The document provides information on preparing for and conducting a health assessment. It discusses ensuring privacy, preparing equipment, positioning the client, and conducting a comprehensive or focused assessment in an aseptic manner. Vital signs including temperature, pulse, respiration, and blood pressure are measured. Methods of assessing different body systems like integumentary, head, eyes, ears, and respiratory are described.

1. Chapter 27 Health Assessment By: Dave Jay S. Manriquez RN.

2. Preparing for the Health Assessment Environment Ensure privacy Quiet, warm room Special needs of the client Surface for placement of equipment

3. Preparing for the Health Assessment Equipment Maintenance Isolation precautions Adequate number of gloves

4. Preparing for the Health Assessment Positioning Ensures accessibility to the body part being assessed. Draping Prevents chilling. Prevents unnecessary exposure.

5. Conducting the Health and Physical Assessment Aimed at establishing a data base against which subsequent data can be compared. Comprehensive Assessment (head to toe) Assessment of a body part (focused) Assessment of a body system (focused)

6. Conducting the Health and Physical Assessment Conducted in an aseptic, systematic, and efficient manner. Requires the fewest position changes for the client.

7. General Survey Initial Observations Client’s physical appearance Mood and behavior Speech patterns and voice intonations Signs and symptoms of distress Vital signs Height and weight

8. General Survey Special Considerations Elderly clients Disabled clients Abused clients

9. Measurement of Height and Weight Height Height is expressed in inches (in), feet (ft), centimeters (cm), or meters (m). A scale for measuring height is usually attached to a standing weight scale. Infant’s length is measured from vertex (top) of head to soles of feet while infant is lying with knees extended.

10. Measurement of Height and Weight Weight Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg). Daily weights should be obtained at the same time of the day, on the same scale, with the client wearing the same type of clothing.

11. Measurement of Height and Weight Weight Types of scales available include chair, stretcher, bed, and platform scales. Infants are weighed on platform or cradle scales.

12. Measurement of Height and Weight Nursing Considerations Accurate recordings are necessary for drug dosage calculations and evaluation of effectiveness of drug, fluid, and nutritional therapy.

13. Measurement of Height and Weight Documentation Height and weight are recorded on the admission assessment form. Daily weights are usually recorded on the vital signs record. Measurements taken at different times or on different scales should be recorded.

14. Vital Signs The taking of vital signs refers to measurement of the client’s body temperature (T), pulse (P) rate, respiratory (R) rate, and blood pressure (BP). Vital signs are the first step in the physical examination.

15. Vital Signs Assessment of vital signs provides specific data regarding the client’s current condition. Variations from baseline values may indicate potential problems with the client’s health status.

16. Vital Signs The sequence for recording vital sign measurements in the nurses’ notes is T-P-R and BP. Vital signs are plotted on graphic forms that facilitate data comparison at a glance.

17. Thermoregulation The body’s physiological function of heat regulation to maintain a constant internal body temperature

18. Physiologic Function Thermoregulation The heat of the body is measured in units called degrees. The core internal temperature of 98.6 degrees Fahrenheit (F) does not vary more than 1.4 degrees F. Core internal temperature is higher than the skin and external temperature.

19. Thermoregulation Heat Production Basal Metabolic Rate (BMR) Vasodilation Vasoconstriction Piloerection

20. Thermoregulation Heat Loss Radiation Conduction Convection Evaporation Insensible Heat Loss

21. Thermoregulation Behavioral Control of Body Temperature The person makes appropriate environmental adjustments in response to the body’s signaling conditions of either being overheated or too cold.

22. Respiration Respiration is the act of breathing. Terms related to respiratory function are: External respiration Internal respiration Inspiration Expiration Vital capacity

23. Respiration Major physiological pulmonary functions are: Ventilation Circulation Diffusion Transport Regulation

24. Hemodynamic Regulation The circulatory system transports nutrients to the tissues, removes waste products, and carries hormones from one part of the body to another.

