERATION
A thorough explanation must
be provided to the patient
regarding each steps of assessment.
Keep explanations simple and clear
Help patient feel free to ask doubts.
Convey an open, professional and
relaxed approach. When the patient
And examiner are of opposite gender
Have a third party of patient gender to assure the patient
that you behave ethically and third party is the witness
to conduct of examiner and patient.

Assessment of Age-Groups
Different interview styles and approaches are needed to
perform a health history and examine patients of
different age-groups.
When assessing children be sensitive and anticipate the
child's reaction to the examination as a strange and
unfamiliar experience.
A comprehensive health assessment and examination of
older adult includes physical data, family relationships
etc and also mental status.
During the examination, recognize that advancing age the
body does not respond vigorously to injury or diseases.

EQUIPMENTS
• The physical assessment will proceed in an efficient manner if
you have gathered all of the necessary equipment beforehand.
The equipment needed to perform a complete physical
examination of the adult patient includes:
• Pen and paper • Marking pen • Tape measure
• Clean gloves • Penlight or flashlight
• Scale (You may need to walk the patient to a central location if
a scale cannot be brought to the patient’s room.)
• Thermometer • Sphygmomanometer
• Tongue depressor • Stethoscope • Otoscope
• Nasal speculum • Ophthalmoscope
• Visual acuity charts

Contin..
• Tuning fork • Reflex hammer • Sterile needle
• Cotton balls • Lubricant • Cervical brush
• Odors for cranial nerve assessment(coffee, lemon,
flowers, etc.)
• Small objects for neurological assessment (paper
clip, key, cotton ball, pen, etc.)
• Inch tape • Various sizes of vaginal speculums
• Cotton-tip applicator • Cervical spatula
• Slide and fixative • Specimen cup
• Lubricant • Goniometer
• Vital signs tray

ARTICLES REQUIRED
• Screen to provide privacy
• Bowl for antiseptic lotion
• Kidney tray and paper bag
• Weighing machine and height scale
• Patient gown

ARTICLES REQUIRED
• Bath blanket to cover the patient
• Pair of leggings
• Draw sheet to cover patient’s chest
• Square drum containing test tube, gauze
piece, cotton swab, specimen bottle,
swabsticks

EQUIPMENTS
• STETHOSCOPE

OPHTHALMOSCOPE

OTOSCOPE

SNELLEN CHART

NASAL SPECULUM

VAGINAL SPECULUM

TUNING FORK

PERCUSSION HARMER

SPHYGMOMANOMETER

Scales For Measuring Weight & Height

Scales For Measuring Weight & Height

Tongue Depressor

Thermometer

Specimen Container

Skinfold Calipers

Goniometer

Audioscope

Sitting Position Fowler Position

STANDING

SUPINE AND PRONE

DORSAL RECUMBENT

Sim’s Position
• In this position
patient is lying on
the left side with
right knee and thigh
drawn up with the
left arm placed
along the back.
Used for rectal
examination.

LITHOTOMY
• In this position
patient is supine
with the feets
and legs raised
and supported in
stirrups. Used for
vaginal and rectal
examinations.

KNEE-CHEST

Trendelenburg Position
• In this position the patien
t is lying on the back with
the pelvis higherthan the
head; the knees are sligh
tly bent, and the legs are
hangingoff the end of the
table. This position is use
d for pelvic surgery andfo
r some radiographic exam
s.