Chapter 27
Health Assessment
Preparing for the Health
Assessment
 Environment
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Ensure privacy
Quiet, warm room
Special needs of the client
Surface for placement of equipment
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Preparing for the Health
Assessment
 Equipment
• Maintenance
• Isolation precautions
• Adequate number of gloves
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Preparing for the Health
Assessment
 Positioning
• Ensures accessibility to the body part being
assessed.
 Draping
• Prevents chilling.
• Prevents unnecessary exposure.
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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)
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Conducting the Health and
Physical Assessment
 Conducted in an aseptic, systematic, and
efficient manner.
 Requires the fewest position changes for
the client.
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General Survey
 Initial Observations
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Client’s physical appearance
Mood and behavior
Speech patterns and voice intonations
Signs and symptoms of distress
Vital signs
Height and weight
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General Survey
 Special Considerations
• Elderly clients
• Disabled clients
• Abused clients
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Vital Signs
 The sequence for recording vital sign
measurements in the nurses’ notes is TP-R and BP.
 Vital signs are plotted on graphic forms
that facilitate data comparison at a
glance.
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Thermoregulation
 The body’s physiological function of heat
regulation to maintain a constant internal
body temperature
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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.
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Thermoregulation
 Heat Production
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Basal Metabolic Rate (BMR)
Vasodilation
Vasoconstriction
Piloerection
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Thermoregulation
 Heat Loss
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Radiation
Conduction
Convection
Evaporation
 Insensible Heat Loss
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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.
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Respiration
 Respiration is the act of breathing.
 Terms related to respiratory function are:
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External respiration
Internal respiration
Inspiration
Expiration
Vital capacity
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Respiration
 Major physiological pulmonary functions
are:
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Ventilation
Circulation
Diffusion
Transport
Regulation
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Hemodynamic Regulation
 The circulatory system transports
nutrients to the tissues, removes waste
products, and carries hormones from one
part of the body to another.
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Hemodynamic Regulation
 Systemic Circulation
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Arteries
Arterioles
Capillaries
Veins
Venules
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Hemodynamic Regulation
 Cardiac Cycle
• Systole
• Diastole
 Stroke Volume
 Cardiac Output
 Compensatory Mechanisms
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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).
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Hemodynamic Regulation
 Blood Pressure
• Measurement of pressure pulsations exerted
against the blood vessel walls during systole
and diastole
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Blood Pressure
 Systolic Pressure
• Maximum pressure exerted against arterial
walls during systole
 Diastolic Pressure
• Pressure remaining in the arterial system
during diastole
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Hemodynamic Regulation
 Hemodynamic regulators for blood
pressure control are:
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Blood volume
Cardiac output
Peripheral vascular resistance
Viscosity
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Factors Influencing Vital Signs
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Age
Gender
Heredity
Race
Lifestyle
Environment
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Factors Influencing Vital Signs
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Medications
Pain
Exercise
Anxiety and Stress
Postural Changes
Diurnal (daily) Variations
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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
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Assessing Body Temperature
 Alterations in Body Temperature
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Pyrexia
Hyperthermia
Heat Exhaustion
Heat Stroke
Hypothermia
Frostbite
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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.
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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.
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Assessing Pulse
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Assessing Pulse
 A pulse deficit occurs when the apical
pulse rate is greater than the radial pulse
rate.
 Pulse Characteristics
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Pulse quality
Pulse rate (bradycardia, tachycardia)
Pulse rhythm (dysrhythmias)
Pulse volume
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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.
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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
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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
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Assessing Respirations
 A stethoscope is used to auscultate
breath sounds throughout the respiratory
system.
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Assessing Respirations
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Dyspnea,
Bradypnea, tachypnea, apnea
Hypoventilation
Hyperventilation
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Assessing Respiratory Function
 Cyanosis
• Bluish appearance in the nail beds, lips, and
skin
• Reduced oxygen levels in the arterial blood
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Assessing Respiratory Function
 Clients with respiratory alterations require
additional nursing assessment.
