NUR 1020 Health Assessment
Health Assessment Chapter 30
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Nursing Assessment
o Health History
o Interview
o Family Health History
o Personal History
o Physical exam: Review
o Appropriate environment:
1. Privacy
2. Quite
3. Lighting
4. Cultural settings
 Face Covering, Religious Beliefs
o Pain: PQRST
1. Precipitating factors
2. Quality
3. Region (Location)
4. Severity (1 to 10)
5. Time
 Onset: When did it start
 Duration: How long it Last
 Pattern: One side, Radiate, Bilateral, Unilateral, More in Morning, More at Night
6. Unrelieved: did things but pain was not relived
 Examples: medication, hot cold techniques, aromatherapy, relaxation, music, massage.
Nursing History
o Patient profile: Education, Work, Maratial status
o Chief Complaint: Why they are here, “In Their Words”
o Past History
o Family History
o Medications: What they take, how often
o Allergies
o Review of Systems
Methods of Examination: Inspect, Carefully look, Listen,
and Smell to distinguish normal from abnormal findings
 Perform in this Order
1) Inspection (LOOK)
a) Carefully Look
b) Listen
c) Smell
2) Palpation (Touch): Except with abdomen assessment you Auscultation the ab first
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NUR 1020 Health Assessment
a) Light: ½ in. (Gets the patient accustomed to your touch.
SUPERFICIAL)
b) Deep: 2 in. (Manual or Bimanual… Identify ENLARGED
Organs)
3) Auscultation: Listen
4) Percussion: This is an advanced nurse technique (Touch)
1) Inspection
a) Carefully Look
 This occurs while interacting with the patient,
watching for Nonverbal Expressions and Mental status
and Assessing Physical Movements and Structural
Components.
 Very IMPORTANT TO PAY ATTENTION TO DETAIL!
 Make sure you have adequate lighting is available, either direct or indirect
 Use a Direct lighting source (Penlight) to inspect body cavities
 Inspect each area for:
o Size
o Shape
o Color
o Symmetry
o Position
o Abnormally
 Position the body so you can inspect all body parts while maintaining privacy
 When possible, check for side to side symmetry by comparing each area with its match
on the opposite side of the body
 VALIDATE FINDINGS WITH PATIENT
b) Listen
 Listen to the patient and inspect with your ears:
 How are they breathing?
 Are they dragging their feet?
 Make noises when they get up or move?
c) Odors
 Recognize the nature and source of body odors
 UNUSUAL ODOR OFTERN INDICATES an UNDERLYING PATHOLOGY
 Olfaction helps to detect abnormalities
o Ex. When a patient breath has a Sweet, Fruity Odor, ASSESS for
signs of DIABETES
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NUR 1020 Health Assessment
Odor
Alcohol
Ammonia
Site or Source
Oral Cavity
Urine
Body Odor
Skin, Particularly in areas where
body parts RUB Together. Ex.
Underarms and Under Breasts
Wound Sites
Vomitus
Feces
Foul-Smelling Stools in Infant
Vomitus/Oral Cavity (Fecal Odor)
Rectal Area
Stool
Halitosis
Oral Cavity
Sweet, Fruity Ketones
Stale Urine
Oral Cavity
Skin
Sweet, Heavy, Thick Odor
Musty Odor
Fetid, Sweet Odor
Draining Wound
Casted Body Part
Tracheostomy (Tracheotomy) of
Mucus Secretions
Potential Cause
Ingestion of ALCOHOL, DIABETES
Urinary Tract Infection, Renal
Failure
Poor Hygiene, EXCESS Perspiration
(Hyperhidrosis), Foul-Smelling
Perspiration (Bromhidrosis)
Wound Abscess
Abdominal Irritation,
Contaminated Food
Bowel Obstruction
Fecal Incontinence
Malabsorption (imperfect
absorption of food material by the
small intestine) Syndrome
Poor Dental and Oral Hygiene,
GUM DISEASE
Diabetic Acidosis
Uremic (Uremia: A serious
condition that occurs when the
kidneys no longer filter properly)
Acidosis
Pseudomonas (Bacterial) Infection
Infection inside Cast
Infection of Bronchial Tree
(Pseudomonas Bacteria)
2) Palpation: Involves using the SENSE of TOUCH to gather information
 Through touch we can make judgments about expected and unexpected findings of the:
o Skin
 Temperature
 Moisture
 Texture
 Turgor: Pinching skin together and see if it stays
 Tenderness
 Thickness
o Underlying Tissue
o Muscle
o Bones
o Abdomen
 Tenderness
 Distention
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NUR 1020 Health Assessment
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 Masses
The palmer surface of the hand and Finger Pads is MORE Sensitive
than the Fingertips and is used determine:
o Position
o Texture
o Size
o Consistency
o Masses
o Fluid
o Crepitus: Grating, Cracking or Popping sounds and
Sensations experienced UNDER the SKIN and JOINTS or a
Cracking Sensation due to the Presence of AIR in the
Subcutaneous tissue.
Area Examined
Skin
Organs (e.g., Liver and Intestines)
Glands (e.g., Thyroid and Lymph)
Blood Vessels (e.g., Carotid or
Femoral Artery)
Thorax
Criteria Measured
Temperature
Moisture
Texture
Turgor and Elasticity
Tenderness
Thickness
Size, Shape, Tenderness, Absence
of Masses
Swelling
Symmetry and Mobility
Pulse Amplitude, Elasticity, Rate,
Rhythm
Excursion
Tenderness
Portion of Hand to Use
Dorsum of Hand/Fingers
Palmar Surface
Palmar Surface
Grasping with Fingertips
Finger Pads/Palmar Surface of
Fingers
Palmar Surface
Entire Palmar Surface of Hand or
Palmar Surface of Fingers
Pads of Fingertips
Eyes….
