Health
Assessment
Flashcards
FIRSTEDITIONI COPYRIGHT
2020
Health Assessment
• Head-to-Toe Health
Assessment (1-30)
e ere ce G ide (31-
)
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In the Head-to-ToeAssessmentsection of the deck (cards 1-30)
L-.:._J you will notice the cross-referencecard icon on some cards. The
numbers in the icon tell you which card or cards in the Reference
Guide section to use for more information on a key aspect of
the Assessment. For example, the cross-referenced card might
include normal ranges, expected/unexpectedresults, and detailed
assessmenttechniquesthat support the Assessment.
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Throughout the flashcard deck, you will find key facts called out
with a magnifyingglass. You definitely need to know these facts!
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When you see the "cool chickenn,we are highlighting a fun or
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Health Assessment
Part One
Head-to-Toe
Assess,ment(1-30)
Whatis in it: This section helps
nurses and nursing students
understandthe key steps in
performinga comprehensive
head-to-toe patient assessment. It
provides informationon WHATto
assess and HOW to assess each
component.
Howto useit: Get used to the
flow of a complete head-to-toe
assessmentwithout getting bogged
down in too much detail about each
assessmentcomponent.
Health Assessment
Part One
Includes:
•
•
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•
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General Survey
Vital Signs
Pain Assessment
Skin and Nail Assessment
Head, Face, Neck, Lymphatics
Eyes, Ears, Nose, Mouth/Throat
Posterior and Anterior Chest
Neck Vessels and Heart
Abdomen
Musculoskeletal System
Nervous System
Physical Assessment Components
Inspection, Palpation, Percussion, Auscultation
1
Health Assessment
Physical Assessment Components
Assessment
What is Included?
Ins ection
Use of touch to assess for temperature, turgor, texture, moisture,
vibrations, shape, size. Use dorsal surface of hand to assess
temperature. Use palmar surface of hand to assess for texture,
Palpation
shape, size, vibration.
jJ)Assess most tender areas last.
rPercussion
Ta in a erson's skin to assess location, size, densi of tissues. ~
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Auscultation Listening with a stethoscope to assess pitch, loudness, quality and ~
duration of bod sounds.
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1--------+-----------------------------tm
Assessment techniques as defined by Fundamentalsof Nursing, Seventh Edition, Lippincott Williams & Wilkins.
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Normal order: Inspect, Palpate, Percuss, Auscultate.
Order for abdominal assessment: Inspect, Auscultate, Percuss, Palpate (this
avoids altering bowel sounds).
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Beginning an Assessment
Key steps for communicating with your patient
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Health Assessment
Beginning an Assessment
1. Perform hand hygiene.
2. Make your presence known (knock on the door).
3. Introduce yourself and state your job title (nurse, tech, nurse assistant).
4. Identify the patient using two patient identifiers (name, date of
birth, MRN#).
ji) Note: room number is NOT a valid patient identifier.
5. Tell the patient why you are there and how long it will take.
6. Explain the reason for the assessment.
7. Determine if they have allergies.
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Patient communication: AIDET (Acknowledge your presence, Introduce
yourself, Duration of the assessment, Explain the reason for assessment,
Thank you).
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Health Assessment
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General Survey
Key observations regarding Physical Appearance,
B,ody Structure/Mobility, Behavior
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Health Assessment
General,Survey
Physical Appearance:Assess level of
# 31- 32
cor1scious11ess,
age, gender expression, facial features,
signs of distress.
Body Structure/Mobility:Assess gait, posture, range of
motion, use of assistive devices, nutritional status, obvious
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deformities.
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Behavior:Assess mood/affect, eye contact, speech, dress, l
grooming.
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Health Assessment
Vital Signs: TemQerature
How to take oral, temporal, tympanic, axillary,
rectal temperature
4
Health Assessment
Vital Signs - Temperature
Oral: Place probe beneath patient's tongue in the posterior
sublingual pocket. Ask the patient to close lips around probe.
