Complete Health Assessment
Clinical Setting
n
Cleanliness
n
Safety – standard precautions, transmission based
precautions
n
Warm, quiet, private environment
n
Good lighting
n
Equipment ready
n
Explain what you are doing
n
Make slow movements
n
Organize steps of assessment to prevent unnecessary
position changes
General Survey
n
Physical appearance
¨
Age
¨
Sex –
appropriate development for age and sex
¨
LOC
¨
Skin –
color, texture, intact
¨
Facial
features – symmetry
n
Body Structure
¨
Stature –
gigantism, acromegaly, dwarfism
¨
Nutrition –
obesity, anorexia
¨
Symmetry
¨
Posture –
scoliosis, lordosis, kyphosis
¨
Position -
tripod
¨
Body build –
arm length compared to height (Marfan’s syndrome – inherited connective tissue
disorder)
General Survey
n
Mobility
¨Gait – shuffling, limping
¨ROM – paralysis, jerky and
uncoordinated
n
Behavior
¨Facial expression – eye contact
¨Mood and affect – appropriate
emotions
¨Speech – articulation
¨Clothing
¨Personal hygiene
Measurements and Vital Signs
n
Weight and Height
¨
Developmental
considerations
n
Vital signs
¨
Temp
n
Thermometer types
¨
Mercury
¨
Electronic
¨
TMT – tympanic membrane thermometer
n
Routes (must be recorded, why?)
¨
Oral
¨
Axillary – add 0.5 C (0.9 F) to reading if don’t
record route
¨
Rectal
¨
Tympanic
n
Other variations
¨
diurnal cycle – higher temp in the evening 1 to 1.5 C
¨
menstrual cycle – increases temp immediately after
ovulation
¨
exercise
¨
age
Vital Signs
n
Pulse – normal varies with age
¨
Sites
n
Radial
n
Carotid
n
Dorsal pedal
n
Posterior tibial
¨
Rate
n
Tachycardia
n
Bradycardia – when is it normal?
¨
Rhythm
n
Arrhythmias – when is it normal?
¨
Force
n
Range from 0 to +3
¨
0 = absent
¨
+1 = weak, thready
¨
+2 = normal
¨
+3 = bounding
¨
Elasticity
n
Respirations
¨
Also vary
with age
¨
10-20
resp/min in adults
Assessing the Pulse
n
Pulse is the pressure felt in the periphery with each
heartbeat.
¨
Palpating
the radial pulse
n
Use pads of your first three fingers and palpate along
the flexor side (anterior) along the radial bone (lateral)
n
Press down until a pulsation is felt
n
Count pulsations for 30 seconds and multiply by 2 if
the rhythm is regular. Count for full 60
seconds if the rhythm is irregular
n
Blood pressure
¨
Review of
physiology
n
Systolic/Diastolic
¨
Systolic – Maximum pressure felt on the artery during
left ventricular contraction
¨
Diastolic – Resting pressure that the blood exerts
constantly between each contraction
n
Pulse pressure
¨
Reflects stroke volume – the amount of blood pumped
with every beat
¨
(SP-DP)
n
MAP – mean arterial pressure
¨
Average arterial pressure during a single cardiac
cycle
¨
Perfusion pressure by organs in the body
¨
(DP + 1/3 PP).
Should be greater than 60
How to take BP
•
Make sure the person is sitting or lying with palms
turned up and the brachial artery at level of heart
•
Center cuff above the brachial artery. Wrap the deflated cuff evenly and snugly
around the upper arm
•
Palpate the brachial a. with fingertips and inflate
the cuff 20 to 30 mm Hg above the point where the pulse disappears
•
Deflate the cuff and wait 30 sec. Place stethoscope over brachial pulse
•
Close the valve on the pressure bulb and inflate the
cuff to 30 mm Hg above the palpated systolic pressure. Slowly release the valve and allow the
mercury to fall at 2 to 3 mm Hg per second
•
Note the manometer pressure reading when the first
clear sound (first Korotkoff sound) is heard.
This is the SYSTOLIC pressure.
•
Continue to deflate the cuff, noting the point at
which the sound disappears. This is the
DIASTOLIC pressure
•
Deflate cuff and remove from arm
Common Errors in BP Measurement
n
Anxiety (from patient)
n
Arm position
n
Leg position
n
Inaccurate cuff size
¨
In general,
a cuff 20% wider than the diameter of the limb must be used in order to obtain
correct BP
¨
If the cuff
is too narrow, both systolic and diastolic pressures will be falsely high and
vice versa
n
Pushing stethoscope too hard
n
Deflating cuff too slowly or quickly
¨
Too slowly
produces venous congestion, which decreases amplitude of Korotkoff sounds
Abnormalities in Blood
Pressure
n
Hypotension
¨
Less than
95/60
¨
Occurs with
acute MI, shock, hemorrhage, vasodilation
¨
Due to:
n
↓ cardiac output
n
↓ total blood volume
n
↓ peripheral vascular resistance
Abnormalities in Blood pressure
n
Hypertension
¨
Primary
(Essential) HTN
n
Has no identifiable cause
¨
Secondary
HTN
n
Brought on by identifiable causes
n
Might actually be cured
Developmental considerations
n
Head circumference – up to 6 years
n
Vital signs
¨
Infants
n
Measure respiration, pulse, then temp.
