By: Mary Hazel S. Facundo, RN, MN

*HEALTH ASSESSMENT

*Objectives

*To identify what are included in the general survey*To be able to perform a general survey to a client*To review the anatomy and fuctions of the skin, hair, and nails

*General Survey

*Include collecting information about the patient’s

Includes Height & WeightPhysical presencePsychological presenceSigns and Symptoms of Distress

1.Physical presence

*Observe the patient’s

Stated age versus apparent age General appearance Body fat Stature Motor activity Body and breath odors

*Stated age vs. Apparent age

*Stated Chronological age should be congruent with apparent age

*Hormone deficiencies or genetic syndromes can make a patient appear younger or older than the stated chronological age

*General Appearance

Observe for

* body symmetry*Any obvious anomaly*Apparent level of wellness

*Body Fat

*Should be evenly distributed*Difficult to estimate accurately w/o the use of calipers*An excess caloric intake and/or decreased energy expenditure are the most common causes of obesity.*Energy expenditures that exceed caloric intake will result in decreased fat stores.

*Stature

*Limbs and trunk should appear proportional body height*Posture should be erect*Slumped or humpbacked is abnormal

Marfan’s syndrome – results in the development of long limbs

*Motor Activity

*Walking gait as well as other body movt’s are smooth and effortless*All body parts should have controlled, purposeful movement

Tics, paralysis, or ataxia may be due to neurologic disturbancesArthritis can result to slow and difficult movement

*Body and breath odors

*Normally, no apparent odor*The type of foods ingested or individual digestive process may result to bad breath*Severe body or breath odor is abnormal

2. Psychological presence

*Observe the patients’sDress, grooming, and personal

hygieneMood and MannerSpeechFacial expressions

*Dress, grooming, and personal hygiene

*Patient should appear clean and neatly dressed*Clothing is appropriate for the weather*Norms and standards of dress and cleanliness may vary among cultures*Psychological or psychiatric disorders may be reflected in inappropriate appearance or inappropriate clothing*Abuse or neglect may result to unclean appearance

*Mood and Manner

*Generally cooperative and pleasant*Further assessment is needed if uncooperative, hostile, tearful adult or unusually elated, or has flat affect*Psychiatric conditions and psychotic disorders produce a distortion in reality, resulting in abnormal behaviours.*Dementia or confusion in elderly can result in disturbance of mood and manner

*Speech

*Should respond to questions and commands easily*Should be clear and understandable*Pitch, rate, and volume should be appropriate to the circumstances*Slow, slurred, mumbled, very loud, or rapid needs further assessment

*Facial expression

*Should appear awake and alert*Should be appropriate for what is happening in the environment and should change naturally*Apathy or depression may cause lack of facial expression due to feeling of lethargy and sadness*Bell’s palsy may cause the mouth to droop and side of the face to appear flaccid

3. Distress

*Observe forLaboured breathing, wheezing or cough, laboured speech

Painful facial expression, sweating, physical protection of painful area

Serious or life-threatening occurrences

Signs of emotional distress or anxiety

*Assessing Distress/Pain

*S- Severity*L- Location*I- Influencing factors*D- Duration*A- Associated Symptoms

*Assessment of the Skin, Hair, and Nails

*Anatomy of the skin

*Skin glands

*Anatomy of the Hair

*Anatomy of the Nails

*Function of the skin

*Protective barrier against invasion from environmental hazards and pathogens*Temperature regulation*Contains receptors for pain, touch, pressure, and temperature*Acts as an organ of excretion for substances

*Function of Hair

*Provides warmth, protection, and sensation to the underlying systems*A status symbol of beauty and wealth

*Function of Nails

*Provides protection to the distal surface of the digits and can be used for self - protection*Length in both men and women is a qualifier of social and economic status

*Assessment of the Skin

*Inspect for

*ColourNormally, uniform whitish pink or brown

Dark – skinned may have freckling of the gums, tongue border, and lining of the cheeks.