• Pulse oximetry
• Apnea monitor
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Assessing Respiratory Function
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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.
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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.
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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.
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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.
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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
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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
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The Physical Examination
 Techniques
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Inspection
Palpation
Percussion
Auscultation
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Integumentary System
 Skin
 Hair and Scalp
 Nails
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Skin Assessment
 Skin assessment provides a noninvasive
window to observe the body’s
physiological functions.
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Skin Assessment
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Color
Lesions
Moisture
Temperature
Texture
Mobility and Turgor
Edema
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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.
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Integumentary System
 Nails
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Clubbing
Koilonychia (spoon nail)
Beau’s line
Paronchia
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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.
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Physical Assessment
 Eyes
• Conjunctive and sclera are assessed for
color, redness, swelling, exudate, foreign
bodies
• Visual acuity
• Fundoscopy
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Physical Assessment
 Ears
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Auditory screening
Inspection and palpation of external ear
Placement, symmetry
Otoscopic assessment
 Nose and Sinuses
• Inspection and palpation
• Use of a penlight
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Physical Examination
 Mouth and Pharynx
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Breath
Lips
Tongue
Buccal mucosa
Gums and teeth
Hard and soft palate
Pharynx
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Physical Examination
 Neck
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Neck muscles
Lymph nodes of head and neck
Thyroid gland
Trachea
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Physical Examination
 Thorax and Lungs
• Landmarks for inspection, auscultation, and
percussion
• Anterior and posterior examination
• Shape and symmetry
• Thoracic expansion
• Tactile fremitus
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Thorax and Lungs
 Auscultation of Normal Breath Sounds
• Vesicular sounds
• Bronchovesicular sounds
• Bronchial sounds
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Thorax and Lungs.
 Auscultation of Adventitious Breath
Sounds
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Crackles
Rhonchi
Wheezes
Pleural friction rub
Stridor
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Heart and Vascular System
 Heart
• Landmarks for inspection, palpation,
auscultation
• Heart sounds
• Palpation for thrills and heaves
• Abnormal auscultatory findings
- Murmurs
- Bruits
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Heart and Vascular System
 Vascular System
• Blood perfusion of peripheral vessels
- Peripheral pulses compared bilaterally
- Skin temperature, color
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Physical Examination
 Lymphatic System
• Lymphatic drainage
• Lymph nodes
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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.
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Breasts and Axillae
 Drainage patterns of
the left breast.
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Abdomen
 Inspection
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Contour
Symmetry
Umbilicus
Surface motion
Scars
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Abdomen
 Auscultation
• All four quadrants in a systematic fashion
• Beginning with the RLQ
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Tympany
Dullness
Bruits
Hyperactive or hypoactive bowel sounds
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Abdominal Quadrants
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Abdomen
 Light palpation in all four quadrants
beginning with the RLQ
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Resistance
Tenderness
Rebound tenderness
Organ enlargement
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Female Genitalia and Anus
 Cultural Considerations
 Inspection and Palpation
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Mons pubis and vulva
Labia majora, labia minora
Clitoris
Urethral meatus and vaginal introitus
Perineum and anus
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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)
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Musculoskeletal System
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Inspection
Palpation
Range of Motion (ROM)
Bilateral Comparison
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Musculoskeletal System
 Muscle
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Hypertrophy
Atrophy
Hypertonicity
Hypotonicity
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Musculoskeletal System
 Joints
• Arthritis
• Osteoarthritis
• Crepitus
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Neurologic System
 Mental Status
• Physical appearance and behavior
• Communication
• Level of consciousness
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Mental Status
 Cognitive Abilities and Mentation
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Attention
Memory
Judgment, insight
Spatial perception
Calculation
Abstraction
Thought process and content
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Neurological Assessment
 Sensory Assessment
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Exteroceptive sensations
Proprioceptive sensations
Cortical sensations
Dermatome map
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Neurological Assessment
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Cranial Nerves Assessment
Motor Assessment
Cerebellar Assessment
Reflex Assessment
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