n
Inguinal temp most accurate
n
Apical pulse rate most accurate and should be used
until 2 years
n
Respirations should be monitored by observing abdomen
n
Pulse and respirations should be monitored for 1 full
minute
¨
Preschoolers
n
Try to avoid invasive procedures. Avoid rectal route for temp.
n
NCLEX hint: explain procedure and encourage handling
of equipment
Developmental Considerations
n
The Aging Adult
¨
Posture –
general flexion, kyphosis
¨
Weight –
deposition of fat on abdomen and hips
¨
Height –
shorter due to shortening of spinal column
¨
Temperature
– decrease in regulatory mechanisms.
Tend to have lower normal temp.
¨
Pulse –
rhythm may be irregular. Easier to
palpate due to arteriosclerosis.
¨
BP –
increase in both systolic and diastolic pressures
Assessment Techniques
•
Inspection
¨
To examine
critically
¨
Begins
immediately after entering the room
¨
Neuromuscular
status, mental and emotional status
•
Palpation
¨
Use
systematic, gentle approach. Warm your
hands
¨
Palpate
tender areas last
¨
Always start
with light palpation before moving to deep palpation
¨
Different
parts of hands used to assess different factors:
n
Fingertips – Skin texture, swelling, pulsation, lumps
or masses, moisture, organ location, tenderness or pain
n
Grasping with finger and thumb – to detect position,
shape, and consistency of mass
n
Dorsa of hands and fingers – temperature since skin is
thinner
n
Base of fingers or ulnar surface of hands – best for
vibration
•
Percussion (if needed)
¨
Tapping a
person’s skin with short, sharp strokes to assess underlying structures
¨
The
vibration and characteristic sound depicts location, size, and density of
underlying organ
¨
Done to
evaluate the size, borders, and consistency of some internal organs, to detect
tenderness, and to determine extent of fluid
¨
Direct –
striking the body directly (sinuses)
¨
Indirect –
striking the stationary hand (interphalangeal joint) with the middle finger of
the striking hand
¨
The
resulting sounds vary due to the density of tissues.
¨
The denser
the tissue, the quieter the percussion
•
Auscultation
¨
Listening to
sounds produced by body
¨
Using a
stethoscope to eliminate and amplify sounds
Percussion Notes
Other Assessment Tools
n
Invasive arterial pressure monitoring
¨
Insertion of
a catheter into an artery – most accurate technique of pressure monitoring
¨
Disadvantage
– infection, invasive
n
Central venous pressure
¨
A catheter
inserted by physician into the right atrium measures adequacy of venous return
and cardiac filling
¨
Normal 7-12
mm H2O
¨
Elevated
CVPs may indicate right ventricular failure
¨
Low CVPs may
indicate hypovolemia
Preparing for the Health Assessment
§ Environment
• Ensure privacy
• Quiet, warm room
• Special needs of the client
• Surface for placement of equipment
§ Equipment
• Maintenance
• Isolation precautions
• Adequate number of gloves
§ Positioning
•
Ensures
accessibility to the body part being assessed.
§ Draping
•
Prevents
chilling.
•
Prevents
unnecessary exposure.
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)
§ Conducted in
an aseptic, systematic, and efficient manner.
§ Requires the
fewest position changes for the client.
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
§ Special
Considerations
•
Elderly
clients
•
Disabled
clients
•
Abused
clients
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.
§ 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.
§ Weight
•
Types of
scales available include chair, stretcher, bed, and platform scales.
•
Infants are
weighed on platform or cradle scales.
§ Nursing
Considerations
•
Accurate
recordings are necessary for drug dosage calculations and evaluation of
effectiveness of drug, fluid, and nutritional therapy.
§ 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.
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.
§ 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.
§ 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.
Thermoregulation
§ The body’s
physiological function of heat regulation to maintain a constant internal body
temperature
Physiologic Function
•
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.
§ Heat
Production
•
Basal
Metabolic Rate (BMR)
•
Vasodilation
•
Vasoconstriction
•
Piloerection
§ Heat Loss
•
Radiation
•
Conduction
•
Convection
•
Evaporation
§ Insensible
Heat Loss
§ 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.
Respiration
§ Respiration
is the act of breathing.