Temporal: Slide probe from the center of the forehead laterally to the
hairline.
Tympanic:For adults pull the pinna up and back, < 3 years old pull
the pinna down and back. Angle thermometer towards the patient's jaw
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line. Note: Ear wax can impact tympanic temperature.
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Axillary: Place probe in center of the axilla. Have patient bring down
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arm close to the body.
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Rectal: Place patient in Sims position, use lubrication and insert -1".
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Health Assessment
Vital Signs: Pulse
What to assess?
How to take radial and apical pulse?
What is the pulse deficit?
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Health Assessment
Vital Signs - Pulse ~--~
Assess:Rate, Rhythm(regularor irregular), Equality (right ~
vs. left side), and Strength(0-4).
• Radial:Palpate using the index and middle finger on the wrist
closest to the thumb.
Apical:Auscultateusing the diaphram of the stethoscopeat
the fifth intercostal space at the left midclavicular line.
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• Pulse deficit = Apical pulse - radial pulse.
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NOTE:For a regular pulse, take for 30 seconds and multiply by
2. Count for a full minute if the pulse is irregular or if the patient
is taking cardiac medications.
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Health Assessment
Vital Signs: Respirations
What to assess?
How to assess?
6
Health Assessment
~ ~~·
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.~--·,.~~ ~ . Vital Signs - Respirations
Assess: Rate, Depth (deep, shallow), Rhythm
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(regular, irregular).
• While your fingers are still in place after taking the
patient's pulse, observe the rise and fall of the patient's
chest without mentioning that you are counting
respirations.
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• For a regular rate, count for 30 seconds and multiply by ~
2. For an irregular rate, count for a full minute.
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NOTE: Also assess pulse oximetry reading if applicable.
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Vital Signs: Blood Pressure
How to assess?
Key points regarding taking blood pressure.
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Health Assessment
Vital Signs - Blood Pressure
-~-~~~--~
AsHHing a brachia!arteryblood Pressure:
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• Estimate the SBP: Palpate the radial pulse and inflate the cuff until the
pulse disappears.Note this point on the gauge.
• Deflate the cuff,wait one minute.
• Place stethoscope over brachial artery. Inflate the cuff 30mmHg past the
estimated SBP. Release pressure and note when you hear the first sound
(SBP) and when the sound disappears(DBP).
Key points:
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(i) BP cuff sizing: The BP cuff width should be 40% of arm circumference.
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Bladder should surround 80% of arm circumference. If it is too large,
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you will get a falsely low reading. If it is too small, you will get a falsely high ~
reading.
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Do not take blood pressure on an arm with an IV infusion running or ~
where a patient had/has a mastectomy, PICC line, or AV fistula.
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Vital Signs: Orthostatic Hypotension
When and how to assess?
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Health Assessment
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Vital Signs - Orthostatic Hypotension
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When to assess for orthosl3tic hypotension:
• Take orthostaticvital signs when ordered by the provider.
• Indications:Patient report of fainting/syncope,hypovolemia, certain
medications(ex: antihypertensivemedications).
How to assess for orthostatic hypotension:
• Have the patient lie in the supine position for 5-10 min. Take the
patient's BP and pulse in the supine position.
•
• Sit patient up, wait 2-3 min, and take patient's BP and pulse sitting. !
• Have the patient stand up, wait 2 min, take the patient's BP and
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pulse standing.
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• Monitor for dizziness,weakness, fatigue during assessment.
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• Evaluate BP changes for the presence of orthoscanc (po tu1a
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hypotensio11.
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Pain Assessment
Components of Pain Assessment
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Health Assessment
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• Locationof pain?
• Quality of pain (patient'swords for describingthe pain).
•
• describedas ..aching" or "throbbing".
Neuropetc pandescribedas ..shooting", "burning".
• Intensityof pain: use appropriate :> ,n c I .
• Timing (onset duration,frequency).
• Effect of pain on the patient'sADLs.
