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1. Fundamental of
Nursing
Health assessment
Dr; mosa alfageh

2. Learning Outcomes
 Identify the purposes and components of a physical
examination .
 Discuss the differences among a comprehensive, focused,
and ongoing physical examination .
 Describe how to prepare for a physical examination.
 Demonstrate the skills used in physical examination .
 Identify the components of the general survey.
 Conduct a full physical examination of a client .
 Document the findings of a physical examination.
 Perform a brief bedside physical examination.

3. Definition:
Health assessment is the systemic
collection,verification, organization,
interpretation and documentation
of data for use by health care
professionals.

4. Definition:
Health assessment is a comprehensive
assessment of the physical, mental,
spiritual, socioeconomic, and
cultural status of an individual,
group, or community.

5. Medical assessments focus on disease
and pathology.
Nursing assessments focus on the
client’s functional abilities & physical
responses to illness & other stressors.

6. Purpose of assessment:
1. To establish a database about patient's
physical, psychological & emotional health.
2. Identify health promoting behaviors as well as
actual and /or potential problems.
3. Determines patient's abilities &/or
dysfunctions
4. To obtain data to establish medical diagnosis,
nursing diagnosis and plan patient's care.
5. To evaluate the physiologic outcomes of health
care & progress of patient's health problem.

7. Type of
assessments

8. Comprehensive physical assessment,
which includes a health history
interview and a complete head-to-
toe examination of every body system.

9. A focused physical assessment is
performed to obtain data about an
actual, potential, or possible problem
that has been identified. It pertains to a
particular topic, body part, or
functional ability.

10. A system-specific assessment is a
focused assessment limited to one body
system (e.g., the lungs, the peripheral
circulation).

11. Equipment

13. 1. Tuning Fork
2. Visual Occluder
3. Ruler
4. Visual Acuity Chart
5. Reflex Hammer (brush
at bottom)
6. Reflex Hammer
7. Pen and Marking Pen
8. Penlight
9. Thermometer
10. Sphygmomanometer
11. Slide and Fixative
12. Specimen Cup
13. Vaginal Speculum
14. Lubricant
15. Goniometer
16. Clean Gloves
17. Cervical Spatula (Ayre Spatula)
18. Cervical Brush (Cytobrush)
19. Cotton-tip Applicator
20. Tongue Depressor
21. Guaiac Material
22. Tape Measure
23. Acoustic Stethoscope
24. Ophthalmoscope
25. Otoscope with Speculum
26. Objects for Neurological
Examination (key & cotton ball)
27. Sterile Needle

14. Techniques used for physical
examination:
Inspection [Look (inspect)].
Palpation. [Feel (palpation)].
Auscultation [Listen (auscultate)]
Percussion. [Tap or thump
(percuss)].
N.B: bilateral body parts are always compared

15. Inspection
Inspect each area of the body for
size, color, shape, position, and
symmetry, noting normal findings and
any deviations from normal.

16. Palpation
Use dorsum of hand & fingers to measure
temperature.
Use palmer of fingers & finger pads to
assess texture, shape, fluid, size, consistency
and pulsation.

17. Light palpation: depress skin & underlying structures
½ inch ( ½’’ ) (1 cm).
Deep palpation: press inward about 1 inch (2.5 cm).
 N.B: For palpating, the hands should be warm &
fingernails short. Any area of tenderness is
palpated last

19. Percussion
Use both hands to produce
sound waves.
Non dominant hand placed
directly on percussed area,
Middle finger placed firmly
on the body surface.
Other hand (dominant)
provides striking force,
initiated by a sharp downward
wrist movement.

20. percussion sounds:
 Tympany (‫)طبلي‬ – over air filled bowel , stomach,
intestine
 Resonance (‫)رنين‬ – over normal lung
 Hyperresonance (‫)طنين‬- abnormal over the lung
with increase amount of air as in COPD
 Flatness – muscle , bone
 Dullness – over liver , spleen

21. Auscultation:
 Auscultation require the use of a stethoscope
to listen for heart sounds, movement of
bowel, lung sounds.
1-Expose body part you want to auscultate.

