PPT on Health assessment on Hospital and Clinics

1. Health
Assessment
Jitendra Bokha
GCON Jodhpur
M.Sc (N) Previous Year
Medical Surgical Nursing
Submitted To
Anju Suthar

2. OUTLINES
 INTRODUCTION OF HEALTH ASSESSMENT
 DEFINITION OF HEALTH ASSESSMENT
 INDICATION OF HEALTH ASSESSMEN
 PURPOSES OF HEALTH ASSESSMENT
 METHOD OF HEALTH ASSESSMENT
 CLASSIFICATION OF HEALTH ASSESSMENT
 PHYSICAL HEALTH ASSESSMENT
 HEALTH HISTORY ASSSESSMENT
 DIAGNOSTIC TESTINGS & ASSESSMENT
 REFERENCE
 BIBLIGRAPHY

3. Introduction Of Health Assessment
 Assessment is the first step in determining the condition of the
patient’s health and their immediate and long-term needs.
 It help to identify the strength of client to promoting health.
 The nursing assessment of patients on admission to hospital is key to
clinical decision-making and to planning patient care that takes
account of the individual patients’ needs and circumstances.

4. Definition of Health Assessment
 Health assessment is defined as systematic and dynamic process by
which nurse through interaction with client, significant others and health
care providers, collect data about the client.
A health assessment is a plan of care that identifies the specific needs of
a person and how those needs will be addressed by the healthcare
system or skilled nursing facility. Health assessment is the evaluation of
the health status by performing a physical exam after taking a health
history.

5. INDICATION OF HEALTH ASSESSMENT
 On admission
 On discharge
 On follow up
 On health camps
 Before and after diagnostic and therapeutic procedure
Health assessment also to be done.

6. PURPOSES OF HEALTH ASSESSMENT
 To collect data about physical, mental & socially well being of client.
 Gather complete baseline data about patient health status.
 To formulate appropriate nursing care plan.
 To detect disease in early stage.
 To determine cause of disease.
 To understand any alteration and variation in disease condition.
 To provide holistic care of nursing health assessment is an essential
feature.

7. METHOD OF ASSESSMENT
 The main method is used to asses are as follow :-
1. Observing
2. Interviewing
3. Examining

8. HEALTH
HISTORY + PHYSICAL
EXAMINATION = HEALTH
ASSESSMENT
HEALTH ASSESSMENT

9. CLASSIFICATION OF HEALTH ASSESSMENT
 Assessing a client’s health status is a major component of nursing
care and has three aspects:
1. the nursing health history
2. the physical assessment, and
3. diagnostic testing.
 The focus of this chapter will be on the physical assessment and
diagnostic testing that is required to diagnose a client’s
condition.

10. Physical Health Assessment
 A complete health assessment is conducted in a systematic and efficient
manner starting at the head and proceeding downward (head- to-toe
assessment).

11.  What Is a Head to Toe Assessment?
 a head to toe assessment is an exhaustive process that checks
the health status of all major body systems. It is a
comprehensive physical examination that shines a light on a
patient’s needs and problems.
 For the most part, head to toe assessments happen during
primary care visits or annual physical exams.

12.  What Equipment Should you Have Ready for a Head
to Toe Assessment?
 Gloves
 Thermometer
 Scale
 Height wall ruler
 Penlight
 Stethoscope
 Blood pressure cuff
 Tongue depressor
 Sterile objects, both soft and sharp
 Pulse oximetry etc.

13. Methods of an examination used in head to toe assessment.
 Inspection
 Palpation
 Percussion
 Auscultation

14. INSPECTION
 Always performed first, inspection also is the most repeated method
of examination. You need to use your sight and smell to check specific
body areas for normal color, shape, and consistency.

15. PALPATION
Touching the patient to sense abnormalities on (or in) the body is known as
palpation. In the process of conducting a head-to-toe assessment, you will employ
two kinds of palpation: light and deep. Light palpation is gentle and gives information
about skin texture and moisture, fluids, muscle guarding, and some superficial
tenderness the patient may be experiencing. On the other hand, deep palpation
explores the internal structures of the body to a depth of four to five centimeters.
Using this technique, RNs can learn more about organs and masses’ position, shape,
mobility, and possible areas of discomfort.

16. PERCUSSION
 This third technique requires the nurse to tap on the patient’s
body to produce sound vibrations. These sounds can confirm the
presence of air, fluid, and solids. It can also pinpoint organ size,
shape, and position.

17. AUSCULTATION
 The last method of examination is auscultation. It implies listening
to the heart, lungs, neck, or abdomen to gather information. Direct
auscultation is done with the unaided ear. Indirect auscultation
requires the presence of amplification or mechanical devices, such
as a stethoscope.

