The document provides information on health assessment. It defines health assessment as collecting subjective and objective data to understand a client's health status. It discusses the purpose of health assessment, which includes establishing a health baseline, identifying risks, and formulating a problem statement. The document also outlines the different components of health assessment, including health history taking, physical examination techniques, and documentation of findings. The physical examination involves inspection, palpation, percussion, auscultation, and assessment of vital signs and reflexes to evaluate the client comprehensively.

1. Health
Assessment
Ms. Hemangi Chaudhari
Assistant Lecturer
Apollo Institute of Nursing
M.sc.Nursing (Pediatric)

2. Definition of Health
•Health is a complete state of
complete physical, mental and social
well-being, not merely absence of
any disease or infirmity.
- WHO

3. Terminologies
• Diagnosis:
Diagnosis is the determination of the nature and
extant of a disease.
• Prognosis:
It is the forecast of the course and duration of a
disease.
• Etiology:
It is the signs of cause of a disease.

4. • Signs:
Signs are objective evidence of disease.
These are directly observed by the nurse and
doctor. The signs are related to the physical
appearance and condition of the client.
E.g., A rapid pulse, low blood pressure,
open wound, pallor, swelling, etc…

5. • Symptoms:
A symptom is defined as any disorder of
appearance, sensation or function experienced
by the patient. It may be indicative of the
certain type of disease.
It called as a Subjective symptoms as these
are felt only by the patient.

6. • Complication:
Another disease which prognosis during
the course of a disease or following the
primary condition is known as
complication.

7. Introduction
• Health assessment is a continuous and
ongoing process in all the healthcare
setting.
• It is very important in the healthcare
setting.

8. There are two components:

9. Definition of health
assessment
• Health assessment refers to collect
subjective data through interviewing the
client and obtain objective data by
physically examining the client.

10. Purpose of health
assessment
• To establish a database of the client’s
normal abilities.
• To identify risk factors that can contribute
to dysfunction.
• To know any current alteration in function.
• To get a clear picture of the client’s health
status and health related problems.

11. • To get a holistic view of the client.
• To identify client’s strength and weaknesses.
• To help formulation a conclusion or problem
statement.
• To organize collected information.
• To identify needs for health teaching.
• To build rapport with patient and family.

12. Types of health
assessment
• Four types:
1. Comprehensive health assessment
2. Ongoing partial health assessment
3. Focused health assessment
4. Emergency health assessment

13. Comprehensive health
assessment
• Comprehensive health assessment includes
health history and complete physical
examination.
• It encompasses the physical, psychological,
social and spiritual dimensions of living.
• It is generally done for any individual in order to
prevent the occurrence of disease or to reduce
the duration of already occurred disease.

14. Ongoing partial health
assessment
• Ongoing partial health assessment is
conducted at regular intervals during the
care of client.
• It is mainly use to assess the progress of the
client during care and to plan the treatment.
• It helps to evaluate the effectiveness of
intervention.

15. Focussed health
assessment
• A focussed health assessment is
conducted to assess a specific health
problem by proper investigation and
treatment.

16. Emergency health
assessment
• Emergency health assessment is
conducted in emergency situation or life
threatening situation in order to provide
immediate assessment and treatment to
the client.

17. Indications
• On admission
• During the treatment
• On discharge
• During follow up

18. Health history
• During the interview, obtain information
about the client’s health history and
family health history.
• A health history is a collection of
subjective data that provides a detailed
profile of the client’s health status.

19. • A full general history is taken with the
object of recording any condition or
abnormality that may affect the health of
individual.

20. History taking includes
the following…
1. Biographic data
2. Chief complaints
3. History of present illness
4. Past history
- Past medical history
- Past surgical history

21. 5. Family history
- Family tree (Pedigree chart/ Family
genogram)
6. Life style/ High risk behavior
7. Obstetrical history

22. Biographic data
• Name, address, gender, age, marital
status, occupation, religious preferences,
primary health care provider, family
income per month or year, educational
qualification, etc.

23. Chief complaints
• It is a brief assessment of client’s
problem for which client seeks medical
care.
• It should be document in client’s
statement.

24. History of present
illness
• Onset
• Signs and symptoms
• Duration
• Treatment taken if any, for the same.
• Other complaints such as loss of appetite, insomnia,
disorders of stomach, etc. also should be found out.
• Client’s health habits- eating, sleeping, etc.