Palmar Surface/Pads of Fingertips
Palmar Surface
Finger Pads/Palmar Surface of
Fingers
Fremitus
Palmar of Ulnar Surface of ENTIRE
Hand
 Touching a patient is a personal experience for both the nurse and the patient
o Display Respect & Concern
o Consider the patient’s condition and ability to tolerate the assessment techniques, paying
CLOSE attention to areas that are PAINFUL or TENDER
o Consider the Environment and Threats to patient’s safety
o Prepare for palpation by:
 Warming hands
 Keeping Fingernails Short
 Use Gentle Approach
o Palpation proceeds SLOWLY, GENTLY, and DELIBERATELY
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NUR 1020 Health Assessment
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o Tell patient to Relax and take Deep Slow Breaths
Two types of Palpation
a) Light Palpation: Pressing inward about 1 cm (1/2 In.)
b) Deep Palpation: Depress the area Approximately 4
cm (2 Inches) using One or Both Hands
a) Light Palpation: Pressing inward about 1 cm
(1/2 In.)
 Pressing inward about 1 cm (1/2 In.)
 Superficial Palpation of structures such
as the Abdomen gives the patient the
chance to identify areas of Tenderness
 Inquire about areas of tenderness and
assess them further for potentially
SERIOUS Pathologies
b) Deep Palpation: Depress the area
Approximately 4 cm (2 Inches) using One or Both Hands
 Depress the area Under Examination Approximately 4 cm (2 Inches) using
One or Both Hands
 Used to examine the condition of Organs such as those in the abdomen
 When using both hands
o Relax one hand (The Sensing Hand, Lower hand)
o Place the sensing hand Lightly on the skin
o The other hand (Active Hand) helps to Apply the Pressure to the
Sensing Hand
o LOWER HAND DOES NOT EXERT PRESSURE DIRECTLY and THUS
REMAINS SENSITIVE to DETECT ORGAN CHARACTERISTICS
3) Percussion: For Safety DEEP Palpation should be used with CAUTION in a patient with Discomfort in
the area to be Palpated Percussion: involves Tapping the Skin with the Fingertips to VIBRATE
Underlying Tissues and Organs
 The Vibration travels through body tissues, and the character of the resulting sound reflects
the density of the underlying tissue
 The Denser the tissue, the quitter the sound is
 By knowing how various densities influence sound, it is possible to locate organs or masses,
map their edges, and determine their size.
 An abnormal sound from what is expected in that are suggests a mass or substance such as
AIR or FLUID within an organ or body cavity
 Types of Sounds
 Flatness: Over Bone or Muscle
 Dullness: Over Liver (Thud)
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NUR 1020 Health Assessment
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Resonance: Over Lungs, Hollow
with low-pitch
 Hyperresonance: Low Pitch
(Booming Sound) Common with
Emphysema, Barrell Chest
 Tympany: Over Belly or Cheek
(Filled with air)
 Nurses usually do not listen to lungs
4) Auscultation: Involves listening to sounds the
body makes to detect variations from normal.
 Some sounds such as Speech and
Coughing can be heard without
additional equipment
 Using the stethoscope Diaphragm (High
Pitch Sounds) and Bell (Low Pitched
Sounds) is necessary to HEAR Internal
body Sounds
 Internal body sounds are created by
Blood, Air, and Gastric Contents and
they move against the Body Structures
 Parts of Stethoscope: Bell & Diaphragm
 The Bell is used for LOW-PITCHED Sounds
such as Vascular and Certain Heart Sounds
 The Diaphragm is best for listening to HIGHPITCHED Sounds such as Bowel and Lung
Sounds
 Sounds you will hear with a Stethoscope
 Pitch: Amplitude (Loud)
 Intensity: Strength
 Duration (Length of time, Short, Medium, or
Long)
 Quality (Blowing or Gurgling)
 Rhythm (Regular or Irregular)
 Frequency (Number of Sound Waves)
 Extraneous sounds created by rubbing against the tubing or chest piece interfere with
auscultation of body organ sounds
 General Survey
 Age: Affects the patient’s ability to participate in some parts of the examination
 Gender & Race: Different physical features are related to gender and Race
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NUR 1020 Health Assessment
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Gender and Race affects the types of examination performed and the order of the
assessment
 Certain Illness are MORE likely to affect a Specific Gender or Race
o Skin Cancer is MORE COMMON in WHITES than in BLACKS
o Prostate Cancer is HIGHER in BLACK MEN than in WHITE MEN
o Cancer in the Bladder is HIGHER in MEN than in WOMAN
 Body build: Body type REFLECTS the LEVEL of HEALTH, AGE, and LIFESTYLE
 Are they Muscular, Obese, Excessively Thin?
 Height & Weight: Assessments screen for abnormal weight changes
 Patients weight normally varies daily because of Fluid LOSS or RETENTION
 Use history to identify possible causes for change in weight
 A downward trend in an older adult who is frail indicates a serious reduction in
nutritional reserves.
 Ask the patient to report current height and weight and of any substantial weight gain
or loss
 A weight gain of 2 to 3 pounds (0.9-1.4 kg) in 1 day indicates fluid-retention problems
 A weight loss is considered significant if the patient has
lost more than 5% of body weight in a month or 10% in
6 months
 When a patient is hospitalized, daily weight is
MEASURED at the SAME TIME of DAY and on the SAME
SCALE
 When measuring and weighing an infant a basket or
platform scale is used
 Posture
 Normal standing Posture shows an UPRIGHT STANCE with PARALLEL ALIGNMENT of
the HIPS and SHOULDERS
 Normal sitting Posture involves SOME degree of rounding of the shoulders
 OBSERVE if the patient has a SLUMPED, ERECT, or BENT POSTURE, which REFLECTS
MOOD or PAIN
 Changes in older adult physiology often result in a STOOPED, FORWARD-BENT
POSTRUE, with the HOPS and KNEES somewhat flexed and the arms BENT
at the elbows
 Gait: Observe as the patient walks into the room or
stands at the beside
 Is the patient Ambulatory?
 Note if movement is coordinated or
uncoordinated
 Is the patient walking normally and smoothly?
With the arms swinging freely at the sides and the head and face leading the body?
 Hygiene and Grooming
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NUR 1020 Health Assessment
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Unkept: Not Bathing
Note the patient’s level of cleanliness by observing the appearance of the Hair, Skin,
and Fingernails
 Are their clothes clean?
 Is the patient capable of grooming him/herself?
 Does the patient use excess cosmetics or colognes, which could indicate a change in
self-perception?