18. Head to Toe Assessment Checklist
1. General Overview
 First, you obtain a general overview of the patient’s health state. These are the details to
keep an eye on in this phase of the assessment.
 Collect their vital signs. (It’s encouraged to ask permission before touching a patient. Also,
explaining what you are doing/what assessment you are performing will help the patient
feel more relaxed.)
 Check heart rate
 Measure blood pressure
 Take body temperature
 Pulse oxymetry
 Respiratory rate
 Check pain levels
 Check height and weight and calculate their BMI

19. 2. Hair/ Skin/ Nails
 Once you have a general overview, you can start from the top of the body and make your way down.
The assessment is called head to toe for a reason. Some things to look out for are:
 Hair distribution(even/uneven)
 Hair infestations (lice, alopecia areata)
 Bumps, nits, lesions on the scalp
 Tenderness on scalp
 Tenderness, lumps on the skin
 Lesions, bruising, or rashes on skin
 Temperature, moisture, and skin texture (is the patient pale, clammy, dry, cold, hot, flushed?)
 Edema
 Consistency, color, and capillary refill of nails
 Pressure areas

20. 3. Head
 Shape is rounded, symmetrical
 Upon palpation, no nodules, masses or depressions are identified
 Face appears smooth and symmetrical with no nodules or masses present.
4. Eyes
 Check external structures
 Assess eye symmetry
 Check conjunctive and sclera
 Check for PERRLA
 Perform visual acuity test
 Check eyes for drainage
 Check vision with Snellen Chart
 Check six cardinal positions of the gaze

21. 5. Nose
 Palpate nose and check symmetry
 Check septum and inside nostrils
 Patency of nares (patient can breath through each nostril)
 Check sense of smell
 Palpate sinuses
6. Mouth and Throat
 Check lips for color and moistness
 Inspect teeth and gums
 Examine tongue
 Inspect the inside of mouth
 Look at tonsils and uvula
 Assess hypoglossal nerve by asking patient to move tongue from left to right
 Check the patient’s ability to taste, to swallow, and their gag reflex

22. 7. Ears
 Inspect for drainage or abnormalities
 Test hearing with whisper test
 Look inside ear: inspect the tympanic membrane and asses ear discharge
 Tuning fork tests (Weber’s Test, Rinne Test)
8. Neck
 Check neck muscles to be equal in size
 Palpate lymph nodes
 Check head movements and whether they happen with discomfort
 Observe neck range of motion.
 Check trachea placement
 Check shoulder shrug with resistance
9. Chest: Cardiovascular Assessment
 Listen to the heartbeat. Areas where to auscultate heart sounds: aortic, pulmonic, Erb’s point, Tricuspid, Mitral
 Palpate the carotid and auscultate apical pulse

23. 10. Chest: Respiratory Assessment
Auscultate lung sounds front and back
Observe chest expansion
Ask abour efforts to breathe/coughing
Palpate thorax etc.

24. 11. Abdomen
 Inspect abdomen
 Listen to bowel sounds in all four quadrants
 Palpate all four quadrants of the abdomen to check for pain or tenderness
 Ask about bowel or bladder problems.
12. Extremities
 Assess range of motion and strength in arms, legs, and ankles
 Assess sharp and dull sensation on arms and legs
 Inspect arms and legs for pain, deformity, edema, pressure areas, bruises
 Palpate radial pulses, pedal pulses
 Check capillary refill on fingernails/toenails
 Assess gait
 Assess handgrip strength and equality.
13. Back area
 Inspect back and spine
 Inspect coccyx/buttocks/including Genitalia etc.

25. Health History
 The purpose of obtaining a health history is to gather subjective data from the
patient and/or the patient’s family so that the health care team and the patient
can collaboratively create a plan that will promote health.
 Health history checklist –
 Biographical data :-
 Source of history
 Name
 Age
 Occupation (past or present)
 Marital status/living arrangement
 Source of history
 Name
 Age

26. Persent history
 Chief complaint
 Onset of present health concern
 Duration
 Signs, symptoms, and related problems
 Medications or treatments used
Past health history
 Allergies (reaction)
 Serious or chronic illness
 Recent hospitalizations
 Recent surgical procedures
 Emotional or psychiatric problems (if pertinent)
 Current medications: prescriptions, over-the-counter, herbal remedies
 Drug/alcohol consumption

27. Family history
 Pertinent health status of family members
 Pertinent family history of heart disease, lung disease, cancer, hypertension,
diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness,
genetic disorders.
Functional assessment (including activities of daily living)
 Activity/exercise, leisure and recreational activities (assess for falls risk)
 Sleep/rest
 Nutrition/elimination
 Interpersonal relationships/resources
 Coping and stress management
 Occupational/environmental hazards

28. REFERENCE
 https://nightingale.edu/blog/head-to-toe-assessment.html
 https://nurseslabs.com/head-to-toe-assessment-complete-physical-
assessment-guide
 Handbook for Brunner & Suddarth's Textbook of Medical
 https://en.wikipedia.org/wiki/Health_assessment
 https://opentextbc.ca/clinicalskills/chapter/2-4-health-history-subjective-
assessment/

29. BIBLIOGRAPHY
 https://nightingale.edu/blog/head-to-toe-assessment.html
 https://nurseslabs.com/head-to-toe-assessment-complete-physical-
assessment-guide
 Handbook for Brunner & Suddarth's Textbook of Medical
 https://en.wikipedia.org/wiki/Health_assessment
 https://opentextbc.ca/clinicalskills/chapter/2-4-health-history-
subjective-assessment/
 www.Google.co.in
 OxfordDictionary
 NNL foundation Book
