Health Assessment Skills
Development
Unit One
Nursing history and physical
examination
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Nurses use physical assessment skills to:
• Develop (obtain baseline data) and expand the data
base from which subsequent phases of the nursing
process can evolve.
• To identify and manage a variety of patient problems
(actual and potential).
• Evaluate the effectiveness of nursing care.
• Enhance the nurse-patient relationship.
• Make clinical judgments.
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Types of Data:
• Subjective data –
– Said by the client,
(S), Patient History
• Objective data –
– Observed by the nurse,
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(O),Physical Assessment
Preparing for the assessment:
• Explain when, where and why the assessment will
take place.
• Help the client prepare (empty bladder, change
clothes).
• Prepare the environment (lighting, temperature,
equipment, drapes, privacy.
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Assessment Sequencing:
• Head – to - Toe Assessment.
• Body Systems Assessment.
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Assessment Techniques:
• Inspection - critical observation.
– Use of one’s senses of vision and smell to consciously
observe the patient
– Take time to “observe” with eyes, ears, nose.
– Use good lighting.
– Look at color, shape, symmetry, position.
– Odors from skin, breath, wound.
– Develop and use nursing instincts.
– Inspection is done alone and in combination with
other assessment techniques.
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Assessment Techniques:
• Palpation - light and deep touch.
– Act of touching the patient in a therapeutic
manner
– Light palpation:
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Superficial, delicate, gentle
Uses finger pads
Depress 1 cm below surface
Provides information on skin texture, moisture, masses,
fluid, muscle guarding, and tenderness
Assessment Techniques:
• Palpation:
– Deep palpation:
• Provide information about the position of organs,
masses, their size, shape, mobility and consistency
• Uses hands.
• Depress 4 to 5 cm below skin surface
• Most commonly used for assessing abdominal and
reproductive structures
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Assessment Techniques:
• Palpation:
– Back of hand to assess skin temperature.
– Fingers to assess texture, moisture, areas of tenderness.
– Assess size, shape, consistency of lesions, temperature,
texture, moisture, organ size and location, rigidity or
spasticity, crepitation, vibration, position, presence of
lumps or masses, tenderness, or pain.
– Tips:
• Warm hands
• Short nails
• Inform patient of when, where, and how the touch will occur
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Assessment Techniques:
• Percussion
sounds
produced by striking body
surface.
– Striking one object against
another to cause vibrations
that produce sound.
– Analyze sounds by intensity,
duration, pitch.
– Any part of the body can be
percussed.
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Assessment Techniques:
• Percussion:
– Most commonly used for abdomen and thorax.
– Assess underlying structures for location, size, density
of underlying organs.
– Direct – sinus tenderness
– Indirect- lung percussion
– Blunt percussion- organ tenderness (CVA tenderness)
– Produces different notes depending on underlying
mass (dull, resonant, hyperresonant, flat, tympani).
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Assessment Techniques:
• Percussion
– Dullness – heart, liver, spleen
– Resonance – air filled lungs (hollow)
– Hyperresonance – emphysematous lung (hyperinflated)
– Flatness – bone or muscle
– Tympany – air-filled stomach (drumlike)
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Assessment Techniques:
• Percussion
– Used to determine size and shape of underlying
structures by establishing their borders and
indicates if tissue is air-filled, fluid-filled, or solid.
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Assessment Techniques:
• Auscultation:
– Listening to sounds produced by the body:
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Heart.
Blood vessels.
Lungs.
Abdomen
– Instrument: stethoscope
• Diaphragm –high pitched sounds (Heart, Lungs, Abdomen)
• Bell – low pitched sounds (Blood Vessels)
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Assessment Techniques:
• Auscultation:
– Direct auscultation – sounds are audible without stethoscope.
– Indirect auscultation – uses stethoscope.
– Know how to use stethoscope properly (practice)
– Describe sound characteristics (frequency, pitch intensity,
duration, quality) (practice).
