Chapter 25 Health Assessment

Purposes of the Health Assessment Establish the nurse-patient relationship. Gather data about the patient’s general health status. Identify patient strengths. Identify actual and potential health problems. Establish a base for the nursing process.

Two Components of a Health Assessment Health history — focus on interviewing skills Physical assessment — head-to-toe sequence, system sequence

Factors to Assess During a Health History Biographical data Chief complaint History of present illness Past medical history Family history Lifestyle

Preparing the Patient for Physical Assessment Consider the physiological and psychological needs of the patient. Explain the process to the patient. Explain that physical assessments will not be painful (decrease patient fear and anxiety). Ask the patient to change into a gown and empty bladder. Answer patient questions directly and honestly.

Preparing the Environment for Physical Assessment Agree upon a time for the assessment. –The time should not interfere with meals, daily routines, or visiting hours. Patient should be as free of pain as possible. Prepare the examination table. Provide a gown and drape for the patient. Gather the supplies and instruments needed for the assessment. Provide a curtain or screen if the area is open to others.

Equipment Used During a Physical Examination Ophthalmoscope — visualizes the interior structures of the eye Otoscope — examines the external ear canal and tympanic membrane Snellen’s chart — screens for distant vision Nasal speculum — visualizes the lower and middle turbinates of nose Vaginal speculum — examines the vaginal canal and cervix Tuning fork — tests auditory function and vibratory perception Percussion hammer — tests deep tendon reflexes and determine tissue density

Positions Used During a Physical Assessment Sitting — used to take vital signs Supine — allows relaxation of abdominal muscles Dorsal recumbent — used for patients having difficulty maintaining supine position Sim’s — assessment of rectum or vagina Prone — assessment of hip joint and posterior thorax

Positions Used During a Physical Assessment (continued) 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

Techniques Used During a Physical Assessment Inspection — assess size, color, shape, position, and symmetry Palpation — assess temperature, turgor, texture, moisture, vibrations, and shape Percussion — assess location, shape, size, and density of tissues Auscultation — assess the four characteristics of sound; i.e., pitch, loudness, quality and duration

Characteristics of Masses Determined by Palpation Shape Size Consistency Surface Mobility Tenderness Pulsatile

Types of Sounds Heard When Using Percussion Flat — soft, e.g., thigh area Dull — medium, e.g., liver Resonance — loud, e.g., normal lung Hyperresonance — very loud, e.g., emphysematous lung Tympany — loud, e.g. puffed-out cheek

Characteristics of Sound Heard When Using Auscultation Pitch — ranging from high to low Loudness — ranging from soft to loud Quality — e.g., gurgling or swishing Duration — short, medium or long

General Survey General appearance Vital signs Height and weight

Physical Assessment Integument Head and neck Thorax and lungs Cardiovascular and peripheral vascular systems Breasts and axillae Abdomen Female and male genitalia Musculoskeletal system Neurological system

Purposes of Documentation Identify actual and potential health problems Make nursing diagnoses Plan appropriate care Evaluate patient’s responses to treatment

Nurse’s Role in Diagnostic Procedures Assist before, during, and after diagnostic tests. Be responsible for other activities associated with diagnostic tests. Witness the patient’s consent. Schedule the test. Prepare the patient physically and emotionally for the test. Provide care after the test. Dispose of used equipment. Transport specimens.