25. Hemodynamic Regulation Systemic Circulation Arteries Arterioles Capillaries Veins Venules

26. Hemodynamic Regulation Cardiac Cycle Systole Diastole Stroke Volume Cardiac Output Compensatory Mechanisms

27. Hemodynamic Regulation Pulse The pulse is caused by the stroke volume ejection and distension of the walls of the aorta. The bounding of blood flow in an artery is palpable at various points in the body (pulse points).

28. Hemodynamic Regulation Blood Pressure Measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole

29. Blood Pressure Systolic Pressure Maximum pressure exerted against arterial walls during systole Diastolic Pressure Pressure remaining in the arterial system during diastole

30. Hemodynamic Regulation Hemodynamic regulators for blood pressure control are: Blood volume Cardiac output Peripheral vascular resistance Viscosity

31. Factors Influencing Vital Signs Age Gender Heredity Race Lifestyle Environment

32. Factors Influencing Vital Signs Medications Pain Exercise Anxiety and Stress Postural Changes Diurnal (daily) Variations

33. Assessing Body Temperature Temperature Scales Centigrade or Fahrenheit scales are used to measure temperature. Glass or electronic thermometers are used. Temperature Sites Oral Rectal Axillary

34. Assessing Body Temperature Alterations in Body Temperature Pyrexia Hyperthermia Heat Exhaustion Heat Stroke Hypothermia Frostbite

35. Assessing Pulse Sites The most accessible peripheral sites are the radial and carotid sites. The carotid site should always be used to assess the pulse in a cardiac emergency.

36. Assessing Pulse A peripheral pulse is palpated by placing the first two fingers on the pulse point with moderate pressure. A Doppler ultrasound stethoscope is used on superficial pulse points. A stethoscope is used to auscultate the heart’s rate and rhythm.

37. Assessing Pulse

38. Assessing Pulse A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate. Pulse Characteristics Pulse quality Pulse rate (bradycardia, tachycardia) Pulse rhythm (dysrhythmias) Pulse volume

39. Assessing Pulse Nursing Considerations An irregular pulse rate, if not previously documented, should be reported immediately. Clients on certain cardiac medications may need to monitor their pulse rate. Routine exercise lowers resting and activity pulses.

40. Assessing Respirations Sites Observation of chest wall expansion and bilateral symmetrical movement of the thorax Placement of back of hand next to client’s nose and mouth to feel expired air

41. Assessing Respirations Rate is counted by number of breaths taken per minute. Observation of thoracic and abdominal movements includes: Depth, rhythm, and symmetry Costal (thoracic) breathing Diaphragmatic breathing

42. Assessing Respirations A stethoscope is used to auscultate breath sounds throughout the respiratory system.

43. Assessing Respirations Dyspnea, Bradypnea, tachypnea, apnea Hypoventilation Hyperventilation

44. Assessing Respiratory Function Cyanosis Bluish appearance in the nail beds, lips, and skin Reduced oxygen levels in the arterial blood

45. Assessing Respiratory Function Clients with respiratory alterations require additional nursing assessment. Pulse oximetry Apnea monitor

46. Assessing Respiratory Function

47. Assessing Blood Pressure The direct method of measuring blood pressure requires an invasive procedure. The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed.

48. Assessing Blood Pressure The most common site for indirect measurement is the client’s arm over the brachial artery. Accurate measurement requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity.

49. Assessing Blood Pressure Korotkoff sounds are five distinct phases of sound heard with a stethoscope during auscultation. The forearm or leg sites can be palpated to obtain a systolic reading when the brachial artery is inaccessible.

50. Assessing Blood Pressure Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure. Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg.

51. Assessing Blood Pressure Orthostatic Hypotension (postural hypotension) Sudden drop in systolic pressure when client moves from a lying to a sitting to a standing position

52. Assessing Blood Pressure False Readings Clients who have recently eaten, ambulated, or experienced an emotional upset Improper cuff width Improper technique in deflating cuff Improper positioning of extremity Failure to recognize an auscultatory gap

53. The Physical Examination Techniques Inspection Palpation Percussion Auscultation

54. Integumentary System Skin Hair and Scalp Nails

55. Skin Assessment Skin assessment provides a noninvasive window to observe the body’s physiological functions.

56. Skin Assessment Color Lesions Moisture Temperature Texture Mobility and Turgor Edema

57. Integumentary System Hair The amount and texture of hair vary with age, sex, race and body part. Vellus Terminal hair The scalp should be smooth, clean, intact, and free of lumps or tender areas.