*skin color

*Cyanosis*Jaundice*Yellow discoloration of the palmar and digital creases*Orange – yellow coloration of palmar and plantar surfaces and forehead

*Grayish cast*Bright red/ruddy*Pale cast*Brown cast*Albinism*Vitiligo

*Inspect for

*Bleeding, ecchymosis, or increased vascularityPetechiaPurpuraEcchymosisSpider angiomaChery angiomasStrawberry HemangiomasGas gangrene

*Inspect for

LESIONS*Non palpable – macule, patch*Palpable – papule, plaque, nodules, tumor, wheal*Fluid – filled cavities – vesicle, bullae, pustule, cyst*Above the skin surface – Scales, crust, lichenification*Below the skin surface – erosion, ulcer, keloid, fissures, scar, excoriation (abrasion)

*Lesions

*Lesions

*Lesions

*Stages of ulcer

I – Area is reddenedII – Epidermal and dermal layers have sustained injuryIII – Subcutaneous tissues have sustained injuryIV – Muscle tissue and perhaps bones have sustained injury

*Stages of ulcer

*Palpation of the Skin

MOISTURE*Normally dry with minimum perspiration*Excessive dryness (xerosis) is abnormal (hypothyroidism)*Diaphoresis (increased metabolism, hyperthyroidism, anxiety or pain)

*Palpation of the Skin

TEMPERATURE*Normally warm and equal bilaterally*Hands and feet may be slightly cooler than the rest of the body*Abnormal – hypothermia, hyperthermia

*Palpation of the Skin

TENDERNESS*Normally nontenderTEXTURE*Normally feel soft even, and firm*A certain amount of roughness in areas are normal

*Palpation of the Skin

TURGOR (elasticity)*Reflects the skin’s state of hydration

EDEMA (accumulation of fluid)* Rate the degree of edema.

*Palpation of the Skin

4 – point scale rating of EDEMA * +0 No pitting*+1, 0 – ¼ inch Mild*+2, ¼ - ½ inch Moderate*+3, ½ - 1 inch Severe*+4, greater than 1 inch Severe

*Assessment of the hair

*Have the client remove any hair clips, hair pins, or wigs.*Wear gloves if lesions are suspected or if

hygiene is poor. Then inspect the scalp and hair.*Inspect amount and distribution of scalp,

body, axillae, and pubic hair. Look for unusual growth elsewhere on the body.

*Excessive generalized hair loss may occur with infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure*It may also result from chemotherapy or

radiation therapy.*Nutritional deficiencies may cause patchy

gray hair in some clients.*Severe malnutrition in African-American

children may cause a copper-red hair colour*Older clients have thinner hair because of

loss of hair follicle

*Assessment of the Nails

*Inspect nail grooming and cleanlinessDirty, broken, or jagged fingernails may be

seen with poor hygiene. They may also result from the client’s hobby or occupation.*Inspect nail color and markings.*Check capillary refill on all four extremities.Pale or cyanotic nails may indicate hypoxia or

anemia. Splinter haemorrhages may be caused by trauma. Beau’s lines occur after acute illness and

eventually grow out. Yellow dis coloration may be seen in fungal

infections or psoriasis. Nail pitting is common in psoriasis.

* A normal nail, showing the convex shape and the nail

plate angle of about 160 degrees

* A spoon-shaped nail, which may be seen in clients with

iron deficiency anemia

* early clubbing; D, late clubbing (may be caused by long-term oxygen lack)

* Beau’s line on nail (may result from severe injury or illness).

Many clients have nails with lines, ridges, spots, and uncommon shapes that suggest an underlying disorder. Some examples follow:

*Head, Neck, and Lymphatics

*The Head and Neck

*Head and neck assessment focuses on cranium , face ,thyroid gland , lymph node structure.

1. Cranium : ( frontal , parietal, temporal , occiptial , ethmiod , spheniod)2. Face : ( maxilla, zygomatic, lacrimal , mandible , nasal )3. Neck4. Muscles and cervical vertebrae5. Blood vessels : ( jugular, carotid)6. Thyroid gland7. Lymph node of the head and neck

*Subjective Data

*Have you noticed any lesion or lumps on your head or neck that not heal or disappear ?

