1. CHAPTER 23 ASSESSMENT UNIT 7 FUNDAMENTAL NURSING CARE
SECTION I BASIC NURSING
UNIT 7 FUNDAMENTAL NURSING CARE
CHAPTER 23
ASSESSMENT

2. NURSING ASSESSMENT
Necessary to analyze each client’s needs in a holistic manner.
Includes both physical and psychosocial aspects.
A thorough assessment includes both health history and physical examination.

3. HEALTH HISTORY
Review of client’s functional health patterns prior to current contact with a health care agency.
Focuses on client’s functional health patterns, responses to changes in health status, and alterations in lifestyle.
Used in developing the plan of care.

4. DEMOGRAPHIC INFORMATION
Name
Address
Date of birth
Gender
Religion
Race/ethnic origin
Occupation
Type of health plan/insurance

5. REASON FOR SEEKING HEALTH CARE
Should be described in the client’s own words.
Important because it explains what is significant about the event from the client’s point of view.
Important to know the time of the onset of symptoms.

6. PERCEPTION OF HEALTH STATUS
Refers to the client’s opinion of own general health.
It may be useful to ask clients to rate their health on a scale of 1 to 10, along with client’s rationale for rating score.

7. ALLERGIES
Any drug, food, or environmental allergies should be noted in the health history, along with the type of reaction to the substance.

8. CURRENT MEDICATIONS All medicines currently taken.
Prescription and over-the-counter.
Record by name, frequency, and dosage.
Ask about birth control pills, laxatives, nonprescription pain relief medications, herbal remedies, and vitamin and mineral supplements.

9. DEVELOPMENTAL LEVEL Essential for:
Considering appropriate norms of behavior.
Appraising the achievement of relevant developmental tasks.

10. PSYCHOSOCIAL AND SOCIOCULTURAL HISTORY
Assesses self-concept and self-esteem.
Explore sources of support for clients in crisis, such as family, significant others, religion, or support groups.
Home environment, family situation, and client’s role in the family is part of the sociocultural assessment.

11. REVIEW OF SYSTEMS
Relies on subjective information provided by the client rather than on nurse’s own physical examination.
Relevant data include location, character, intensity, timing, aggravating/alleviating factors.

12. PHYSICAL EXAMINATION Performed in all health care settings.
Performed for all age groups.
Done in a sequential, head-to-toe fashion.

13. SPECIFIC ASSESSMENT TECHNIQUES
Inspection–thorough visual observation of the client.
Palpation–uses the sense of touch to assess texture, temperature, moisture, organ location and size, etc.

14. SPECIFIC ASSESSMENT TECHNIQUES (continued)
Percussion–uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs.
Auscultation–listens to sounds in the body that are created by movement of air or fluid.

15. POSITIONS USED IN PHYSICAL EXAMINATION
Sitting
Dorsal recumbent
Prone
Supine
Sims’
Knee-chest
Lithotomy

16. IMPORTANT CONCEPTS IN HEAD-TO-TOE ASSESSMENT
Respect the client’s privacy.
Eliminate distracting noises.
Perform under natural light.
Explain all procedures.
Maintain confidentiality of data acquired.
The elderly, disabled, and abused will require special consideration.

17. VITAL SIGNS “Signs of Life”
Includes temperature (T), pulse (P), respirations (R), blood pressure (BP), and pain assessment.

18. TEMPERATURE Electronic, chemical, or mercury thermometer.
Body temperature by five routes: oral, rectal, axillary, skin, tympanic membrane.
Hot or cold food or beverage, smoking 15–30 minutes before taking an oral temperature can affect results.

19. PULSE
Measures pressure pulsation when heart contracts and ejects blood into aorta.
Provides clinical data regarding the heart’s pumping action.
Most accessible pulse points are the radial and carotid sites.
Normal adult rate: 60–100 per minute.

20. PULSE TERMINOLOGY Bradycardia–heart rate less than 60.
Tachycardia–heart rate greater than 100.
Pulse rhythm–regularity of the heartbeat.
Pulse amplitude–can be normal, weak, thready, bounding.
Pulse deficit–when the apical pulse is greater than the radial pulse.

21. RESPIRATION Assess breathing pattern.
Observe chest wall expansion and bilateral symmetrical movement of thorax.
Assess the rate, depth, and rhythm of each breath.
Include the use of any type of oxygen equipment, including route and flow rate.

22. RESPIRATION TERMINOLOGY
Eupnea–easy respirations
Bradypnea–10 or fewer per minute
Hypoventilation–shallow respirations
Tachypnea–rate greater than 24 per minute
Hyperventilation–deep, rapid respirations
Dyspnea–difficulty in breathing

23. BLOOD PRESSURE
The result of the interaction of cardiac output and peripheral resistance.
Pulse pressure–the difference between the systolic and diastolic pressures.
Brachial artery is the most common site for blood pressure measurement.

24. PAIN Considered the “fifth” vital sign.
Assessment should include pain intensity and quality.

25. HEIGHT AND WEIGHT MEASUREMENT
Routinely taken on visits to physicians’ offices, clinics, on admission to acute care facilities, and in other health care settings.
Provides data about growth and development in infants and children.
Alterations may indicate illness at any age.

26. HEAD AND NECK ASSESSMENT
Hair and scalp
Eyes
Nose
Lips and mouth
Neck

27. MENTAL AND NEUROLOGICAL STATUS
Level of orientation to person, place, time, and the environment
Level of consciousness
Pupil response
Hand grasps and foot pushes
Affect

28. SKIN ASSESSMENT Color Moisture or dryness Temperature Turgor Edema
Integrity

29. CARDIOVASCULAR STATUS
Apical pulse and heart tones
Nail beds
Personal habits contributing to or preventing cardiovascular disease
Chest pain or shortness of breath
Dizziness
Edema

30. RESPIRATORY STATUS Breath sounds.
Assess from side to side so the two sides can be compared.
Difficulty breathing.
Cough–productive or nonproductive.
Exposure to dust, chemicals, vapors, tobacco, paint fumes, irritants.

31. NORMAL BREATH SOUNDS
Bronchial–loud, high-pitched with hollow quality from air moving through trachea
Bronchovesicular–medium-pitched, blowing sounds from air moving through large airways
Vesicular–soft, breezy, low-pitched from air moving through smaller airways

32. RESPIRATORY TERMINOLOGY
Adventitious breath sounds–abnormal
Sibilant wheezes–high-pitched, whistling, heard during inhalation and exhalation
Sonorous wheezes–low-pitched snoring, louder on exhalation
Crackles–popping, heard on inhalation or exhalation, not cleared by coughing

33. RESPIRATORY TERMINOLOGY (continued)
Pleural friction rub–low-pitched grating sound, heard on inhalation and exhalation
Stridor–high-pitched, harsh sound heard on inspiration when trachea or larynx is obstructed

34. THORACIC ASSESSMENT
Includes wounds, scars, drains, tubes, and dressings.
Includes assessment of the breasts in the male and female client.

35. ABDOMINAL ASSESSMENT Gastrointestinal and genitourinary systems.
Note any wounds, scars, drains, tubes, dressings, or ostomies.
Auscultate bowel sounds.
Genitourinary assessment: abdomen, urinary meatus, genitalia, and urine.

36. MUSCULOSKELETAL AND EXTREMITY ASSESSMENT
Assess strength and symmetry by watching gait and postural movements.
Note aids to ambulation.
Muscles in both extremities: note equality of size, contour, tone, strength.
Assess lower extremities for changes, abnormalities.