Health Assessment
Chapter 25
Competencies for Ch 25, Health
Assessment
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By the end of this unit, the student will:
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Demonstrate techniques to obtain patient
information
Describe the components of a health assessment
Describe how to prepare the patient for the exam
List the equipment needed for an examination
Demonstrate a brief head to toe physical
assessment
Health Assessment

Two components of the health
assessment
 Health History
 Physical Assessment
What happens during a health
assessment between a patient and
nurse?
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Establish the nursepatient relationship
Gather dataphysiological,
psychological,cognitive,
sociocultural,
developmental, spiritual
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Identify patient
strengths
Identify actual and
potential health
problems
Establish a base for
the nursing process
(Assessment)
General Guidelines for Physical
Assessment
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Instrumentation
Positioning
Draping
Preparation of the environment
Patient preparation
Techniques of physical assessment
Positioning
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Sitting –used in an
upright chair or dangling
off exam table
Supine-lie flat on your
back
Dorsal recumbent-lie
back with knees bent
Sims’s-lies on either right
or left side lower arm
behind the body and the
upper arm is bent at the
shoulder and elbow and
knees are both bent
•Prone-Pt. Lies on
abdomen
•Lithotomy- patient is
in a dorsal recumbent
position with buttock at
the edge of the
examining table and
feet support in stirrups.
•Knee to Chest-using
the knees and chest to
bear the weight of body.
•Standing
Draping, preparing the environment
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Draping prevents
unnecessary exposure,
provides privacy, and
keeps the patient warm
during the physical
exam (P.E.).
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Prepare examination
table
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Place a gown and drape on
the table
Set up any supplies that
are needed.
-Example: otoscope,
tuning fork,
ophthalmoscope.
Pull curtain around or
close door to exam room
Techniques for examination
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Inspection- observing, listening or smelling to
gather data
Palpation-assessment that uses sense of touch
Percussion-act of striking on e object against
another to produce a sound
Auscultation-act of listening with a stethoscope to
sounds produced with in the body.
Inspection
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Deliberate,
purposeful,
observations in a
systematic manner
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Nurse use the
physical senses:
visualizing,
hearing, and
smelling
Instrumentation or Equipment used
for inspecting
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Ophalmoscope
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Exam the eyes
Otoscope- examine the
ears, mouth and nostrils
Tuning fork - hearing
Nasal speculum-visualized
the turbinates of the nose
Stethoscope
Instrumentation or Equipment used
for
vision screening
Snellen chart- used
to check eye sight
Palpation
technique using the sense of touch
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The hands and fingers are sensitive tools and
assess:
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Temperature- use the dorsum of the hand
Turgor
Texture
Use the palmer (front side) of
Moisture
the hand
Vibrations
Shape
Percussion-the act of striking one object against
another to produce a sound
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Percussion tones are
used to assess
location, shape, size
and density of tissue
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Percussion Tones
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Flat
Dull
Resonance
Hyper resonance
Tympany
Auscultation-act of listening with a stethoscope to
sounds produced with in the body
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Four characteristics assessed by auscultation
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Pitch- ranging from high to low
Loudness- ranging from soft to loud
Quality- gurgling or swishing
Duration (short, medium, long)
General Survey
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Gather information
regarding
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Patient's appearance,
behavior
Measuring vitals signs
Height, and weight
General appearance
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Gender and race
Body build, posture and
gait
General appearance
 Hygiene, grooming
(note body odor,
cleanliness).
 Signs of illness
 Affect, mood, attitude
(speech and facial
expressions)
 Cognitive process
(speech content,
patterns, orientation,
appropriate verbal
responses)
Vital Signs, Height and Weight
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Take Vital signs (VS)
and determine normal
or abnormal -document
Height and weightdocument
(Check the height and
weight table to
determine if a patient is
under, normal or over
weight.)
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Physical Assessment
Head to Neck
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General survey
Height and weight
Vital Signs
•Head
–Skin
–Face, skull, scalp, hair
–Eyes
–Nose and sinuses
–Mouth and or pharynx
–Cranial nerves
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Neck
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Skin
Lymph nodes
Muscles
Thyroid
Trachea
Carotid arteries
Neck veins
Integument structures
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Skin
Nails
Hair
Scalp
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Obtain history of rashes,
lesions, changes of color or
itching
History of bruising or
bleeding
Exposure to sun
Note presence of wounds,
abrasions
Changes in mole size,
shape or color
SKIN
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Inspect for color,
vascularity, lesions and
body odors
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Color-pinkish white to
various shades of
brown.
Skin Color
variations
Assessment areas
Possible causes
Redness (erythema,
flushing
Facial area
Blushing, ETOH
intake, fever, injury or
infection
Bluish (cyanosis)
Exposed areas,
ears,lips, inside of
mouth, hands feet,
nail beds
Cold environment,
cardiac or respiratory
Yellowish (jaundice)
Overall skin areas,
mucus membranes,
sclera
Liver disease
(increased bilirubin)
Vitiligo
Whitish patchy areas De-pigmentation
(autoimmune)
Tanned or brown
Sun-exposed
Melanin production
Pregnancy brown spots?
Head and Neck
Assessment includes
 Skull
 Face
 Eyes
 Ears
 Nose
 Sinuses
 Mouth
•Pharynx
•Trachea
•Thyroid glands
•Lymph nodes
Skull and face
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Inspect size and shape
Symmetry
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Face- examine color
Symmetry
Distribution of facial
hair
Assess facial nerve and
facial muscles-
cellulitis
Eye and Ears
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EYE
Inspect external
structures
Pupils and Iris
Internal structures
Vision
Extra ocular movement
Peripheral vision
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EAR
Inspect external ear for
shape, size, location
bilaterally, ear should
be smooth
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Gently palpate ear for
pain, edema, or presence
of lesions
Check hearing
Inspect internal ear
Bacteria Conjunctivitis
Acute Glaucoma
Healthy Ear
Acute otitis media
Chronic otitis media, stapes extruding
Cerumen in ear
Nose and Sinuses
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Nose
Inspect size, shape and
location
Check for patency
(open air
passageways.)
Inspect using otoscope
nares and turbinates
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Sinuses
Inspect the sinuses
and gently palpate
maxillary bone and
frontal sinus
Normally the sinuses
are not painful.
Hematoma
Polyp
MOUTH AND PHARYNX
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Composed of many
structures
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Lips, tongue, teeth, gums
hard and soft
palate,salivary gland,
tonsillary pillars, and
tonsils
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Equipment needed:
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Penlight, tongue blade,
4X4 gauze sponge, and
gloves
Tonsillitis
Hairy tongue
Neck
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Trachea- note location
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Midline at the
suprasternal notch
Thyroid- thyroid is
normally not palpable.
Palpate for size shape,
symmetry tenderness
and presence of any
nodules
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Lymph nodes
Generally not palpable
If palpated, should be
small mobile, smooth
non-tender
Abnormal- enlarged,
indicate infection,
autoimmune, or
metastasis of cancer
ASSESSMENT
Part I
COURSE OBJECTIVES
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Students will learn:
Components of a health assessment
To prepare the patient for the exam
What equipment is needed for the exam
A variety of techniques to obtain patient
information
How to examine the patient head to toe
HEALTH ASSESSMENT

