Miss.M.N Priyadarshanie BSc.Special in Nursing

Session 2 Health Assessment

Components of a Health Assessment Health history — focus on interviewing skills Physical assessment: — head- to- toe sequence, — or systems sequence.

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

Purposes of Health Assessment To evaluate the client’s current physical condition. To detect early signs of developing health problems. To establish a baseline for future comparisons. To evaluate the client’s responses to medical and nursing interventions.

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.

Preparing the Patient for Physical Assessment Prepare equipment needed for assessment ( stethoscope, torch, disposable gloves, pin,…) Have good lightening (daylight or artificial). Answer patient questions directly and honestly. Screen the bed to provide privacy. Assure quite environment. Wash hands. Explain procedures for examination. Instruct for appropriate seating. Ask the patient to change into a gown and empty bladder.

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, 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

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

Components of the Health History Biographical data Present health–illness Past history Family history Psychosocial history Review of body systems

Biographical Data Demographic data about the client Name Address Age Date of birth

Biographical Data Occupation Demographic data about the client Birthplace Gender Marital status Race Occupation

The Present Health or Illness History Past and current health problems and concerns Reason for seeking care Health beliefs and practices Health patterns Medications

Past History Childhood diseases Immunizations Allergies Blood transfusions Major illnesses Injuries

Past History Hospitalizations Childbirths Surgeries Psychiatric problems Use of alcohol, tobacco, and other substances

Family History - Determines whether Genetic or Familial Patterns of Health Impact the Client’s Current or Future Health Status Genogram - Pictorial Representation of Family Relationships and Medical History

Psychosocial History Occupation Education Finances Roles and relationships Ethnicity and culture Family Spirituality Self-concept

Review of Body Systems - Provides Subjective Information About Each Body System and Its Organs

Sources of Information for the Health History Primary source Client Secondary sources Other individuals Client records and charts

Physical Assessment Techniques Inspection. Palpation. Percussion. Auscultation.

Inspection Is the process of performing deliberate, purposeful observations in systematic manner, nurse observes visually and uses hearing and smelling to gather data.

Palpation Is an assessment technique that uses the sense of touch by hand and fingers which can assess temperature, shape , vital sign , tenderness , internal injury …. etc

Auscultation Is the act of listening with a stethoscope to sounds produced within the body. Auscultation is performed by placing the stethoscope diaphragm or bell against the body part being assessed. This method uses the stethoscope to augment the sense of hearing. The stethoscope must be constructed well and must fit the user. Earpieces should be comfortable, the length of the tubing should be 25 to 38 cm (10–15 inches), and the head should have a diaphragm and a bell. The bell is used for low-pitched sounds such as certain heart murmurs. The diaphragm screens out low-pitched sounds and is good for hearing high-frequency sounds such as breathe sounds.

Auscultation (Cont’d)

Percussion Is the act of striking one object against another to produce sound , the sound waves produced by the striking action over body tissues are known as percussion tones , percussion used to assess the location , shape , size and density of tissues .

Percussion (Cont’d) Warm your hands Perform percussion as follows: Mediate percussion: Hyperextend the middle finger of the left hand Press the distal portion and joint firmly against the surface to be percussed .(other fingers touching the surface will damp the sound). Cock the right hand at the wrist, flex the middle finger upwards, place the forearm close to the surface to be percussed. (The right hand and forearm should be as relaxed as possible) Strike with the tip of the right middle finger behind the nailbed of the extended. left middle finger Lift the right middle finger rapidly to avoid damping the vibrations.

Percussion (Cont’d) b- Identify percussion sounds as follows : Flatness : Percuss over the bone or thigh Dullness : Percuss over the liver Resonance : Percuss over the normal lung (intercostal spaces) Tympani : Percuss over the stomach Hyperresonancc: Percuss over emphysema lung. c- Immediate percussion:- Use one or more fingers of one hand. Strike the body surface. d- Fist percussion:- Place one hand flat against body surface Strike the back of hand with the other hand clenched in a fist

Percussion (Cont’d)

Equipment Used During a Physical Examination Ophthalmoscope - visualizes the interior structures of the eye . Otoscope - examines the external ear canal and tympanic membrane. Laryngoscope- visualizes the trachea. Snell en's chart- screens for distant vision Nasal speculum - visualizes the lower and middle turbinate's of nose . Vaginal speculum- examines the vaginal canal and cervix. Tuning fork – tests auditory function and vibratory perception.

Equipments (Cont’d) Percussion hammer - tests deep tendon reflexes and determine tissue density . ECG. Glucometer Stethoscope. Sphygmomanometer.

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.

The End