Basic Nursing: Foundations of Skills & Concepts Chapter 25 ASSESSMENT

Nursing Assessment A complete nursing assessment is necessary to analyze each client’s needs in a holistic manner. Nursing assessment includes both physical and psychosocial aspects to evaluate a client’s condition.

Basic Components Health History. Physical Examination.

Health History A review of the client’s functional health patterns prior to the current contact with a health care agency.

Components of Health History Demographic Information. Reason for Seeking Health Care. Perception of Health Status. Previous Illnesses, Hospitalizations, and Surgeries. Client/Family Medical History. Allergies. Immunizations/Exposure to Communicable Diseases. Current Medications. Developmental Level. Psychosocial History. Sociocultural History. Activities of Daily Living. Review of Systems.

Demographic Information Name. Address. Date of Birth. Gender. Religion. Race/Ethnic Origin. Occupation. Type of Health Plan/Insurance.

Reason for Seeking Health Care Should be described in client’s own words.

Perception of Health Status Refers to the client’s opinion of his or her general health.

Developmental Level Knowledge of developmental level is essential for considering the appropriate norms of behavior. Any recognized theory of growth and development can be applied for assessment purposes.

Psychosocial History The assessment of such dimensions as self-concept and self-esteem. Sources of stress for the client and the client’s ability to cope. Sources of support for clients in crisis, such as family, significant others, religion, or support groups.

Sociocultural History Home environment. Family situation. Client’s role in the family.

Review of Systems A brief account from the client of any recent signs or symptoms associated with any of the body systems.

Relevant Data Regarding Symptoms Location (area of the body in which symptom, such as pain, is felt). Character (the quality of feeling or sensation, e.g. sharp, dull, stabbing). Intensity (the severity or quantity of the feeling and its interference with functional ability). Timing (onset, duration, frequency, and precipitating factors of the symptoms). Aggravating/Alleviating Factors (activities or actions that make the symptom better or worse).

Physical Examination Inspection (thorough visual observation). Palpation (touching to assess texture, temperature, moisture, organ location and size, swelling, etc.). Percussion (short tapping strokes on the surface of the skin to create vibrations of underlying organs). Auscultation (listening to sounds in the body created by movement of air or fluid). Performed head-to-toe using these specific assessment techniques:

Positions for Physical Examination Sitting (to examine head, back, lungs, breast, heart, extremities). Supine (to examine head, neck, lungs, breast, abdomen, heart, extremities). Sims (to examine rectum and vagina). Knee-chest (to examine rectum). Dorsal recumbent (to examine head, neck, lungs, breast, heart). Prone (to examine posterior thorax, lungs, hip). Lithotomy (to examine female genitalia, rectum, genital tract).

Introduction of the Nurse Introduction of the nurse at the beginning of a physical assessment enhances the ability to accomplish the complete assessment. Special considerations involved during the physical examination of: Elderly. Disabled clients. Abused clients.

Vital Signs “Signs of life” of an individual. Include: Temperature. Pulse. Respirations. Blood Pressure.

Terms Pertaining to Pulse Pulse rate (indirect measurement of cardiac output obtained by counting the number of peripheral pulse waves over a pulse point). Pulse rhythm (regularity of the heartbeat). Pulse amplitude (measurement of the strength or force exerted by the ejected blood against the anterior wall with each contraction). Pulse deficit (condition in which the apical pulse rate is greater than the radial pulse rate).

Terms Pertaining to Respiration Eupnea (easy respirations with a rate of breaths-per-minute that is age- appropriate). Hypoventilation (shallow respirations). Hyperventilation (deep, rapid, respirations). Dyspnea (difficulty in breathing).

Blood Pressure Favored site is the brachial artery. Alternative is popliteal artery, behind the knee. Pulse pressure is the difference between the systolic and the diastolic blood pressures.

Height and Weight Measurements As important as assessing the client’s vital signs. Routinely taken on admission to acute care facilities and on visits to physicians’ offices, clinics, and other health care settings.

Neurological Assessment Focuses on: Level of consciousness. Pupil response. Hand grasps. Foot pushes.

Assessing Affect When describing a client’s affect, the nurse must utilize terms that are descriptive of the specific behavior observed, not the nurse’s judgment about the behavior.

Thoracic Assessment Focuses on: Cardiovascular status. Respiratory status. Wounds, scars, drains, tubes, dressings. Breasts.

Types of Normal Breath Sounds Bronchial (loud and high-pitched with a hollow quality). Bronchovesicular (medium-pitched and blowing). Vesicular (soft, breezy, and low-pitched).

Terms Pertaining to Breath Sounds Adventitious breath sounds (abnormal). Sibilant wheezes (high-pitched, whistling). Sonorous wheezes (low-pitched snoring). Crackles (popping sounds heard on inhalation or exhalation. Pleural friction rub (low-pitched grating sound heard on inhalation or exhalation). Stridor (high-pitched, harsh sound heard on inspiration while trachea or larynx is obstructed).

Abdominal Assessment Focuses on gastrointestinal and genitourinary status. Includes use of inspection, auscultation, percussion, and palpation within the four quadrants of the abdomen to establish bowel function and status.

Musculoskeletal and Extremity Assessment Through observation of client gait and overall range of movement, the nurse is able to obtain some knowledge of the symmetry and strength of muscles.

Assessment of Wounds, Drains, Tubes, and Dressings The nurse must maintain accurate documentation of the amount of drainage, color, or other changes.