*Do you have any difficulty moving your head or neck ?*Do you have experience neck pain ? Describe*Do you have any facial pain? Describe .*Describe any pervious head or neck problems ? ( past

history)*Have you ever undergone radiation therapy for problem

in your neck region? (past history)* Is there history of head neck cancer in your family ?

( family history )*PQRST*Headaches* Jaw tightness/pain*Neck pain*Nasal congestion/nose bleeds*Mouth lesions*Sore throat/hoarseness

*Position: Sitting*Approach : anterior –

posterior*Technique :Inspection , Palpation , Percussion , Auscultation

Equipment1. Penlight, Transilluminator of light2.Stethoscope3.Glass of water4.Tongue depressor5.Tape measure6.Gloves7.Gauze 4×48.Nasal speculum or ophthalmoscope

* Inspect Shape and contour of Head

*Check for shape and symmetry*Head should be normocephalic and

symmetrical*Abnormalities: hydrocephalus,

acromegaly, craniosynostosis

*Palpation of the Head

*Place finger pads on the head and palpate all its surfaces:

Frontal-parietal-temporal-occipitalContour, masses, depressions, tendernessSuperficial temporal artery (weaker pulse)*Abnormalities:Masses – hard or soft Craniotabes – softening of the skull

caused by hydrocephalus or demineralization of the bone due to rickets

Laceration and bleeding of scalp

* Inspection of the Face

*Symmetry of facial structures, expression, shape*Shape and featuresShape can be oval, round or slightly squareNo edema, disproportionate structures, or

involuntary movements*Abnormalities:Down’s Syndrome,hypertelorism, scleroderma,

exophthalmos, myxedema, cachexia, immobile and expressionless (Parkinson’s), nasal crease, moon face

*Palpation and Auscultation of the

mandible

*Place the middle three finger of each hand bilaterally over each joint then gently press on the joint , ask the client to open and close the mouth *Palpate the muscle on both sides of the

face while the client smiles, frown , grits the teeth and puffs out of the cheek.*Check temporal artery pulse the should

equal and strength and rhythm.*Auscultate for any sound while the client

opens and closes the mouth

*Palpation and Auscultation of the

mandible

*Normal:No discomfort with movementJoint should articulate smoothly and w/o

clicking or crepitus

*Abnormal:+ for tenderness, clicking, crepitus+ snapping sound

*Assessment of the Neck

*Assess for:Range of motion (ROM)Muscle strengthLymph nodesCervical vertebraeTracheaThyroid Gland

*Assessment of the Neck

*Full range of motion is assessed by asking the client to tilt the head backward and side to side.*Neck should be symmetrical. No neck vein distention should be visible.*Trachea should be centered , move easily. place your fingers in the sternal notch feel each side of the notch and palpate the tracheal rings when the clients swallow.*On the posterior aspects of the neck the cervical vertebrae are inspected and palpated for symmetry, tenderness, masses or swelling.

*Assessment of the Neck

*Normal :*Muscles are symmetrical w/o palpable

masses or spasm; head in a central position*Able to move head through full ROM w/o

discomfort*Abnormal:*Pain w/flexion; reduced ROM*Slight or prominent lateral deviation of

neck (Torticollis)

*Assessment of the Thyroid

*To inspect :Face client and ask him to look straight ahead w/ the head slightly extended *Have him drink a sip of water and swallow

twice*As patient swallows, observe the front

neck in the area of thyroid and the isthmus for masses and symmetrical movement

Posterior Approach

*Lower the chin slightly to relax neck muscles

Anterior Approach

*Flex the head slightly forward

*Palpation of the Thyroid

*Normal:No enlargement, masses or tenderness

*Abnormal:Smooth and softGland reveals to be 2 to 3 times larger than

normal sizeLateral deviationTendernessPresence of bruits on auscultation

*Assessment of the Lymph Nodes

*Assessment of the Lymph Nodes

*Normal:Not visible or inflamedShould not be palpable (small, discrete

movable nodes are sometimes present)*Abnormal:Enlargement and inflammationPalpable nodes