1. Health Assessment Review

2. What is health assessment?
Concerned with health promotion and disease prevention
Used to make a judgment or diagnosis about the health of an individual
A guide for data collection and health evaluation

3. Medical diagnosis vs. Nursing diagnosis
Medical diagnosis concerned with the etiology of disease
Nursing diagnosis concerned with the impact of the health problem on the whole person and with the individual’s response to the problem
Nurses constantly observe and collect data: all part of assessment

4. Interviewing
An assessment tool is used to collect data to assist in formulating a diagnosis
Assess culture: a set of values, beliefs and traditions that are passed down
Language barriers can sometimes create communication problems, nurses need to be aware of this and be creative in interviewing

5. Interview Essential to ensure privacy
Make the environment conducive to an interview
Listen to the client and/or family and allow adequate time for answering questions
Always introduce yourself, including status and why you are there
Take special care with the patient with visual & hearing impairments or who does not speak english

6. Collecting information
Use open ended and closed ended questions to obtain data
Open ended asks the client for narrative or a chance to provide their story
Closed questions solicit yes or no answers and can be useful for clarification
There are many responses the nurse can make that will encourage or discourage conversation
Always remember to conclude the interview

7. Nonverbal skills
Messages that are productive and enhance the relationship
Defeating and non-productive: inattentiveness, authority, superiority, rolling eyes, behaviors that demonstrate a lack of respect

8. History: Adult Chief complaint/ characteristics Biographical data
Source of history
Reason for seeking care
History of present illness
Past history: can include surgeries, childhood illnesses
Family history
Review of systems

9. Integumentary Skin is an indicator of health status
Assessed by inspection and palpation
structures assessed are: the skin, hair, nails and scalp
Always assess the subjective data first, usually a series of questions aimed at getting the client’s perspective

10. Inspection Inspect for colour, vascularity, lesions and body odours
Inspect for obvious deviations from normal
Abnormals: blue, red, yellow
Document colour, type, location of lesions

11. Palpation
Temperature and moisture
Turgor
Edema
Texture

12. Nails Inspect shape, colour, angle and texture
Shape should be convex and follow the curve of the finger
Angle between the nail and its base should be about 160 degrees
Clubbing is an abnormal sign
Capillary refill

13. Pressure ulcers
Important aspect to assess in client’s with restricted mobility
Stages 1-4
Also a stage x which refers to those ulcers which are not able to be staged
Preventable with nursing attention

14. Musculoskeletal
Begin with subjective data related to the client’s musculoskeletal health
Assess for any risk factors
Techniques used are inspection and palpation
The client’s range of motion is also assessed

15. ROM Test the range for each joint and move the client through
Compare both sides
Do not force the joint beyond its normal range
If the client expresses pain or discomfort stop

16. Stance and gait
Stance should be evenly distributed, able to stand on heels, toes, and to have erect posture
Gait: toes point straight ahead, erect posture, stride equal on both sides
Assess client walking into room

17. Inspection Inspect for symmetry Redness and swelling over joints
Muscle tone and strength
Ability to perform ROM

18. Palpation Palpate for warmth over joints Crepitus in a joint
Normal range of motion without any stiffness, or grinding of joints
Decrease in total bone mass as we age

19. Abdominal and Nutritional
Abdomen contains several vital organs
Assess the client’s subjective data
Assess any risk factors that the client may have
Make sure the client is lying down and that you have a warm stethoscope
Patient should also have an empty bladder

20. Assessment Abdomen divided into 4 quadrants Each quadrant is assessed
The sequence is always inspection, auscultation and palpation
Palpation may stimulate bowel sounds and is done after auscultation of the abdomen

21. Inspection
Look at skin colour and surface characteristics, including the umbilicus, contour, symmetry, peristalsis, pulsations and masses

22. Auscultation Used to assess bowel sounds and vascular sounds
Performed systematically, using the 4 quadrants
Listen for bowel sounds and note frequency and characteristics
Bowel sounds are clicks and gurgles that should be heard every 5-30 seconds
Listen for 1-5 minutes

23. Palpation Palpate: light and deep
Watch patient’s face for signs of discomfort
Abdomen should be soft, relaxed and free of tenderness
Palpate liver, spleen, kidneys: liver, spleen not palpable, only right kidney may be palpable