 Signs of Illness
 Affect: MOOD How a person appears to others
 Patients Express Mood or Emotional State Verbally and Nonverbally
 Determine whether Verbal Expressions match Nonverbal Behavior and weather mood
is appropriate for the situation
 Cognitive Processes
 Alert Times 3: Orientated or Disorientated
o Self: Person Name
o Place: Where are you?
o Time: What Year is it? Who is THE President
of the US
 Alert Times 4 includes Situation (why are they here)
 Cognition is a term referring to the mental processes
involved in gaining knowledge and comprehension.
These cognitive processes include thinking, knowing, remembering, judging, and
problem-solving.
 Dress
 Is the patient wearing appropriate clothing? For the weather and the setting?
 People who are Depressed or Mentally ill may not be able to select proper clothing
 Older patients may wear extra clothing because they are always cold
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NUR 1020 Health Assessment
Clinical Indicator of Abuse
Physical Findings
Behavioral Findings
Child Abuse
Vaginal or penile discharge
Blood on underclothing
Pain, itching, or unusual odor in genital area
Genital injuries
Difficulty sitting or walking
Pain while urinating; recurrent urinary tract infections
Foreign bodies in rectum, urethra, or vagina
Sexually transmitted infections
Pregnancy in young adolescent
Problem sleeping or eating, anxiety,
depression
Fear of certain people or places
Play activities recreate the abuse situation
Regressed behavior: Older acting like a Kid
Sexual acting out Knowledge of explicit
sexual matters
Preoccupation with others’ or own genitals
Profound and rapid personality changes
Rapidly declining school performance
Poor relationship with peers
Intimate Partner Violence
Injuries and trauma inconsistent with reported cause
Multiple injuries involving head, face, neck, breasts, abdomen, and
genitalia (black eyes, orbital fractures, broken nose, fractured skull, lip
lacerations, broken teeth, vaginal tears)
X-ray films showing old and new fractures in different stages of healing
Abrasions, lacerations, bruises/welts
Burns from cigarettes or other
Human bites
Unexplained injuries (e.g., bruises, fractures, and welts)
Strangulation marks on neck from rope burns or bruises; throat pain,
voice changes, trouble swallowing; damage to hyoid bone
Stress-related disorders such as irritable bowel syndrome, exacerbation
of asthma, or chronic pain
Overuse of health services
Thoughts of or attempted suicide
Eating or sleeping disorders
Anxiety and panic attacks
Pattern of substance abuse (follows physical
abuse)
Low self-esteem
Depression, problems with eating or sleeping
Sense of helplessness
Guilt
Smoking
Stress-related complaints (headache,
anxiety)
Financial dependence on abuser
Isolation from others
Unsafe sexual behaviors
Older-Adult Abuse
Injuries and trauma inconsistent with reported cause (scratch, bruise,
or bite)
Hematomas, bruises at various stages of resolution
Unexplained bruises or welts, pattern bruises
Burns
Bruises, chafing, excoriation on wrist or legs (restraints)
Fractures inconsistent with cause described
Dried blood
Overmedication or undermedication
Exposure to severe weather, cold or hot
Torn, bloody underwear or vaginal and anal bruises
Sunken eyes or loss of weight
Extreme thirst
Bed sores
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Dependent on caregiver
Physically and/or cognitively impaired
Combative, verbally aggressive
Wandering
Minimal social support
Prolonged interval between injury and
medical treatment
Life circumstances do not match size of
patient’s estate
Uncommunicative or isolated
NUR 1020 Health Assessment
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Substance Abuse: Unusual or Inconsistent behavior may be an indicator for substance abuse, which CAN
AFFECT ALL SOCIOECONOMIC GROUPS
A tool such as the online Tobacco, Alcohol, Prescription medication, and
other Substance use (TAPS) tool can be used to assess a patient’s risk
for substance abuse (NIDA, 2018).
If you suspect that alcohol abuse is a major problem, the CAGE
questionnaire provides a useful set of questions to guide assessment.
CAGE is an acronym for the following:
 CUT DOWN: Have you ever felt the need to Cut Down on your
drinking or drug use?
 ANNOYED: Have people Annoyed you by criticizing your
drinking or drug use?
 GUILTY: Have you ever felt bad or Guilty about your drinking or
drug use?
 EYE-OPENER: Have you ever used or had a drink first thing in the
morning as an Eye-Opener to steady your nerves or feel normal?
Among older adults, risk factors for development of alcohol-related
problems include chronic medical disorders, sleep disorders, social
isolation, loneliness, bereavement, and acute or chronic pain.
When assessing adolescents there are brief online tools to screen substance use
 The Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD)
 Screening to Brief Intervention (S2BI)
 Dietary History for Older Adults
 Need help shopping and prep food?
 Income adequate for food purchasing? Food Stamp or Public Assistance Required?
 Does patient Skip Meals?
 Take Multi Vitamins?
 Take Medication affecting appetite or absorption of nutrients?
 Religious or Cultural beliefs and practices that influence diet?
 Have special diet restrictions? Food intolerances or Allergies?
 Patient diet include unusual amount of Alcohol, Sweets, or Fried Food?
 Problem Chewing, Swallowing, or Salivation?
 Have gastrointestinal problems that interfere with food intake?
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NUR 1020 Health Assessment
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Integumentary System refers to the Skin, Hair, Scalp
and Nails
 Skin: Use Sight, Smell, and Tough while
inspection and Palpating the Skin
 Assessment of the Skin Reveals the
Patient’s health status to
OXYGENATION, CIRCULATION,
NUTRITION, LOCAL TISSUE DAMAGE,
and HYDRATION
Daylight is the BEST CHOICE for IDENTIFYING VARIATIONS in THE SKIN COLOR, ESPECIALLY for DETECTINGG SKIN
CHANGES IN PATIENTS WITH DARK SKIN. Fluorescent lighting is the next best thing
 Room temp affects skin color
o If room is too warm, it will cause SUPERFICIAL VASODILATION, RESULTING in INCREASED REDNESS of
the SKIN: Erythema (Reddish Skin Color)
o If room is too cool it will cause a SENSITIVE Patient to Develop CYANOSIS (Bluish Skin Color) around the
LIPS and NAIL BEDS
 It is more difficult to note changes such as Pallor (Decrease in Color) or Cyanosis (Bluish Skin Color) in
patients with Dark Skin
 A patient’s sclera is the best site to inspect for Jaundice (Yellow-Orange Discoloration)
 Normal reactive hyperemia, or redness, is most often seen in regions exposed to pressure such as the sacrum,
heels, and greater trochanter.