• Accompanyingsymptoms(ex: nausea).
• What relievesthe pain?
• What makes the pain worse?
Skin nd
ails
What to assess?
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Health Assessment
Skin and,Nails
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Skin:
•
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Note kin olor. Appropriatefor ethnicity?
Is the skin warm and dry to the touch?
Assess for
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Assess for I 101 , incisions.wounds. rashes.
Note tattoos and piercings.
Assess for skin tenting by lifting the skin on the sternum or forearm.
Tentingcan indicatedehydrationand/or aging.
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Nails:
• Pink, no clubbing,no discoloration,clean?
• Capillary refill under two seconds?
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What to assess?
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Health Assessment
HudandF c
Haag:
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• Is It norm~~
lie and midi ne?
• Assessfor lesk>ns.
lumps.tenderness.
Infestations.
• Palpatethe
ularjoint (TMJ)when the patientopens
and closes his/hermouthfor crepitus.tenderness.
face:
• Are facial features
ri t?
• Is the p tient's , ~~c·on appropriatefor the situation?
• Assessfor involuntarymo ements.
• Palpate the frontal and maxillary sinuses, assessfor tenderness.
If indicated,assess
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N1eck
What to assess?
12
Health Assessment
Neck
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•
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Does the patient have full range of motion?
Is the trachea midline?
Assess for visible pulsations or masses.
Palpate the thyroid from posterior, ask them to
swallow. Should be symmetrical with no enlargement,
tenderness, or nodules.
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If indicated, assess cranial nerve XI (Spinal Acee
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Regional Lym(?hatics
Lymph nodes to assess in the head/neck
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Health Assessment
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Regional Lymphatics
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Palpatethe lymph nodesfor lymphadenopathy:
• Normal lymph nodes are moveable,soft, nontender,and
<1cm
• Lymphadenopathyis enlarged,tender, hard lymph nodes.
This can indicate infection, allergy, or neoplasm.
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Assessthe followinglymphnodes:preauricular,
postauricular,occipital, submandibular,submental,
jugulodigastric, superficialcervical, posterior cervical, deep
cervical, and supraclavicular(see illustrationon next card).
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Health Assessment
Head/Neck L~mph Node Locations
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Health Assessment
Head/Neck Lymph Node locations
Lymph
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NodeLocations:
Preauricular
Postauncular
Occipital
Submandibular
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• Jugulodigastric
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, cervical
• Posterior cervical
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• Sup, aclav,cufar
Preauricular
Oec;pital
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Posterior Cervicnl
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E~es
What to assess?
15
Health Assessment
Eyes
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Are they symmetrical?
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Is the conjunctiva pink and the sclera white?
Assess for swelling, lesions, and discharge.
Check eyeballs for protrusion or sunken appearance.
PERRLA (Pupils are Equal, Round, Reactive to Light and
Accommodation).
° Check for pupillary light reflex by asking the patient to look straight ,
ahead. Advance light from the side. Note constriction of both pupils. !
° Check for accommodation by asking the patient to focus on a
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distant object (pupils dilate), then to a near object (pupils constrict). ~
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If indicated, assess cranial nerve II (optic), cranial ne,ve Ill (oculor11otor
cranial nerve JV (troc/7/ear),cranial nerve VI (abducen").
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Ears
What to assess?
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Health Assessment
Ears
• Assess for alignment and symmetry.Top of auricles should be at ~
the same height as the inner canthus of the eyes.
• Inspect external ear (pinna, tragus, and mastoid process) for swelling,
redness, discharge.
• Pull pinna up and back for adults and children > 3 years old. Pull pinna
down and back for children < 3 years old.
• Insert otoscope 1cm to inspect external canal and tympanic
membrane.
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External canal:Cerumen is an expected finding. Check for swelling, ~
erythema, lesions, discharge.
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membrane:
Pearly gray, intact, no bulging. Light reflex ~
at 5 o'clock on right ear and 7 o'clock on left ear.