22. Auscultation:
2-Use stethoscope diaphragm to listen to pitched
sounds, (normal heart sounds, breath sounds, and
bowel sounds, and press diaphragm firmly on body
part being auscultated.
3-Use stethoscope bell to listen for low pitched
sounds, as abnormal heart sounds and bruits
abnormal loud, blowing, or murmur sounds.

23. I. Patient's preparation:
 Explain procedure to patient, examined body
structures, & assessments painless.
 Ask the patient to wear a gown.
 Ask to empty bladder to be more comfortable
 Answer questions directly and honestly.
 Avoid undesirable nonverbal communication
 Keep patient warm. Provide a lightweight blanket.

24. I. Patient's preparation:
 Keep your hand smooth.
 Choose assessment time, patient free of
pain as possible, not interfere with meals,
daily routines, treatment or visiting hours.
 Keep necessary instruments & equipment
assembled, and ready for use.

25. Environmental preparation:
 Provide clean, well ventilated, quite and
private environment.
 Warm instruments; for example, warm
bell of stethoscope by rubbing it between
your hands before placing it on a patient.

26. Positioning

27. Sitting
Use to assess
vital signs,
head & neck,
chest,
cardiovascular
system, &
breasts.
Supine
Use to assess the
abdomen,
breasts,
extremities, and
pulses.

28. Dorsal
Recumbent
Use for
abdominal
assessment if
your client has
abdominal or
pelvic pain.
Flexing the
knees promotes
relaxation
Lithotomy
Use for a female
pelvic exam;
provides
maximum
exposure of
genitals.

29. Sims’
Use to examine
the rectal area.
Use for a female
pelvic exam if the
patient is unable
to assume the
lithotomy
position.
Prone
Use to examine the
musculoskeletal
system, especially
hip extension; may
also be used to
examine the back
and buttocks.

30. Lateral
Recumbent
Left lateral
recumbent is
used to evaluate
heart murmur or
during a
thorough
cardiovascular
assessment.
Knee–Chest
Provides good
visualization for
examining the
rectal area.

31. 2- Health history
a- Chief Complaint:
1.Description of major problem
2.Location: "Where does it hurt?"
3.Quality: “What does it looks like?“
4.Quantity: "on a scale of one to ten with
ten most severe.
5.Chronology: symptom in relation to
time; Begin gradually or suddenly? Stay
the same in quality & intensity?
6.Aggravating or alleviating factors:
7.Associated factors: Assess the
associated factors of symptoms.

32. COLOR
VARIATION
DESCRIPTION
Pallor White in light-skinned clients: loss of
pink or yellow tones. In dark-skinned
clients: a loss of red tones
Cyanosis A blue-gray coloration of skin, (ashen)
Jaundice A yellow-orange cast to the skin
Flushing A widespread, diffuse area of redness
Erythema A reddened area
Petechiae Tiny, pinpoint red or reddish-purple
spots
Mottling
‫مرقط‬
,
‫مرقش‬
Bluish marbling

34. Mottling

37. Past health history
 Previous disorders & contacts with health care
setting and professionals.
 Pediatric and adult illness
 Operations and injuries
 Allergies or sensitivities.
 Current medications.
 Previous hospitalization & its reason.
 Transfusions.
 Current treatments e.g., respiratory therapy,
Immunizations.

38. Family health History:
 Present health status of parents & siblings for:
medical problems, similar illness or symptoms
in family.

40. Systems review
General appearance and
functional abilities

41. Condition of hair:
 Normal amount & distribution
 Healthy looking or brittle
 Baldness  natural or due to
illness
 Grooming  clean, tidy,
presence of lice nits or
dandruff.

42. Condition of the scalp:
 Intact
 Presence of scratches,
lacerations infected areas
nodules or circumscribed
alopecia.