Color
Cyanosis (Bluish)
Pallor (Decrease in Color)
Condition
Increased amount of
DEOXYGENATED
HEMOGLOBIN
(Associated with
Hypoxia)
Reduced amount of
Oxyhemoglobin
Reduced Visibility of
Oxyhemoglobin
Resulting from
Decreased Blood Flow
Causes
Heart of Lung disease,
Cold Environment
Assessment Locations
Nail Beds, Lips, Mouth, Skin in
Severe Cases
Amemia
Face, Conjunctivae, Nail Beds,
Palms of Hands
Skin, Nail Beds, Conjunctivae, Lips
Shock
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NUR 1020 Health Assessment
Loss of Pigmentation
Vitiligo
Jaundice (Yellow-Orange)
Increased deposit of
Bilirubin in Tissues
Erythema (Red Skin)
Increased Visibility of
Oxyhemoglobin caused
by Dilation or Increased
Blood Flow
Tan-Brown
Increased amount SUNTAN,
of Melanin
PREGNANCY
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Congenital or
Autoimmune Condition
Causing LACK of Pigment
Liver Disease,
Destruction of RED
BLOOD CELLS
Fever, Direct Trauma,
Blushing, Alcohol Intake
Patchy Areas on Skin OVER Face,
Hands, and Arms
Sclera (White Outer Layer of
Eyeball), Mucous Membranes,
Skin
Face, Area of Trauma, Sacrum,
Shoulders, Other Common Sites
for Pressure Injuries
Areas exposed to SUN: Face,
Arms, Areolas, Nipples
Moisture: Hydration of the Skin
o The Wetness and Oiliness of the Skin
o Skin is normally Smooth and Dry
o Skinfolds are normally moist, such as the axillae
o Causes of excess sweating
 Activity
 Exposure to Warm environments
 Obesity
 Anxiety
 Excitement
o Use ungloved fingertips (Ewwww) to palpitate skin surfaces observe for:
 Dullness
 Dryness
 Crusting
 Flaking that resembles Dandruff
 Excessively dry skin is common in older adults because their Sebaceous and Sweat Gland activity
Decreases, Reducing Perspiration
 Excess dryness worsens existing skin conditions such as Eczema and Dermatitis
 Excessive moisture may cause Maceration of the Skin or Softening of the Tissues, Resulting in an
Increased Risk for Breakdown
Temperature: Depends on the Amount of Blood Circulating through the Dermis
o Increased Skin Temperature indicates Increased Blood Flow
o Decreased Skin Temperature indicates Decreased Blood Flow
o Always check for skin temperature for patients at risk of having Impaired Circulation such as after a Cast
Application or Vascular Surgery.
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NUR 1020 Health Assessment
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Texture: Refers to the Appearance of the Surface of the Skin and how the Deeper layers feel
o Is the skin
 Smooth or Rough
 Thin or Thick
 Tight or Supple
 Indurated (Hardened) or Soft
 Skin is normally Smooth, Soft, Even and Flexible in Children and
Adults
 Skin in Older Patients can become Wrinkled and Leathery because
of a Decrease in Collagen, Subcutaneous Fat and Sweat Glands
Turgor: Refers to the Elasticity of the Skin
o Used to check for Dehydration, Done on the BACK of the FOREARM or STERNAL Area with the fingertips
and Release
o Since the skin on the back of the hand is normally LOOSE and THIN, Turgor is NOT Assessed Reliably at
that Site.
Vascularity: The Circulation of the Skin Affects Color in Localized areas and leads to the appearance of Superficial
Blood Vessels
o Vascularity appears:
o Reddened
o Pink
o Pale
 With aging, capillaries become fragile and more easily injured.
Petechiae are non-blanching, pinpoint-size, red or purple spots on
the skin caused by small hemorrhages in the skin layers. Many
petechiae have no known cause; but some may indicate serious
blood-clotting disorders, drug reactions, or liver disease.
 Edema: (Page 541) Areas where Skin becomes Swollen or
Edematous from a Buildup of Fluid in the Interstitial Space.
o Two common Causes of Edema
 Direct Trauma
 Impairment of Venous Return
 Edematous Skin will Appear STRETCHED and SHINY
 Palpate Edematous areas to determine Mobility,
Consistency, and Tenderness
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When pressure from the examiners fingers leaves
an indentation in the Edematous Area, it is called
PITTING EDEMA
 To assess the degree of Pitting Edema, Press
the Edematous Area FIRMLY with the
THUMB for SEVERAL Seconds and Release
 The Depth of Pitting, RECORDED in
MILIMETERS, Determines the DEGREE of
EDEMA
 1+ Edema = 2 mm Depth
 2+ Edema = 4 mm Depth
 3+ Edema = 6 mm Depth
 4+ Edema = 8 mm Depth
Lesions: Refers Broadly to any unusual finding of the
Skin Surface
o Common Lesions
 Freckles
o Common Age-Related Changes
 Skin Tags
 Senile Keratosis: Thickening of Skin
 Cherry Angiomas: Ruby Red papules
 Atrophic Warts
o Primary Lesions occur as an initial spontaneous sign
of a pathological process such as with a
insect bite
o Secondary lesions result form later formation
or trauma to a primary lesion such as a
pressure injury
o When you find a lesion, collect standard
information
 Its color
 Location
 Texture
 Size
 Shape
 Type
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 Grouping (Clustered or
Linear)
 Distribution (Localized or
Generalized)
o Next observe for:
 Exudate
 Odor
 Amount
 Consistency
o Measure the size of the lesion in
centimeters by using a small, clear,
flexible ruler. Measure each lesion for
height, width, and depth.
o Palpation helps determine the mobility,
contour (flat, raised, or depressed), and
consistency (soft or indurated) of a lesion
o Types of Primary Skin Lesions
 Macule: Flat, nonpalpable change in skin color. Smaller than 1 cm.