58. Integumentary System Nails Clubbing Koilonychia (spoon nail) Beau’s line Paronchia

59. Physical Examination Head Skull and face assessment involves inspection and palpation. The client’s face has its own unique characteristics related to race, state of health, emotions, environment.

60. Physical Assessment Eyes Conjunctive and sclera are assessed for color, redness, swelling, exudate, foreign bodies Visual acuity Fundoscopy

61. Physical Assessment Ears Auditory screening Inspection and palpation of external ear Placement, symmetry Otoscopic assessment Nose and Sinuses Inspection and palpation Use of a penlight

62. Physical Examination Mouth and Pharynx Breath Lips Tongue Buccal mucosa Gums and teeth Hard and soft palate Pharynx

63. Physical Examination Neck Neck muscles Lymph nodes of head and neck Thyroid gland Trachea

64. Physical Examination Thorax and Lungs Landmarks for inspection, auscultation, and percussion Anterior and posterior examination Shape and symmetry Thoracic expansion Tactile fremitus

65. Thorax and Lungs Auscultation of Normal Breath Sounds Vesicular sounds Bronchovesicular sounds Bronchial sounds

66. Thorax and Lungs. Auscultation of Adventitious Breath Sounds Crackles Rhonchi Wheezes Pleural friction rub Stridor

67. Heart and Vascular System Heart Landmarks for inspection, palpation, auscultation Heart sounds Palpation for thrills and heaves Abnormal auscultatory findings Murmurs Bruits

68. Heart and Vascular System Vascular System Blood perfusion of peripheral vessels Peripheral pulses compared bilaterally Skin temperature, color

69. Physical Examination Lymphatic System Lymphatic drainage Lymph nodes

70. Breasts and Axillae Palpation of four quadrants of breasts Palpation of supraclavicular, infraclavicular, and axillary nodes Education and encouragement of questions about breast self-examination (BSE) Breast cancer can also occur in males.

71. Breasts and Axillae Drainage patterns of the left breast.

72. Abdomen Inspection Contour Symmetry Umbilicus Surface motion Scars

73. Abdomen Auscultation All four quadrants in a systematic fashion Beginning with the RLQ Tympany Dullness Bruits Hyperactive or hypoactive bowel sounds

74. Abdominal Quadrants

75. Abdomen Light palpation in all four quadrants beginning with the RLQ Resistance Tenderness Rebound tenderness Organ enlargement

76. Female Genitalia and Anus Cultural Considerations Inspection and Palpation Mons pubis and vulva Labia majora, labia minora Clitoris Urethral meatus and vaginal introitus Perineum and anus

77. Male Genitalia, Anus, and Rectum Testes and male gonads Seminal vesicles and bulbourethral glands Epididymis, vas deferens, ejaculatory ducts Scrotum, penis, spermatic cord Anorectral exam including the prostate Monthly testicular self-examination (TSE)

78. Musculoskeletal System Inspection Palpation Range of Motion (ROM) Bilateral Comparison

79. Musculoskeletal System Muscle Hypertrophy Atrophy Hypertonicity Hypotonicity

80. Musculoskeletal System Joints Arthritis Osteoarthritis Crepitus

81. Neurologic System Mental Status Physical appearance and behavior Communication Level of consciousness

82. Mental Status Cognitive Abilities and Mentation Attention Memory Judgment, insight Spatial perception Calculation Abstraction Thought process and content

83. Neurological Assessment Sensory Assessment Exteroceptive sensations Proprioceptive sensations Cortical sensations Dermatome map

84. Neurological Assessment Cranial Nerves Assessment Motor Assessment Cerebellar Assessment Reflex Assessment