25. Past history
• Childhood illness: mumps, measles and
so on.
• Allergies, mental diseases, accidents,
injuries, surgeries, blood transfusions, use
of over the counter products, herbal or
dietary supplements.

26. Family history
• Information about all family members
(Father, mother, grandparents, brothers
and sisters) living or dead, cause of death
(if dead) condition of their health (if
living). Family history of any
illness…E.g., Diabetes Mellitus, cancer,
heart diseases, etc.

27. S
r
.
N
o
.
Name of
the
family
members
Relation-
ship with
patient
Age
/
Sex
Marital
status
Occupation Educa
tional
status
Health
status
1
2
3
4
5
6

29. Life style/ High risk
behavior
• Smoking, alcoholism, substance abuse.
If yes, how much and since when?
• Food habits, likes and dislikes, sleep
pattern, exercise, healthcare facilities
available.

30. Obstetrical history
• Menstrual history, history of pregnancy,
labour and their complications (if any),
history of children alive or dead etc.

31. Physical examination
•Physical examination define as
complete head to toe assessment
of the patient’s physical and
mental status.

32. Purpose of physical
examination
• To understand physical and mental
wellbeing of the client.
• It helps to gather baseline information
regarding the client’s health status at the
time of hospitalization.
• To identify the deviation from the
normal.

33. • To detect diseases in the early stage.
• To determine cause of the illness.
• To derive nursing diagnosis on which
planning nursing interventions and
evaluations are base.
• To understand any changes in the condition
of the disease or any improvement in
client’s condition.

34. • To find out nursing care needed to the
client.
• Offers opportunity for health teaching.
• To find out whether the person is
medically fit or not for a particular task.

35. Physical examination is
done by…
1.Observing…
2.Interviewing…
3.Examining the client

36. Observing
• Observation is a conscious, and a skill that
developed with an organized approach.
• E.g., Client data observed through four senses
that is through vision, smell, hearing and touch.

37. Interviewing

38. Examining

39. Techniques/Methods of
physical examination
• There are main four basic techniques of physical
examination.
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
5. Olfaction

40. Inspection
• It is the systematic visual examination
of the client, or it is the process of
performing purposeful observations in a
systematic manner.
• It involves observation of the colour,
shape, size, rashes, scar of the body parts.

41. Points to be kept in mind to
make an accurate inspection
1. Inspect each area for size, shape,
colour, symmetry and find out any
deviations from normal.
2. Good lighting
3. Use additional lights for examining
body cavities.

42. Palpation
• 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 is
vary.
• It reveals any swelling, coldness, hotness, stiffness,
hardness, smoothness, pain and roughness.

44. Points to be kept in mind
while doing palpation
1. The client should be relaxed and
comfortable.
2. Observe sings of discomfort during
palpation.
3. Palpation to be done with warm hands,
short fingernails and a gentle approach.

45. Percussion
• Percussion is a method of Tapping body
parts with fingers, Hands, or Small
instruments as part of a physical
examination.
• It is done to determine the size,
consistency and borders of body organs.

46. • It elicits sounds which indicate whether
the underlying tissues are solid or filled
with air or fluid.

47. The percussion can be
done by two methods:

48. Direct percussion
• Tapping the body surface directly
with one or two fingers.

49. Indirect percussion
• Placing the middle finger of the non-
dominant hand firmly against the body
surface and tapping the distal joint of
non-dominant finger with the middle
fingers of the dominant hand.

50. Auscultation
• Auscultation is listening to the internal
sounds of the body, usually using a
stethoscope.
• Auscultation is performed for the
purposes of examining heart and breath
sounds as well as the GI system (bowel
sounds).

51. Olfaction
• It is assessment of odour characteristics.
• Olfaction helps to detect serious
abnormalities.

52. Site Odour Cause
Oral cavity Alcohol Ingestion of
alcohol
Skin Body odour Poor hygiene
Wound site Foul smelling Wound abscess
Vomitus Foul smelling Bowel
obstruction
Rectal area Foul smelling Faecal
incontinent

53. Manipulation
• It is the moving of a part of the body to
note it’s flexibility.

54. Testing of reflexes:
• The response of the tissues to external
stimuli is tested by means of percussion
hammer, safety pin, wisp of cotton or
hot and cold water.

55. Reflexes
• A reflex is an autonomic response of the
body to a stimulus.
• Biceps reflex: This is tested with the
doctor’s thumb on the biceps tendon and
gently tapping with a percussion
hammer. The contraction of the muscle
is noted.