 Example: Freckle, Petechiae
 Papule: Slightly Raised, Palpable, Circumscribed, Solid Elevation in Skin. Smaller than 1 cm
 Example: Elevated Nevus
 Nodule: Elevated Solid Mass, Deeper and Firmer than papule. 1-2 cm
 Example: Wart
 Tumor: Solid mass that extends DEEP through Subcutaneous tissue. Larger than 1-2 cm
 Example: Epithelioma
 Wheal Bite: Irregularly Shaped
elevated area or Superficial
Localized Edema. Varies in size
 Example: Hive, Mosquito
bite
 Vesicle: Circumscribed elevation
of skin filled with serous fluid,
SMALLER than 1 cm
 Example: Herpes Simplex, Chickenpox
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NUR 1020 Health Assessment
 Pustule: Circumscribed elevation of Skin
Similar to Vesicle but filled with PUS.
Varies in size
 Example: Acne, Staphylococcal
Infection
 Ulcer: Deep loss of skin surface that
extends to dermis and frequently
BLEEDS and Scars. Varies in size
 Example: Venous Stasis Ulcer
 Atrophy: Scar’s Thinning of skin with loss of normal skin furrow, with skin appearing shiny and
translucent. Varies in Size
 Example: Arterial Insufficiency
 Cancerous Lesions
 Cancerous lesions have distinct features and over time undergo changes in color and size
 Basal cell carcinoma is most common in areas exposed to the sun and frequently occurs with a history
of sun damage; it almost never spreads to other parts of the body
 Squamous cell carcinoma is more serious than basal cell and develops on the outer layers of sunexposed skin; these cells may travel to lymph nodes and throughout the body
 Malignant melanoma, a skin cancer that develops from melanocytes, begins as a mole or other area
that has changed in appearance and is usually located on normal skin
o Note: Melanoma also can originate in noncutaneous primary sites,
including mucosal epithelium [GI tract], retinas, and leptomeninges.)
 In African Americans (more than in other races) it can also appear under
fingernails or on the palms of the hands and soles of the feet
 Use the ABCD mnemonic to assess the skin for any type of carcinoma
A. Basal Cell Carcinoma
 0.5- to 1-cm crusted lesion that is flat or raised and has a rolled, somewhat
scaly border
 Frequent appearance of underlying, widely dilated blood vessels within
the lesion
B. Squamous Cell Carcinoma
 Occurs more often on mucosal surfaces and
nonexposed areas of skin than basal cell
 0.5- to 1.5-cm scaly lesion sometimes ulcerated or
crusted; appears frequently and grows more rapidly
than basal cell
Page 16 of 30
NUR 1020 Health Assessment
C. Melanoma
 0.5- to 1-cm brown, flat lesion; appears on sun-exposed or nonexposed
skin; variegated pigmentation, irregular borders, and indistinct margins
 Ulceration, recent growth, or recent changes in long-standing mole are
ominous signs
Wounds
Assessment
Ask patient about history of changes in skin: dryness,
pruritus, sores, rashes, lumps, color, texture, odor, and
lesion that does not heal.
Consider whether patient has the following history: fair,
freckled, ruddy complexion; light-colored hair or eyes;
tendency to burn easily.
Determine whether patient works or spends excessive
time outside. If so, ask whether patient wears sunscreen
and the level of protection.
Rationale
Patient is best source to recognize change. Usually
skin cancer is first noticed as a localized change in
skin color.
Characteristics are risk factors for skin cancer.
Exposed areas such as face and arms are more
pigmented than rest of body. The American Cancer
Society (2018b) recommends sun safety and use of
sunscreen and lip balm with broad-spectrum
protection and a sun protection factor (SPF) of 30 or
higher and not sunbathing or indoor tanning.
Determine whether patient has noted lesions, rashes, or
Most skin changes do not develop suddenly. Change
bruises.
in character of lesion can indicate cancer. Bruising
indicates trauma or bleeding disorder.
Question patient about frequency of bathing and type of
Excessive bathing and use of harsh soaps cause dry
soap used.
skin.
Ask whether patient has had recent trauma to skin.
Some injuries cause bruising and changes in skin
texture.
Determine whether patient has history of allergies.
Skin rashes commonly occur from allergies.
Ask whether patient uses topical medications or home
Incorrect use of topical agents causes inflammation
remedies on skin.
or irritation.
Ask whether patient goes to tanning parlors, uses
Overexposure of skin to these irritants can cause
sunlamps, or takes tanning pills.
skin cancer.
Ask whether patient has family history of serious skin
Family history can reveal information about
disorders such as skin cancer or psoriasis.
patient’s condition.
Determine whether patient works with creosote, coal, tar, Exposure to these agents creates risk for skin
petroleum products, arsenic compounds, or radium.
cancer.
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NUR 1020 Health Assessment
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Fingernails pics from slides 12 & 13
 Nail Assessment
 Clubbing: Change in angle between nail and nail base (eventually larger than 180⁰); nail bed
softening with nail flattening; often enlargement of fingertips
 Chronic lack of O2 (Heart or Pulmonary Disease)
 Beau’s Lines (Lines in the nails): Transverse depressions in nails indicating temporary
disturbance of nail growth (nail grows out over several months).
 Systemic Infection such as severe infection, Nail injury
 Koilonychia (Spoon Nail): Concave Curves
 Fe, Iron Deficiency anemia, Syphilis, Use of Strong Detergents
 Splinter hemorrhages: Red or Brown Streaks in the nail bed
 Subacute bacterial Endocarditis, Trichinosis, Minor trauma to the nail
 Paronychia: Inflammation of the nail
 Local Infection, Trauma
 Head and Neck:
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
Palpate the Scalp: Normal is called Normal Cephalic
Inspect Scalp and Hair
o Inspect the Color, Distribution, Quantity, Thickness, Texture and Lubrication of Body Hair
o Assess for changes in the thickness, texture, and lubrication of scalp hair
o Conditions such as thyroid disease alter the condition of the hair making it Fine and Brittle
o Hair Loss (Alopecia) (From Malnutrition if easily pluckable) or thinning of the hair is usually related
to genetic tendencies, endocrine disorders such as diabetes, thyroiditis, and menopause
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NUR 1020 Health Assessment
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o The oil of sebaceous glands lubricates the har, but
excessively oily hair is associated with Androgen
Hormone Stimulation
o The three types of lice are
 Pediculus humanus capitis (head lice)
 Greyish White Bodies
 Pediculus humanus corporis (body lice)
 Greyish White Bodies
 Pediculus pubis (crab lice)
 Red Legs
Facial Symmetry: Note if the face is symmetrical, if not take
note. Could be caused by a Neurological Disorder like Facial
Nerve Paralysis
o Eyelids Symmetrical?
o Eyebrows Symmetrical?
o Nasolabial Folds Symmetrical?
o Mouth Symmetrical?