Two components of the health assessment
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
Health History
Physical Assessment
WHAT HAPPENS DURING THE
ASSESSMENT
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Establish the nurse patient relationship
Gather data in the following areas
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Physiological
Psychological
Cognitive
Sociocultural
Developmental
Spiritual
Identify patient strengths
Identify actual and potential health problems
Establish base for nursing process
GENERAL GUIDELINES






Instrumentation
Positioning
Draping
Preparation of the environment
Patient preparation
Assessment techniques
POSITIONING
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
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Sitting – use upright chairor
dangle of exam table.
Supine – flat on the back
Dorsal Recumbant – on
back with knees bent
Sim’s – lie on side, lower
arm behind back, upper arm
bent at the shoulder and
elbow, knees both bent
ASSESSMENT part 2
PULMONARY
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HISTORY
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
BREATH SOUNDS
PULMONARY
CARDIOVASCULAR
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History
Inspection
Palpation
Auscultation
Heart sounds
Peripheral vascular system
CARDIOVASCULAR
BREAST/AXILLA
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History
Inspection
Palpation
ABDOMEN
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History
Inspection
Auscultation
Percussion
Palpation
GENITALIA
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Female
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History
Inspection
Male
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History
Inspection
MUSCULOSKELETAL
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History
Inspection
Palpation
Testing
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Tone
Strength
Bones and Joints
NEUROLOGICAL
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History
Mental Status
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Orientation
Level of Consciousness
Memory
Abstract Reasoning
Language
CRAINIAL NERVES
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Olfactory (I)
Optic(II)
Oculmotor (III),
Trochlear(IV),
Abducens(V)
Trigeminal(VI)
Hypoclosseal (VII)
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Facial (VIII)
Acuoustic (IX)
Glossopharyngeal (X)
Vagus (XI)
Accessory (XII)
SENSORY MOTOR FUNCTION
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Motor
Balance and gait
Coordination
Sensory
REFLEXES
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Abdominal
Babinskis
Bicepts
Triceps
Patellar
Achilles Tendon