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If indicated,assessctanial nerve VIII (vestibulocochlear/a 'OU t, .
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Health Assessment
Nose
What to assess?
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Health Assessment
Nose
#43
• Is it symmetrical, midline, and proportional to other
facial features?
• Assess for lesions, drainage, and bilateral patency.
• Gently lift up on the tip of the nose and insert an otoscope to
inspect the nasal cavity.
• Inspect septum (check for deviated septum) and turbinates.
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Assess for the presence of foreign objects, swelling, or
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If indicated, assess cranial ne,ve I (olfactory).
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Mouth/Throat
What to assess?
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Health Assessment
Mouth/Throat
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#52-531
• Assess lips for color, hydration status
1 #55
(pink/moist vs. dry/cracked), and lesions.
• Assess for missing teeth.
• Are the gums, oral mucosa, buccal mucosa pink and moist
with no lesions or cracking?
• Is the tongue midline?
• Assess for lesions on and underneath the tongue.
• Assess palate for odor, color, moisture, and lesions.
If indicated, assess cra11ial ne,ve IX (glossopha1y11ge ·,
11e,vex (vagus), and crat,ial 11e1ve XII (l1ypoglos a .
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Posterio r Chest
1
Inspection, Palpation, Percussion
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Health Assessment
Posterior Chest - lnspecti·on, Palpation,, Perrcussion
.
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Inspection:
'1141-42
,
#56
• Inspect skin for cleanliness and ,~<;inns.
• Check anteroposterior to transverse diameter (AP:T) ratio (1 :2 is
expected).
Palpation:
• Palpate for tenderness and masses.
• Assess for symmetrical chest expansion.
• Test for tactile fremitus by placing your hands on the patient's
back and having them say "ninety-nine" each time you move your
hands.
Percussion:
• P rcuss lungs.
• Percuss for CVA (costovertebral angle) tenderness.
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Posterior Chest
Auscultation
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Health Assessment
Posterior Chest
Auscultate all lung sounds using the diaphragm
of the stethoscope (using the below "S" pattern).
Are bilateral breath sounds equal and clear?
,#56-57
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Health Assessment
Anterior Chest
Inspection, Palpation, Percussion, Auscultation
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Health Assessment
Anterior Chest
Inspection:
#ss-s1
• Assessfor use of accessorymuscles,retractions,shortnessof
breath.
• Assessfor symmetryand visible pulsations.
Palpation:
• Palpatefor symmetricalchest expansion.
• Palpatefor tendernessand masses.
• Assess for tactile fremitus.
Percussion:
• Percussanteriorchest.
Auscultation:
• Auscultatebreath sot1ncls.
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Neck Vessels
Inspection, Palpation, Auscultation
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Health Assessment
Neck Vessels
Inspection:
• Assess for Jugular Venous Distention (JVD).
Position the patient at a 30-45° angle and inspect the
jugular with a penlight.
Note visible pulsations or signs of JVD.
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Palpation:
• Palpate each carotid pulse (one at a time!).
Auscultation:
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• Use the bell to listen for any bruits (swishingsound,which is 3
an indicationof cardiovasculardisease).Ask the patientto
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inhale, exhale,and hold his/her breathwhile you listen.
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Heart
Inspection, Palpation, Auscultation
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Health Assessment
Heart
Inspection:
• Observe for lifts and heaves.
Palpation:
• Palpate acrossthe precordiumfor thrills.
Auscultation:
• Auscultate with diaphragmAND bell.
• Identify rate/rhythm.S1 and S2 sounds. Listen for extra heart
sounds, munnurs at 5 locations (APETM):
Aortic valve: 2nd intercostalspace, right sternal border.
Pulmonic valve: 2nd intercostalspace, left sternal border.
Erb's point: 3rd intercostalspace, left sternal border.
Tricuspid valve: 4th intercostalspace, left sternal border.