24. Vital Signs Provide data to reflect the status of the client’s health
Measure the temperature first, then pulse, respirations and blood pressure
Important to know the client’s normal readings prior to beginning

25. Temperature Assess by oral, rectal, tympanic, axilla
Several factors may impact on normal temperature
Rectal is most accurate
Tympanic is quickest but may not be as accurate
Axilla used for children

26. Pulse Measures contraction of the heart
Assess rate, rhythm, amplitude, contour and elasticity
Rate: normal is beats per minute
Tachycardia: greater than 100
Bradycardia: less than 60

27. Amplitude and contour describe the strength of the pulse
Never use your thumb to measure pulse
Count for one full minute
Various areas for assessing pulse

28. Respirations
Monitor by observing the client’s chest rise and fall with each breath
Count respirations for 30 seconds and multiply by 2
Don’t let the client know that you are counting respirations as this may change breathing pattern
Normal rate: breaths per minute with a regular rhythm and equal bilateral chest expansion

29. Blood Pressure
Reflects the pressure that is exerted on the walls of the arteries
Expressed as the ratio of the systolic pressure over the diastolic pressure
BP will normally vary over the day
Normal: systolic mm Hg; diastolic mm Hg
A difference of about 10 mm Hg between arms is normal
If concerned always check the other arm , try different equipment or get another nurse to verify

30. Cardiac Assessment Subjective data: look at past history, risk factors
Teach risk reduction measures
Tie BP, skin, nails, head, neck and thorax and lungs, and peripheral pulses into this assessment
Techniques inspection, palpation and auscultation

31. Inspection
Observe the neck and precordium ( front of the thorax or chest) for any visible pulsations
Inspect the epigastric area for pulsation of the abdominal aorta
Client should be supine with the head of bed elevated degrees

32. Palpation
Systematic
Assess specific cardiac landmarks: aortic, pulmonic, tricuspid, and mitral areas
Each area is palpated for pulsations or thrills
Assess the apical pulse in the mitral area (4th or 5th intercostal space). Use one finger pad for accurate palpation…can auscultate apical as well

33. Auscultation
Used to determine the heart sounds caused by closure of the heart valves
Use same landmarks as previously
Listening for rate and rhythm
Listen for the heart sounds (S1 and S2), these are the “lub” Dup” sounds
Listen for the full lub-dup for apical pulse

34. Peripheral Vascular Assess subjective data. Assess risk factors
Teach risk reduction measures
Includes measuring the BP and assessing peripheral pulses
Techniques used are inspection and palpation

35. Inspection
Inspect for size, symmettry, presence of edema and venous patterning
Look at skin colour
Look at nail colour (hands and feet): clubbing
Inspect for varicosities
Look at distribution of hair

36. Palpation Palpate for temperature
Palpate the pulses: peripheral, brachial, radial, carotid
Use the pads of the fingers
Palpate for symmetry and amplitude
Palpate for edema
If an occlusion is suspected you can try to auscultate

37. Capillary refill
Quick and easy way to get a picture of the client’s peripheral vascular status
Compress the nail bed until it blanches
Release it and note the time it takes for colour to return

38. Genitourinary Assess subjective data
Normal urine should be straw coloured with no offensive odour or sediment
Usually about mls of urine in bladder will stimulate the need to void but bladder can distend to hold mls
Techniques inspection and palpation

39. Inspection Inspect organs associated with urination.
Looking for obvious signs of discharge or infection
Any noticeable deviations from normal

40. Palpation Palpate for urethral discharge in men
Physicians can palpate the prostate gland
The urinary bladder can be palpated if it is full
The kidneys can be palpated but it can be difficult to feel anything

41. Kidneys Integral part of body functioning
Role is to filtrate waste from the body

42. Fluid balance Essential part of assessment
Intake includes fluid from IVs, oral, liquid meals
Output includes urine, diarrhea, emesis, wound drainage
Important to ensure an adequate fluid balance: positive balance when intake is greater than output, negative balance when intake is less than output

43. Labs Review your readings Review your notes
The areas covered from labs will be the “common sense” types of questions
Take your time!!