2. DEFINITION :
•Health assessment is an essential nursing
function which provides foundation for quality
nursing care and interventions.
•It helps to identify the strength of the clients in
promoting health.
3. •Health assessment is refers to systematic appraisal
of all factors relevant to client’s health.
OR
• Health assessment includes collecting subjective
data through interviewing the client and obtaining
objective data by physically examining the client.
4. •Indication of health assessment :
• On admission
• On discharge
• On follow up
• Health camps
• Before and after diagnostic and therapeutic
procedure.
5. 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.
6. •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.
7. • 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.
• 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.
• 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.
8. • 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.
• Shift assessment:
When individuals are hospitalized, nurses conduct assessment each
shift. The purpose is to identify changes in a patient’s condition from baseline .
• 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.
10. • 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
11. • 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
12. • 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.
13. • 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.
14. • 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
15. •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)
16. • 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.
17. • 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.
18. • 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.
• 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"
19. •Reflex Testing
• Means automatic response to a given stimulus. It reveals reflex is
present or not, strength and movement of hands and legs.
20. •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
21. • PREPARING THE 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
22. • PREPERATION OF THE PATIENT
• 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.
23. • 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
24. • 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