57. •Triceps reflex: The client’s arm
is supported in a relaxed position
and is tapped with a percussion
hammer just above olecranon
process. Normally the forearm
will straighten.

59. •Patellar reflex (Knee jerk reflex) :
The client is seated at the edge of
the examination table with legs to
dangle (hanging freely). Tape the
area just below the patella. Normally
the lower leg will kick forward.

61. •Achilles reflex(Ankle jerk reflex) :
Again in the same position, the foot
is supported with one hand and the
achilles tendon is tapped. The
normal response is a downward jerk
of the foot.

63. •Plantar reflex: The sole of the
foot is stroked with a sharp
instrument such as a pin.
Normally all toes bend
downwards.

65. Role of nurse in
physical examination
• Preparation of Patient
• Preparation of environment
• Preparation of equipments

66. Preparation of patient
• It is very important to prepare the
patient both physically and mentally.
• Adequate explanation needs to be given
about the nature of assessment.

67. Physical preparation
• Maintain privacy
• Empty bladder and bowel
• Loose clothing
• Appropriate draping. Expose only
needed areas

68. • Warmth/adequate temperature
• Comfortable table
• Appropriate position according to area to
be assessed.

69. Sitting position
Areas assessed:
•Head and neck, back,
posterior lungs, breasts,
axillae, heart, vitals signs,
upper extremities

71. Supine position
Areas assessed:
•Head and neck, anterior
lungs, breasts, axillae, heart,
abdomen, extremities, pulses

73. Dorsal recumbent
position
Areas assessed:
•Head and neck, anterior
lungs, breasts, axillae, heart

75. Lithotomy position
Areas assessed:
•Female genitalia and genital
tract

77. Sims position
Areas assessed:
•Rectum and vagina

79. Prone position
Areas assessed:
•Musculoskeletal system and
back

81. Knee chest position
Areas assessed:
•Rectum

83. Psychological preparation
• The client may be quite new to the
hospital situation and he may be anxious
about his illness.
• He may have false ideas about the
medical examination.

84. • It is the duty of the nurse to allay his
anxieties and fears by proper explanation.
• Explain the sequence of the procedure
to gain his confidence and cooperation.

85. Preparation of the
environment
Maintenance of privacy
• A separate examination room is needed.
• Keep the doors closed.
• The relatives are not allowed.
• Drape the client according to the parts that
are exposed.

86. Lighting
• As far as possible, natural light should be
available in the examination room
because if a client is jaundiced, it may
not be detected in the artificial light.
There should be adequate lighting.

87. Comfortable bed or
examination table
• The client should be placed comfortably
throughout the examination.
• There should be provision for the
maintenance of a suitable position.

88. E.g., A lithotomy position may be
maintained when examining the genitalia.
• To maintain the position, a special
examination table is needed.
• The room should be warm and without
draughts.

89. Preparation of the
equipments
• All the articles needed for the physical
examination are kept ready for the
examination at hand.

90. Articles required Purpose
Sphygmomanometer To measure
blood pressure.
Foetoscope To listen the Fetal
heart sound.
Stethoscope To listen the body
sounds

91. T.P.R tray To assess the vital
signs
Tongue depressor To examine the
mouth and throat.
Pharyngeal retractor To examine the
pharynx
Laryngoscope To examine the
larynx.

92. Measurement tape To measure height,
circumferences of
the head and
abdomen.
Torch To visualize any part
Weighing machine To check the weight.
Ophthalmoscope To examine the inner
part of eyeballs.

93. Otoscope To examine the ear.
Tuning fork To test the hearing.
Nasal speculum To examine the nostrils.
Percussion hammer,
safety pin, cotton ball,
cold and hot water in test
tubes.
To test the reflexes.

94. Vaginal speculum To examine the
genitals in women.
Proctoscope To examine the
rectum.
Gloves To examine the pelvis
internally.
Sterile specimen
bottles, slides
To collect the
specimens if
necessary.

95. General examination OR
head to toe examination
• The examination is carried out in an orderly
manner focussing upon one area of the body
at a time.
• The observation of the client starts as the
client walks into the examination room.
• E.g., A limp may be noted as the client walks
in.

96. General appearance
• Nourishment: Well nourished or under
nourished
• Body build: Thin or obese
• Health: Healthy or unhealthy
• Activity: Active or dull (tired)

97. • Hygiene and grooming: Note the client’s
level of cleanliness by observing hair,
skin, nail and clothes.
• Mood and affect: Affect is the person’s
feeling as they appear to others and
mood is expressed verbally and non-
verbally.