Sinuses Palpation
o Allergies or Infection will cause the interior of the sinuses to become
Inflamed and Swollen
o The most effective way to assess for tenderness is by externally palpating the frontal and maxillary
facial areas
Eyes slide 15 eyes on GAZE: EOM Movements
o PERRLA: Pupils Equal Round Reactive to Light and Accommodation
 Pupils normally constrict when looking at close objects
 Pupils should respond Equally
 Pupils should be Round
 Pupils should React to Light
 Testing for Accommodation is important ONLY if the
patient has a Defect in the Pupillary Response to Light
 If assessment of Pupillary reaction is normal in ALL tests,
record the abbreviation PERRLA
o Convergence: Test for Strabismus Condition where eyes are
unable to work together when looking at Nearby Objects
o Extra Ocular Muscle (EOM): Test for Nystagmus: Up Down Left Right CN3, CN4,
o Six Muscles that Control movment of the Eye
1) Superior Rectus (RS): Look Medialy & Upward
2) Lateral Rectus (LS): Look Laterally
3) Inferior Oblique (IO): Look Laterally & Upward
4) Inferior Rectus (IR): Look Medially & Downward
5) Medial Rectus (MR): Look Medially
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NUR 1020 Health Assessment
6) Superior Oblique (SO): Look Laterally & Downward

Cranial Nerves
1) Olfactory Nerve:
Sensory
2) Optic Nerve: Sensory
3) Oculomotor Nerve:
Motor
4) Trochlear Nerve:
Motor
5) Trigeminal Nerve: Sensory & Motor
 Sensory: To Skin & Face
 Motor: To Muscles of Jaw
6) Abducens Nerve: Motor
7) Facial Nerve: Sensory & Motor
8) Auditory Nerve: Sensory
9) Glossopharyngeal Nerve: Sensory & Motor
10) Vagus Nerve: Sensory & Motor
 Sensory: To Pharynx
 Motor: To Vocal Cords
11) Spinal Accessory Nerve: Motor
12) Hypoglossal Nerve: Motor
 Ears
o The 3 parts of the ear are the External, Middle and Inner ear
o Inspect and Palpate external ear structures which consist of the Auricle, Outer Ear Canal, and
Tympanic Membrane (Eardrum)
o Middle ear is inspected with an Otoscope
o Observe:
 Color
 Discharge
 Scaling
 Lesion
 Foreign bodies
 Cerumen (Ear Wax) color
o Normally cerumen is dry (light brown to gray and flaky) or moist (dark yellow or
brown) and sticky.
o Dry cerumen is common in Asians and Native Americans
o A reddened canal with discharge is a sign of inflammation or infection.
 Inspect Nose: Inspection and Palpation
o Penlight is used to examine each Naris
o More detailed examination requires use of Nasal Speculum to inspect the deeper nasal turbinates
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NUR 1020 Health Assessment

o When inspection the external nose observes for:
 Shape
 Size
 Skin Color
 Presence of Deformity or Inflammation
o Normal mucosa is pink and moist without lesions
o Pale mucosa with clear discharge indicates Allergy
o A mucoid discharge indicates rhinitis (Inflammation of Mucus Membrane)
o An Infection (viral or bacterial) results in
 Yellowish or Greenish discharge
 Red in Color with no discharge
Mouth: Determine patients Oral Hygiene needs and therapies needed
o Use a Penlight and Tongue Depressor or gauze square
o Observe teeth
o Is smile symmetrical? If so, does it show normal facial nerve function?
o Note color of teeth
 Cavities
 Tartar
 Extraction Sites
o Older Adults:
 Often loose teeth due to Bone Resorption Increases
 Teeth also feel rough when tooth enamel calcifies
 Yellow or darkened teeth are also common due to general war and tear that exposes the
Darker Underlying Dentin
o Inspect Mucosa
 Color
 Hydration
 Texture
 Lesions
o Ulcers
o Abrasions
o Cysts
o Inspect Buccal Mucosa
 Should be
o Glistening
o Pink
o Soft
o Moist
o Smooth
 Patients who smoke cigarettes, cigars, or pipes and those who use smokeless tobacco
o Have an increased risk
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Oral
Pharyngeal
Laryngeal
Esophageal cancer oral, pharyngeal, laryngeal, and esophageal cancer. These
individuals may have leukoplakia or other lesions anywhere in their oral
cavity (e.g., lips, gums, or tongue) at an early age. These usually appear as
cream-white patches throughout the inner mouth area.