Mitral valve (point of maximum impulse): 5th intercostalspace,
left midclavicularline.
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Heart
Auscultation Sites
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Health Assessment
Heart Auscultation Sites
; Hint: "All People Enjoy Times Magazine" or "All Physicians
Eagerly Take Money".
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Health Assessment
Abdomen
Inspection, Auscultation, Percussion, Palpation
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Health Assessment
Abdomen
Inspection:
,
• Assess the contour of the abdomen, the umbilicus.
• Assess for lesions, scars, striae.
• Assess for distention, visible pulsations, and symmetry.
Auscultation:
• Auscultate bowel so,.1nds in all four quadrants: RLQ, RUQ, LUO, LLQ.
• Use the bell to listen for bruits over the abdominal aorta.
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percussion:
• Percuss the liver for size.
Palpation:
• Palpate each quadrant and assess for muscle guarding, rigidity,
masses, and tenderness.
jD Palpate tender areas LAST.
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Musculoskeletal system
Inspection/Palpation, Spinal Curvatures,
Range of Motion, Muscle Strength
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Health Assessment
~Musculoskeletal
Inspection/Palpation:
#59-61
• Assess joints for heat, erythema, swelling, masses, deformities.
Spinal Curvatures:
• Check for normal curvatures of t/Je spine.
Range of Motion:
• Use active or passive ROM as appropriate. Assess for pain,
crepitus.
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• Check for appropriate joint n1overnents.
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Muscle Strength:
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• Have the patient resist against your opposing force.
• Assign grade 0-5 for muscle strength (5 = full ROM, full resistance). ~
Muscle strength should be equal bilaterally.
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Upper Extremities
Inspection, Palpation, ROM, Muscle Strength
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Health Assessment
------~------~~-~-~
Upper Extremities -~-~-~-
Inspection:
• Inspect arms for symmetry, co/or, edema, deformities,
venous patterning.
Palpation:
• Assess temperature, swelling, tenderness.
• Palpate ulnar, radial, brachia/ pulses.
• Palpate epitrochlear lymph nodes.
• Check capillary refill.
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Check Range of Motion and Muscle Strength.
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Lower Extremities
Inspection, Palpation, Auscultation,
ROM, Muscle Strength
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Health Assessment
Lower Extremities
Inspection:
.#3:1o
• Inspect legs for symmetry, color, edema, deformities, varicosities.
• Assess hair distribution on the legs.
Palpation:
• Assess temperature, swelling, tenderness.
• Palpate the femoral. popliteal. dorsa/1s pedis, postenor t b1al pt
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Note any deviation from upper extremity pulses.
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• Palpate inguinal lymph nodes.
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Auscultation:
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• Auscultate femoral pulse for bruits.
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Check Range of Motion and Muscle Strength.
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Nervous System
Balance, Coordination, Sensory Function, Reflexes
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Health Assessment
ervous System
#63-64
aa1ance:
•
Assess
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gait,
,
tandemwalk
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(heel-to-toe
walk).
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Coordination:
• Rapidaltematingmovements
(finger
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finger,finger-+ nose, heel -. shin).
Sensory:
• Assess sensoryresponseto sharp/duH.light touch, vibration.
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Reflexes:
• D ~Ptt ndon , fl
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: Checkthe followinglocations:biceps,tri-
ceps, brachioradialis,pateHar,achilles.
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Health Assessment
Closing Remarks & Safet~ Checks
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Health Assessment
Closing Remarks & Safety Checks
•
•
•
•
•
Reassess pain level.
Explain to the patient you are done with the exam.
Ask if they have any questions, offer comfort measures.
Ask if there is anything else you can do for them.
Ensure the bed is in the lowest position, call button is
within reach, and the bed alarm is set (if applicable).
• Make sure the appropriate number of side rails are up.
Putting up all 4 side rails poses a safety risk for
patients who will try to get out of bed on their own.
• Thank the patient for their time.
• Perform hand hygiene upon exiting.
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