43. Condition of face
 Pale, flushed, mottled, cyanosed or
jaundiced
 Presence of swelling, abrasions,
contusions, lacerations or scars
 Presence of tingling, numbness,
burning, loss of sensation or
muscles twitching
 Paralysis of facial muscle, (facial
palsy).

45. Condition of eye:
 Sight  normal, impaired sight, wears
glasses, squinting & loss of eyes blindness
 Eyelids  scaly eyelids, redness of lids,
puffiness of lids or dropping of lids
 Ecchymosis of eyes, redness, jaundiced
eyes, excessive tearing or discharge
 Eye Ball  bulging or sunken.
 Pupils  regular, equal or not equal
 Blurring of vision or pain in the eye.

47. Condition of ears:
Inspect external ear for intactness, general hygiene, a
buildup of wax, discharge, redness, and swelling.
* If discharge, note color, amount, consistency & clarity.
Palpate external ear for nodules & tenderness and mastoid
process for tenderness.
Complains of pain  indicates external ear infection.
N.B: if patient complains from pain in mastoid process, otitis
media is a possibility).

48. Condition of nose
Inspect deformed, edematous or inflamed nares
Observe discharge from nose running nose,
mucus, bloody or purulent
Assess impaired sense of smell
Assess nasal breathing difficulty

49. Condition of mouth
Lips pale, cyanosed, dry,
inflamed, or deformities.
Tongue  pale, ulcers, or loss of
taste.
Gums pale, edematous,
bleeding. Inflamed or discharge.

50. Condition of mouth cont.
Breathe  foul, ammonia, alcoholic or acetone.
Teeth healthy, missing, broken, loose,
Abnormality of the jaws  deformity or due to
surgery.
Has difficulty of speech  aphasia, route or
unusual speech manner.

51. Condition of neck
Inspect color, symmetry, thyroid gland
enlargement, abnormal pulsations, lymph
nodes masses, impaired ROM, lesions, scars.
 Palpate for temperature & texture.
 Instruct to move neck through full ROM.
 Palpate carotid rate & rhythm, pulsation

56. Condition of the chest, lung & heart
I. Posterior chest:
Inspect: skeletal deformities that could affect
respiratory system
Common abnormalities as kyphosis
Palpate: For tenderness & masses.
Auscultation: to assess air flow, presence of fluid,
mucus or obstruction.

57. Condition of the chest, lung & heart
II. Anterior chest:
Inspect: For any skeletal deformities which are
barrel chest
pigeon chest (forward projection of sternum), &
funnel chest (sternum pointing posteriorly).
Palpate: For tenderness.

59. Heart:
Auscultate apical pulse which is situated
between 5th & 6th intercostal spaces.
Assess rate and rhythm.

61. Condition of the
Abdomen

63. Vital signs

64. 1) Body temperature:
 Range ( OC).
 Site oral, axillary, tympanic or rectal.
 Presence of abnormality hyperthermia,
hypothermia.
 Pattern of fever  constant, intermittent or
remittent.

65. Respiratory status
Rate / minute (c/m)
Depth deep or shallow
Rhythmregular or irregular.
Presence of difficulty dyspnea, orthopnea.
Use of oxygen therapy.
Interference with normal breathing, cough,
sputum or chest pain

66. Pulse status
Site  peripheral or apical.
Rate beat/minute (b/m).
Rhythm regular or irregular.
Strength  strong or weak.
Volume  full or thready.

67. Blood pressure status
Blood pressure reading  Systolic &
diastolic
Pulse pressure.

68. Pain assessment
Radiation  (back radiation)
Duration (time of pain)
Severity  (mild- moderate - sever)
Site  (upper outer quadrant of the abdomen)
Frequency  (the repetition of pain attack)
Aggravating factors  (factors causing pain)
Alleviating factors  (factors causing relieve of pain).
Pain rating scale from zero to ten.
0 indicates no pain.
From 1 < 3 mild pain.
From 3< 6 moderate.
From 6 – 9 severe.
10 very severe pain.

69. Reflexes
Deep tendon reflexes
Each tendon reflex utilizes certain spinal
segments and help in utilizing a lesion