98. •Speech: Normal speech is
understandable, moderately paced
and shows an association with the
thoughts.

99. Mental status
• Consciousness: Conscious, unconscious,
talking incoherently
• Look: Anxious or worried, depressed,
etc.

100. Posture
• Body curves: Lordosis, kyphosis,
scoliosis
• Movement: Any limp
Height and weight

101. Lordosis

102. Kyphosis

103. Scoliosis

104. Skin conditions
• Colour: Pallor, jaundice, cyanosis, etc.
• Texture: Dryness, Wrinkling or excessive
moisture
• Temperature: Warm, cold
• Lesions: Macules, papules, vesicles, wounds,
etc.

105. Macules

106. Vesicles

107. Head and face
• Shape of the skull and fontanels (noted
in the newborn)
• Skull circumference

108. Fontanels

109. • Scalp: Cleanliness, condition of the hair,
dandruff, pediculi, infections….
• Face: Pale, fatigue, puffiness, pain, fear,
anxiety, etc…

110. Puffiness

111. Eyes:
• Eyebrows: Normal, symmetrical or
absent
• Eye lashes: Infection, stye

112. Stye

113. • Eye lids: Oedema, lesions, ectropion
(Eversion), entropion (Inversion)
• Eyeballs: Sunken

114. Oedema

116. Ectropion

117. Entropion

118. Sunken

119. • Conjunctiva: Pale, red, purulent
• Sclera: Jaundiced
• Cornea and iris: Abrasions
• Pupils: Dilated, constricted, reaction to
light
• Lens: Opaque or transparent

120. • Eye muscles: Strabismus (Squint)
• Vision: Normal, myopia (short site),
hypermetropia (Hyperopia, Long sight)

123. Ears
• External ear: Discharges, Obstructed ear
passage
• Tympanic membrane: Perforations,
lesions, bulging
• Hearing: Hearing acuity

125. Nose
• External nares: Discharge
• Nostrils: Inflammation of the mucus
membrane, deviated septum

126. Mouth and pharynx
• Lips: Redness, swelling, cyanosis, angular
stomatitis, angular cheilitis.
• Odour of the mouth: Foul smelling
• Teeth: Discoloration and dental caries

127. Angular stomatitis

128. Angular cheilitis

129. • Mucus membrane and gums: Ulceration
and bleeding, swelling, pus formation
• Tongue: Pale, dry, lesions, tongue tie, etc.
• Throat and pharynx: Enlarged tonsils,
redness, pus

130. Neck
• Lymph nodes: Enlarged and palpable
• Thyroid gland: Enlarged
• Range of motion: Flexion, extension and
rotation

131. Chest
• Thorax: Shape, symmetry of expansion and
posture
• Breath sounds: Wheezing, crepitations,
pleural rub, etc.
• Heart: Size and location, cardiac murmurs
• Breasts: Enlarged lymph nodes

132. Abdomen:
• Inspection: Skin rashes, scar, hernia,
ascites, distension, pregnancy, etc.
• Palpation: Liver margin, Palpable spleen,
tenderness at the area of appendix

133. • Percussion: Presence of gas, fluid or
masses
• Auscultation: Bowel sounds, foetal heart
sounds/rate

134. Extremities
• Movement of joints, tremors, clubbing
of fingers, ankle oedema, reflexes, etc.
Back
• Spina bifida, curves

136. Genitals and rectum
• Inguinal lymph glands- Enlarged, palpable.
• Vaginal discharge
• Presence of sexually transmitted diseases (STD)
• Haemorrhoids
• Enlargement of prostate gland
• Pelvic masses

137. Neurological test
• Test for sensation
• Reflexes
• Coordination tests
• Equilibrium tests

138. • Coordination tests
• This includes finger to nose test. In this,
the client is asked to extend the arms at
shoulder height and rapidly touch the
nose alternately with one index finger,
then with the other. In abnormal
response, client will miss the nose.

139. • Equilibrium test
• Abnormalities of gait or posture can be
detected by this test.
• The client is asked to stand with the eyes open
and the feet together. If he does not loose
balance or does not fall, the test is repeated
with the eyes closed. It is important to be
prepared to help the client, should be begin to
fall.

140. Systematic examination
• To take height and weight
• To measure the length of the baby who
cannot stand or place the baby on the
hard surface, with the sloes of the feet
supported in an upright position.

141. • The knees are extended and the
measurements are taken from the soles
of the feet to the vertex of the head.
• The head should be in such a position
that the eyes are facing the ceiling.