§ Terms
related to respiratory function are:
•
External
respiration
•
Internal
respiration
•
Inspiration
•
Expiration
•
Vital
capacity
§ Major
physiological pulmonary functions are:
•
Ventilation
•
Circulation
•
Diffusion
•
Transport
•
Regulation
Hemodynamic Regulation
§ The
circulatory system transports nutrients to the tissues, removes waste products,
and carries hormones from one part of the body to another.
§ Systemic
Circulation
•
Arteries
•
Arterioles
•
Capillaries
•
Veins
•
Venules
§ Cardiac
Cycle
•
Systole
•
Diastole
§ Stroke
Volume
§ Cardiac
Output
§ Compensatory
Mechanisms
§ 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).
§ Blood
Pressure
•
Measurement
of pressure pulsations exerted against the blood vessel walls during systole
and diastole
§ Systolic
Pressure
•
Maximum
pressure exerted against arterial walls during systole
§ Diastolic
Pressure
•
Pressure
remaining in the arterial system during diastole
§ Hemodynamic
regulators for blood pressure control are:
•
Blood volume
•
Cardiac
output
•
Peripheral
vascular resistance
•
Viscosity
Factors Influencing Vital Signs
§ Age
§ Gender
§ Heredity
§ Race
§ Lifestyle
§ Environment
§ Medications
§ Pain
§ Exercise
§ Anxiety and
Stress
§ Postural
Changes
§ Diurnal
(daily) Variations
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
•
Rectally
§ Alterations
in Body Temperature
•
Pyrexia
•
Hyperthermia
•
Heat
Exhaustion
•
Heat Stroke
•
Hypothermia
•
Frostbite
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.
§ 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.
§ 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
§ 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.
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
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
§ A
stethoscope is used to auscultate breath sounds throughout the respiratory
system.
Assessing Respirations
§ Dyspnea,
§ Bradypnea,
tachypnea, apnea
§ Hypoventilation
§ Hyperventilation
Assessing Respiratory Function
§ Cyanosis
•
Bluish
appearance in the nail beds, lips, and skin
•
Reduced
oxygen levels in the arterial blood
§ Clients with
respiratory alterations require additional nursing assessment.
•
Pulse
oximetry
•
Apnea
monitor
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.
§ 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.
§ 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.
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.
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
§ 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
The Physical Examination
§ Techniques
•
Inspection
•
Palpation
•
Percussion
•
Auscultation
Integumentary System
§ Skin
§ Hair and
Scalp
§ Nails
Skin Assessment
§ Skin
assessment provides a noninvasive window to observe the body’s physiological
functions.
Skin Assessment
§ Color
§ Lesions
§ Moisture
§ Temperature
§ Texture
§ Mobility and
Turgor
§ Edema
§ 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.
§ Nails
•
Clubbing
•
Koilonychia
(spoon nail)
•
Beau’s line
•
Paronchia
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.
Physical Assessment
§ Eyes
•
Conjunctive
and sclera are assessed for color, redness, swelling, exudate, foreign bodies
•
Visual
acuity
•
Fundoscopy
§ Ears
•
Auditory
screening
•
Inspection
and palpation of external ear
•
Placement,
symmetry
•
Otoscopic
assessment
§ Nose
and Sinuses
•
Inspection
and palpation
•
Use of a
penlight
§ Mouth
and Pharynx
•
Breath
•
Lips
•
Tongue
•
Buccal
mucosa
•
Gums and
teeth
•
Hard and
soft palate
•
Pharynx
§ Neck
•
Neck muscles
•
Lymph nodes
of head and neck
•
Thyroid
gland
•
Trachea
§ Thorax
and Lungs
•
Landmarks
for inspection, auscultation, and percussion
•
Anterior and
posterior examination
•
Shape and
symmetry
•
Thoracic
expansion
•
Tactile
fremitus
§ Auscultation
of Normal Breath Sounds
•
Vesicular
sounds
•
Bronchovesicular
sounds
•
Bronchial
sounds
§ Auscultation
of Adventitious Breath Sounds
•
Crackles
•
Rhonchi
•
Wheezes
•
Pleural
friction rub
•
Stridor
Heart and Vascular System
§ Heart
•
Landmarks
for inspection, palpation, auscultation
•
Heart sounds
•
Palpation
for thrills and heaves
•
Abnormal
auscultatory findings
-
Murmurs
-
Bruits
§ Vascular
System
•
Blood
perfusion of peripheral vessels
-
Peripheral pulses compared bilaterally
-
Skin temperature, color
§ Lymphatic
System
•
Lymphatic
drainage
•
Lymph nodes
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.
§ Drainage
patterns of the left breast.
Abdomen
§ Inspection
•
Contour
•
Symmetry
•
Umbilicus
•
Surface
motion
•
Scars
§ Auscultation
•
All four
quadrants in a systematic fashion
•
Beginning
with the RLQ
-
Tympany
-
Dullness
-
Bruits
-
Hyperactive or hypoactive bowel sounds
Abdominal Quadrants