Lips
o Anemia (Deficiency of Red Blood Cells or Hemoglobin in the Blood) causes Pallor (Skin turning Pale)
o Respiratory or Cardiovascular problems cause Cyanosis
o Carbon Monoxide Poisoning Causes Cherry-Colored Lips
 Neck
o ROM: Range of Motion
o Lymph Nodes: Extensive system of Lymph Nodes Collects Lymph from the
Head, Ears, Nose, Cheeks, and Lips
 An abnormality of superficial lymph nodes sometime reveals the
presence of an infection or Malignancy
 With patients Chin Raised and head tilted slightly, First inspect the area
where lymph
nodes are
distributed and
compare both
sides
 Check for:
o Enlarged
Nodes
o Edema
o Erythema
o Red
Streaks
 Nodes are normally NOT VISIBLE
 A = Palpation of preauricular lymph nodes
 B = Palpation of supraclavicular lymph nodes
Palpate Trachea: Part of the upper Respirotory System and you DIRECTLY PALPATE
 Normally Located in the Midline above the suprasternal notch
 Masses in the neck or mediastinum and pulmonary abnormalities cause displacement laterally
 Have Patient Sit or Lie Down DURING Palpation
 Determine the position of the trachea by palpating at the suprasternal notch, slipping the thumb and
index fingers to each side
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NUR 1020 Health Assessment
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 Palpate Carotids
 Auscultate Carotids
Assess for JVD: Jugular Vein Distention
 Increased pressure in the Superior Vena Cave
 RIGHT HEART FAILURE
Chest: Lungs
 Diseases of the Lungs affect other body systems. Ex. the Brain is VERY
Sensitive to Oxygen Levels
 The number of each intercostal space corresponds with that of the rib just
above it
 Use Auscultation to assess the movement of air through the
Tracheobronchial Tree an DETECT Mucus or Obstructed Airways
 Breath Sounds
 Anterior: Bronchial, Bronchovesicular, Vesicular
 Posterior: NO Bronchial Sounds, Will Hear Bronchovesicular, & Vesicular
 Define Chest Sounds: pg 552 table 30.30
 Bronchial sounds
 Well Sounds:
 Coarse, Loud
 ILL Sounds:
 Rhonchi: Coarse, LowPitched
 May clear with cough
 Bronchovesicular
 Well Sounds:
 Combination
Bronchial and Vesicular, Normal in some areas
 ILL Sounds:
 Wheeze: Whistling, High-Pitched Bronchus
 Bronchial: Coarse, Loud, Heard with Consolidation
 Vesicular
 Well Sounds:
 Low-Pitched, Breezy
 ILL Sounds:
 Rub: Scratchy, High-Pitched
 Crackles: Fine Crackling, High-Pitched
 Adventitious Breath Sounds
o Crackles
o Rhonchi
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NUR 1020 Health Assessment
o Wheezes
o Pleural Friction Rub
Breathing Sounds
Sound
Crackles
Site Auscultated
Most common in
dependent lobes:
Right and Left Lung
Bases
Cause
Random, Sudden
Reinflation of groups of
Alveoli; Disruptive
passage of Air through
Small Airways
Rhonchi
(Sonorous
Wheeze)
Primarily heard
over Trachea and
Bronchi; If Loud
Enough, ABLE to
be heard over
MOST Lung Fields
Heard over all lung
fields
Muscular spasm, fluid,
or mucus in larger
airways; new growth or
external pressure
causing turbulence
Wheezes
(Sibilant
Wheeze)
Constrictive
Broncus
Pleural
friction rub
High-velocity airflow
through severely
narrowed or obstructed
airway
Character
 Fine Crackles are High-Pitched Fine, Short,
Interrupted Crackling Sounds heard during end
of Inspiration; usually NOT Cleared with
Coughing
 Medium Crackles are Lower, Moister Sounds
Heard during Middle of Inspiration; NOT
Cleared with Coughing
 Coarse Crackles are LOUD, BUBBLY Sounds
heard during inspiration; NOT Cleared with
Coughing
Loud, low-pitched, rumbling, coarse sounds are
heard either during inspiration or expiration;
sometimes cleared by coughing
High-pitched, continuous musical sounds are like a
squeak heard continuously during inspiration or
expiration; usually louder on expiration.
Heard over
anterior lateral
lung field (if patient
is sitting upright)
Inflamed pleura; parietal Dry, rubbing, or grating quality is heard during
pleura rubbing against
inspiration or expiration; does not clear with
visceral pleura. Inflamed
coughing; heard loudest over lower lateral anterior
Pleure rubbing on Chest
surface.
Wall
 If abnormalities in tactile fremitus (Vibration transmitted through the body) or auscultation, Perform the Vocal
Resonance Test (Spoken and whispered Voice Sounds)
 Place the Stethoscope over the same Locations used to assess breath sound and have the patient say
“Ninety-Nine” in a normal voice tone
 Should sound MUFFLED if NO Fluid is in cavity
 If Fluid in compressing the lung, the voice will be transmitted through the chest wall and will
sound CLEAR (Bronchophony)
 Whispered voice
 Should sound Faint and Indistinct if no abnormalities exist
 If abnormalities exist voice will become CLEAR and DISTINCT (Whispered Pectoriloquy)
 Respirations
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NUR 1020 Health Assessment
 Healthy Men and Children usually demonstrate Diaphragmatic Breathing
 Women tend to use Thoracic Muscles to Breathe, Assessed by observing movements in the upper chest
 Labored Respirations usually Involve the Accessory Muscles of Respiration Visible in the Neck
 Unlabored Respirations are normal breathing
 O2 Saturation is Usually between 95% and 100%
 Chest Shape: Normal (In Book pg. 550, 1/3 to 1/2) 2:1 Diameter
 Measuring across chest from left to right is twice as big as the Anteroposterior (A/P) diameter (Front to
Back Measurement)
 Barrel Chest
 Can be caused when CO2 is retained and now the diameter is 2:2
 Anteroposterior diameter equals transverse diameter
 Chest Excursion: Depth of Breathing
 Place hands on along the spinal processes at
the 10th rib
 Thumbs 5 cm (2 in) apart pointing toward the
spine, fingers pointing laterally
 Inhalation will separate the thumbs
 Chest Symmetry: Symmetrical Excursion
 Tactile Fremitus and Symmetrical Excursion
Heart
Locate and Discuss
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Each cycle of the S1 and S2 are the “Lub-Dub” sound
S1: First Heart Sound (Heard BEST at APEX)
 At normal rates S1 occurs after the Long
Diastolic Pause and Before the Short Systolic
Pause
 S1 is HIGH PITCHED, DULL in quality, and heard
BEST at the APEX
 If it is difficult to hear the S1 time it in relation to
the Carotid Pulsation
S2: Second Heart Sound (Heard BEST at BASE)
 Follows the Short Systolic pause and proceeds the
long diastolic pause
 BEST Heard at the AORTIC Area
Normally will not see pulsation EXCEPT perhaps at eh PMI
(Point of Maximal Impulse or Apical Impulse)
Follow a systematic pattern, beginning at the Aortic area and
inching the Stethoscope across each of the anatomical sites
o Auscultation sites: Know Locations and How to!!!