142. • After a child can stand, the height can be
measured, if the child stands with the
heels, back and head against a wall.
• A small flat board held from the top of
the head to the wall will give an accurate
measures of the height, that is the
distance from the floor to the board.

143. •The weight of the person who can
stand is generally measured by a
standing scale. The client stands on
the platform and the weight is noted
on the dial. Usually the weight is
taken without shoes.

144. • 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.
• It is important to weight a baby
unclothed or to weigh the clothes
separately and subtract the weight.

145. • To measure the skull circumference
• The skull is measured at its greatest
diameter from above the eyes to the
occipital protuberance.

146. • Examination of the eyes
• The examination is done in a lying or
sitting position.
• The examiner frequently uses a head
mirror that reflects light to the client’s
face.

147. • The first examination is one of the
inspection to determine the movements
of the eyes, reaction to light,
accommodation to near and far objects.
• For detailed examination of the internal
parts of the eye an ophthalmoscope is
used.

148. • Examination of the ears
• The client may be placed either in a lying or
sitting position with the ear to be examined
turned towards the examiner.
• Articles used for the examination are a head
mirror, ear speculum of various sizes, cotton
tipped applicators and autoscope.
• Tuning fork is used to test the hearing.

151. • A child needs to be carefully restrained.
Young children sit on their mother’s lap with
their legs restrained between the mother’s
knees and their arms held against their back.
• The mother holds the child’s head against
her chest.
• Very small infants can be laid on the
examination table.

152. • Webbers test:
• To perform the Webbers test, place the stem of the
vibrating tuning fork in the centre of the forehead,
ask the person where the sound is heard best.
• Normally the sound is heard equally well in both ears
as it is conducted through the bones.
• Note the sound, if sound heard in any one ear better
than the other.

153. • Rinnies test:
• Hold the vibrating tuning fork, parallel to
the auricles and their tip 2 cm away from
the ear. Then place vibrating tuning
fork’s stem on the next bony process of
the mastoid bone.

154. • Ask the client to inform which of the
sound conduction was better, when kept
near the external ear i.e., air conduction
or by when kept over the mastoid bone
i.e., bone conduction.

155. • Examination of Nose, Throat and Mouth
• The client is usually seated with the head resting
against the back of the chair.
• For the examination of the throat, a tongue
depressor and a good light are needed.
• For examination of the nose, a nasal speculum
and a head mirror are used. Sometimes the
autoscope is also used.

156. • Examination of the Neck:
• The neck needs to be palpated for lymph
nodes. In order to assess the thyroid
glands, the client is asked to swallow
saliva.

157. • Examination of the Chest:
• While examining the anterior chest, the
client is placed in a horizontal recumbent
position.
• The chest is examined in several ways.
• It is percussed to determine the presence of
the fluid.

158. • The physician listens to the sounds
within the chest by means of a
stethoscope.
• To examine the posterior chest, the client
is placed in a sitting position. The heart
and lungs are examined by percussion
and auscultation.

159. • The breasts are examined by palpation
for the presence of lumps or growths.
• The axillae are palpated for the enlarged
lymph nodes.
• During the examination, the client’s face
is turned away from the doctor.

160. • Examination of the abdomen:
• The abdomen is examined while the client is
in a dorsal recumbent position and the knees
are slightly flexed to promote relaxation of
the abdominal muscles.
• The abdomen is inspected, palpated,
auscultated and percussed to detect any
abnormalities.

162. • Examination of the extremities: (Arm
and legs)
• Extremities are inspected, palpated and
moved.
• A fine tremors suggestive of
hyperthyroidism can be observed, if the
client is asked to hold the arms out in front
of him for a few minutes.

163. • A pitting oedema may be observed at the
ankle joint by pressing the skin against the
bone.
• Varicose veins may be observed on the
posterior part of the leg over the calf
muscles.
• The joints are moved in all directions to
assess the movements of the joints.

164. • Examination of the spine:
• In a standing position the spine is
examined for abnormal curvature. The
fingers are moved over the spine to
detect the spina bifida in a newborn
infant.

165. • Examination of the Genitalia:
• The client is placed in a dorsal
recumbent or lithotomy position. For the
examination of the female genitalia, clear
rubber gloves, vaginal speculum, a good
source of light and a lubricant are
necessary.

166. Conclusion
• The physical examination is a key part of
a continuum that extends from the
history of the present illness to the
therapeutic outcome. Its important to
understand the patient’s condition.