Health Assesment

7/31/2019 Health Assesment

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Health History Physical Assessment Subjective database

Obtained through interview

ID strength, actual orpotential health problems,support system, teaching

needs, DC and referral needs

Use of effectivecommunications skills

Objective database

Obtained by observation and

physical assessmenttechniques

Completes the clients health

picture

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Complete Health History

Biographical data Reason for Seeking Care History of Present Illness Past HealthAccidents and Injuries Hospitalizations and Operations Family History Review of Systems

Functional Assessment ( Activities of Daily Living) Perception of Health

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Physical Assessment Environment Adequate lighting. Facilities for handwashing. Easy access to a restroom. A door or curtain that ensure privacy.

Adequate warmth for client comfort. A padded, adjustable table or bed. A lined receptacle for soiled articles. Sufficient room for moving to either side of the

client. A clean counter for placing examination

equipment.

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Positions Used During aPhysical Assessment

Sitting used to take vital signs Supine allows relaxation of abdominal

muscles Dorsal recumbent used for patients having

difficulty maintaining supine position Sims assessment of rectum or vagina Prone assessment of hip joint and posterior

thorax, Lithotomy assessment of female rectum and

vagina; used for brief period only Knee-chest assessment of the rectal area;

used for brief period only Standing assessment of posture, gait, and

balance

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Assessment Sequencing Head to - Toe Assessment

Body Systems Assessment


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Head-to-toe Assessment

Physical Assessment using head toe approachTest hearingCranial nervesInspect lymph nodesInspect neck veinsChest

Inspect and palpate breastInspect and auscultate lungsAuscultate heartAbdomenInspect, auscultate, palpate four

quadrants

Palpate and percuss liver, stomach,bladder

Bowel eliminationUrinary elimination

General SurveyGeneral health statusVital signs and weightNutritional statusMobility and self care

Observe postureAssess gait and balanceEvaluate mobilityActivities of daily livingHead face and neckEvaluate cognition

LOCOrientationMoodLanguage and memorySensory functionTest vision

Inspect and examine ears


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Head to Toe Assessment

ExtremitiesPalpate arterial pulsesObserve capillary refillEvaluate edemaAssess joint mobility

Measure strengthAssess sensory functionAssess circulation,movement, & sensation

Deep tendon reflexesInspect skin and nails

Skin, hair and nailsInspect scalp, hair & nailsEvaluate skin turgorObserve skin lesionAssess wounds

GenitaliaInspect female clientInspect male client


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Body System approachReview Of Systems

General presentation of symptoms: Fever, chills, malaise, pain, sleep

patterns, fatigability

Diet: Appetite, likes and dislikes, restrictions, written dairy of food intake

Skin, hair, and nails: rash or eruption, itching, color or texture change,

excessive sweating, abnormal nail or hair growth

Musculoskeletal: Joint stiffness, pain, restricted motion, swelling, redness,

heat, deformityHead and neck:

Eyes:visual acuity, blurring, diplopia, photophobia, pain, recent change in

vision

Ears:Hearing loss, pain, discharge, tinnitus, vertigo

Nose: Sense of smell, frequency of colds, obstruction, epistaxis, sinuspain, or postnasal discharge

Throat and mouth: Hoarseness or change in voice, frequent sore throat,

bleeding o swelling, of gums, recent tooth abscesses or extractions, soreness

of tongue or mucosa.


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Endocrine and genital reproductive: Thyroid enlargement or

tenderness, heat or cold intolerance, unexplained weight

change, polyuria, polydipsia, changes in distribution of facial

hair; Males: Puberty onset, difficulty with erections, testicular

pain, libido, infertility; Females: Menses {onset, regularity,

duration and amount}, Dysmenorrhea, last menstrual period,

frequency of intercourse, age at menopause, pregnancies

{number, miscarriage, abortions} type of delivery,complications, use of contraceptives; breasts {pain, tenderness,

discharge, lumps}

Chest and lungs: Pain related to respiration, dyspnea, cyanosis,

wheezing, cough, sputum {character, and quantity}, exposure to

tuberculosis (TB), last chest X-ray

Heart and blood vessels: Chest pain or distress, precipitating

causes, timing and duration, relieving factors, dyspnea,

orthopnea, edema, hypertension, exercise tolerance


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Gastrointestinal: Appetite, digestion, food intolerance, dysphagia,

heartburn, nausea or vomiting, bowel regularity, change in stool color,

or contents, constipation or diarrhea, f latulence or hemorrhoids Genitourinary: Dysuria, f lank or suprapubic pain, urgency, frequency,

nocturia, hematuria, polyuria, hesitancy, loss in force of stream,

edema, sexually transmitted disease

Neurological: Syncope, seizures, weakness or paralysis, abnormalities

of sensation or coordination, tremors, loss of memory

Psychiatric: Depression, mood changes, difficulty concentrating

nervousness, tension, suicidal thoughts, irritability.