– Flat diaphragm picks up high-pitched respiratory sounds best.
– Bell picks up low pitched sounds such as heart murmurs.
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Commonly Used Equipment:
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Pen and paper.
Tape measure.
Clean gloves.
Penlight.
Scale.
Thermometer.
Sphygmomanometer.
Commonly Used Equipment:
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Stethoscope.
Otoscope .
Opthalmoscope.
Visual acuity charts.
Tuning fork.
Reflex hammer.
Lubricant.
Complete History and Physical Assessment:
• Nursing history is subjective – includes:
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Biographic data,
The chief complaint,
History of present illness,
Past medical history,
Immunization history,
Allergies,
Habits (tobacco, ETOH),
Stressors,
Family history including genogram,
Patterns of health care,
A review of the body’s systems.
History of Present Illness:
• HPI is a chronological story of what has been happening.
• Must get details of the problem, therefore must be
systematic.
• OLFQQAAT:
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Onset,
Location,
Frequency,
Quality,
Quantity,
Aggravating factors,
Alleviating factors,
Associated symptoms,
Treatments tried (include all treatments - Rx, OTC, herbal, folk).
Subjective head-to-toe review:
• General - recent wt. change, fatigue, fever.
• Skin - rashes, lesions, changes, dryness, itching, color
change, hair loss, change in hair or nails.
• Eyes - change in vision, floaters, glasses, pain.
• Ears - pain, loss of hearing, vertigo, ringing, discharge,
infections.
• Nose and sinuses - frequent colds, congestion,
nosebleed
• Mouth and throat - condition of teeth and gums, last
dental visit, hoarseness, frequent sore throats.
• Neck - lumps, stiffness, goiter.
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Subjective head-to-toe review:
• Breasts - lumps, pain, discharge.
• Respiratory - cough, sputum, wheezing, asthma, COPD, last CXR,
smoking history (can do here, or with “habits”)
• Cardiac - heart trouble, chest pain, SOB, murmur, h/o rheumatic
fever, past EKG.
• GI - problems swallowing, heartburn, vomiting, bowel habits, pain,
jaundice.
• Urinary - frequency, incontinence, pain, burning, hesitancy,
nocturia, polyuria.
• Genitalia - lesions, discharge, sexual orientation, sexual function,
menstrual history, contraception, pregnancy history.
• Peripheral vascular - intermittent claudication, varicose veins, blood
clots.
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Subjective head-to-toe review:
• MS - muscle or joint pain, redness, stiffness,
warmth, swelling, family history.
• Neuro - fainting, blackouts, seizures, weakness.
• Endocrine - sweats, skin change, heat or cold
intolerance,
excessive
thirst
(polydipsia),
excessive urination (polyuria), weight change,
menstrual changes.
• Psychiatric - mental illness, thoughts of harming
self or others
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Subjective head-to-toe review:
• History is subjective; Physical assessment is objective.
• Objective portion of exam begins with the general
survey; Each body system reviewed in text has nursing
history at the beginning of the procedure for the
objective exam.
• In actual practice, you get most of the history before
ever touching the client, but there are usually
additional history questions to ask during the exam.
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General Survey:
• General appearance:
– Gait,
– Nutrition status (NOT to be confused with
nutrition history),
– State of dress,
– Body build,
– Obvious disability,
– Speech patterns,
– Affect (mood),
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General Survey:
• General appearance:
– Hygiene,
– Body odor,
– Posture,
– Height,
– Weight,
– Vital signs.
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General Survey:
• Height up to age 2 is recumbent.
• Add head circumference if child is less than 2
years old
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Body Mass Index:
– BMI is a measure of body fat based on height and
weight that applies to adult men and women.
– BMI = weight in kilograms/heigh im meter2
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Below 18:5 : under weight
18.5 – 24.9 Normal
25 – 29.9 overweight
30 & above Obese