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o Aortic Valve: Right 2nd ICS
o Pulmonic Valve: Left 2nd ICS
o ERB’s Point: Left 3rd ICS
o Tricuspid Valve: Left 4th or 5th ICS
o Mitral Valve/Apex: Left 5th ICS Mid Clavicular
ERB’s Point: Left 3rd ICS
PMI (Point of Maximal Impulse or Apical Impulse)
 Area where the apex touches the anterior
chest wall at approximately the fourth to fifth
intercostal space just medial to the left
midclavicular line
Apex
o Breasts
o Axilla
Abdomen
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Inspect, Auscultate for abdominal organ sounds, Palpate
Add Pic from PP
Quadrants, Belly button is the Center Point
Auscultate Abdomen in this order!
1) Right Lower Quadrant
o Your Ileocecal Valve: Fluid is rushing into Large Intestine from Small Intestine
o Listen for one sound, wait for second sound. Amount of Time BETWEEN the 2 Sounds
2) Right Upper Quadrant
3) Left Upper Quadrant
4) Left Lower Quadrant
 Contour:
 Flat Abdomen forms a Horizontal Plane from the Xiphoid Process to the Symphysis Pubis
 Protuberant: Bulging of the abdomen
 Size: Round
 Pain assessment
 Note if patient’s posture while lying in bed with knees drawn up, or moving restlessly
 A patient free of abdominal pain does not guard or splint the abdomen
 Stand on the patient’s RIGHT side and inspect from above the abdomen, assess abdominal contour
 Bowel Sounds: Audible Passage of Air and Fluid that Peristalsis (Movement of contents through the
intestines) Creates
 Normal Bowel Sounds range from 5 to 35 per min
 Normally take 5-20 seconds to hear a Bowel Sound
 It TAKES 5 MINUTES OF CONTUNIOUS LISTENING TO DERTERMINE THAT BOWEL SOUNDS ARE
ABSENT: Sometimes common after abdominal surgery
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
Ileus: No Movement of Bowles
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Hypoactive: > 20 Seconds
 May be common after surgery following anesthesia
 Normoactive 5 – 20 Seconds from one sound to the next
 Hyperactive: < 5 Seconds
 Growling Sounds called Borborygmi indicate Increased GI motility and can be caused by:
 Inflammation of the Bowel
 Anxiety
 Diarrhea
 Bleeding
 Excessive Ingestion of Laxatives
 Reaction of the Intestines to certain foods
 Tenderness: Area and Number
Press hand slowly and deeply into the involved area and letting go quickly; if discomfort is present, then the
test is positive
Rebound tenderness occurs in patients with peritoneal irritation such as occurs in Appendicitis; Pancreatitis;
or any peritoneal injury causing Bile, Blood, or Enzymes to enter the Peritoneal Cavity
 Palpate Bladder: Symphysis Pubis
Make sure patient EMPTYS Bladder so the Uterus and Ovaries are readily Palpable
Breast exam
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Nipple retracted or any discharge, its typically Breast Cancer
Symmetry
Nipple and Areola discharge
Slides about inspection
Note shape and size of abnormal findings
Genitalia


Female: Inspect for symmetry, inflammation,
edema, lesions, or lacerations
Male
o Palpate any lesion gently to note
tenderness, size, consistency, and
shape
o A patient who has lain in bed for a
prolonged time sometimes develops dependent edema in the penis shaft
Page 27 of 30
NUR 1020 Health Assessment
Musculoskeletal
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Observe patient’s Gait (How they walk)
The assessment of Musculoskeletal Function FOCUSES on Determining RANGE
of Joint Motion, Muscle Strength and Tone, and Joint and Muscle Condition
Musculoskeletal assessment can be performed as a sperate examination or
integrated with other parts of the total physical examination
Assessing musculoskeletal integrity is especially important when a patient
reports pain or loss of function in a joint or muscle
Muscular disorders are often the result of neurological disease
Is the foot dragging, limping, shuffling? What is the position of the trunk in relation to the legs?
Kyphosis (Hunchback): Exaggeration of the posterior curvature of the thoracic spine
Lordosis (Swayback): An Increased lumbar curvature
Scoliosis: Lateral spinal curvature
Osteoporosis: Systemic Skeletal Condition that is noted to have both decreased bone
mass and deterioration of bone tissue, making bone Fragile and at Risk for Fracture
Nervous
Peripheral Vascular
Extremities


ROM Range of Motion Present?
Do not do Homan!
o Flexion: Movement Decreasing angle between two adjoining bones; Bending
of Limb
 Ex: Elbow, Knee, Fingers
o Extension: Movement Increasing angle between two adjoining bones
 Elbow, Knee, Fingers
o Hyperextension: Movement of Body Part Beyond its Normal Resting Extended Position
 Head
o Pronation: Movement of Body part so the Front
of Ventral surface faces DOWNWARD
 Hand, Forearm
o Supination: Movement of Body part so the Front
of Ventral surface faces UPWARD
 Hand, Forearm
o Abduction: Movement of Extremity AWAY from
Midline of Body
 Leg, Arm, Fingers
o Adduction: Movement of Extremity TOWARD
Midline of Body
 Leg, Arm, Fingers
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o Internal Rotation: Rotation of Joint Inward
 Knee, Hip
o External Rotation: Rotation of Joint Outward
 Knee, Hip
o Eversion: Turning of body part AWAY from midline
 Foot
o Inversion: Turning of body part TOWARD midline
 Foot
o Dorsiflexion: Flexion of toes and foot UPWARD
 Foot
o Plantar Flexion: Bending of toes and foot DOWNWARD
 Foot
o
Capillary refill: Normal is 2 seconds
Muscle strength Scale
Muscle Function Level
Grade
% Normal
Lovett Scale
No evidence of Contractility
0
0
0 (Zero)
Slight Contractility, No Movement
1
10
T (Trace)
Full Range of Motion, Gravity Eliminated
2
25
P (Poor)
Full Range of Motion with Gravity
3
50
F (Fair)
Full Range of Motion Against Gravity, Some Resistance
4
75
G (Good)
Full Range of Motion Against Gravity, Full Resistance
5
100
N (Normal)
 Discuss the documentation of findings in narrative nursing notes format, identifying acceptable terminology
and abbreviations and following head-to-toe format
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Peripheral pulses: Pulses that can be felt whenever an Artery passes over a Solid Structure
Page 30 of 30