Pediatrics: along with systemic approach in case of pediatrics,

measure anthropometric measurement and neuromuscularassessment.


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Assessment techniques

Setting Environment &Equipment Technique

General survey

Head to toe or systems approach

Minimize exposure

Areas to assess first unaffectedareas, external before internal

parts


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Physical Health Exam-General Survey

Appearance

Age, skin color, facial features

Body Structure - Stature, nutrition, posture, position, symmetry

Mobility - Gait, ROM

Behavior

Facial expression, mood/affect, speech, dress, hygiene

Cognition

Level of Consciousness and Orientation (x4)

Include any signs of distress- facial grimacing, breathing problems


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Inspection Close and careful visualization of the person as a whole

and of each body system

Ensure good lighting Perform at every encounter with your client


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Palpation

Temperature, Texture,Moisture

Organ size and location

Rigidity or spasticity

Crepitation & Vibration

Position & Size

Presence of lumps or masses

Tenderness, or pain

Palpation Techniques

Light

Deep


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Percussion assess underlying structures forlocation, size, density ofunderlying tissue.

Direct

Indirect

Blunt percussion


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Percussion Sounds

Resonance: A hollow sound. Hyper resonance: A booming sound.

Tympany: A musical sound or drum sound like thatproduced by the stomach.

Dullness: Thud sound produced by dense structures suchas the liver, and enlarged spleen, or a full bladder.

Flatness: An extremely dull sound like that produced byvery dense structures such as muscle or bone.


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Percussion sounds

Example oforigin

QualityLengthPitchIntensitySound

Normal lungHollowLongLowLoudResonance(heard over partair and part solid

Lung withemphysema

BoomingLongLowVery loudHyper-resonance(heard over

mostly air

Puffed-outcheek,gastricbubble

Drum likeModerateHighLoudTympany (heardover air)

Diaphragm,pleuraleffusion

Thud likeModerateMedium

MediumDullness (heardover more solidtissue

Muscle,Bone, Thigh

FlatshortHighSoftFlatness (heardover very dense

tissue


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Auscultation Listening to soundsproduced by the body

Instrument: stethoscope(to skin)

Diaphragmhighpitched sounds

Heart

LungsAbdomen

Bell low pitchedsounds

Blood vessels


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Normal Breath SoundsVesicular sounds

Soft rustling sounds heard over most lung tissue

Bronchovesicular sounds Has characteristics of above two

Heard only over major airways

Tracheal sounds

Hollow tubular sounds


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Abnormal (Adventitious)

Breath Sounds Crackles (rales)

discontinuous pop-like sounds

generally heard on inspiration but can be heard on exhalationalso

Wheezes

high-pitched continuous musical sounds

can be heard on both inspiration or exhalation


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Abnormal Breath Sounds Continued Rhonchi

low-pitched snoring sound that is continuous

can be heard on inspiration or exhalation

Bronchial Breath Sounds

same as Tracheal Sounds except heard over lungparenchyma


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Abnormal Breath Sounds Continued Stridor - high pitched raspy sound

is heard at its loudest over the trachea

indicates upper airway narrowing

heard in such conditions as;

post extubation stenosis

croup in young children


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Abnormal Breath Sounds Continued Pleural Friction Rub

Egophony - e to a changes

first section heard is the normal e sound second sound heard is the example of egophony: letter

e heard as a


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Crackles can indicateAtelectasis

Bronchitis

Pneumonia Pulmonary edema

Pulmonary fibrosis (dry crackles)


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Ronchi indicates Secretions in larger airways

frequently clear with a cough

seen in any condition that creates lung mucus

in COPD ronchi may occur because of airf lowobstruction unrelated to secretions


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Other Less Common Sounds Pleural friction rub

occurs when pleural surfaces rub together

seen in some pneumonias effecting pleural surfaces

Stridor

High pitched rasping sound heard mainly on inspiration

Indicative of upper airway obstruction


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Breathing Patterns Cheyne-Stokes Breathing

Irregular patterns of deep breathing followed by periodsof shallow breathing; usually ending with a period ofapnea

Biots Breathing

Irregular patterns of breathing; usually very

disorganzied. May be periods of apnea Kussmauls Breathing

Rapid & deep breathing


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More Breathing Patterns

Apneustic Pattern

Prolonged inspirations; serial inspirations w/oexhalation after each followed by summative

exhalationAsthmatic Pattern

Excessively long expiratory periods

Paradoxical Breathing Is present when a portion of chest wall moves in the

opposite direction as it should during the breathingcycle


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Voice Sounds Egophony

1. Place stethoscope over lung area

2. Ask patient to say the letter e3. If you actually hear the hard a sound;

4. The area has a fluid or consolidation

Bronchophony

An increase in intensity and clarity of vocal sounds.


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Cardiac Sounds Lub - Dub

S1, S2

PMI (Point of Maximal Impulse) Fifth intercostal, mid clavicular, left side

PVCs are common

Heaves, gallops, murmurs, bruits

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Health Assesment