Chapter 27

Health Assessment

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Preparing for the Health Assessment

Environment• Ensure privacy• Quiet, warm room• Special needs of the client• Surface for placement of equipment

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Preparing for the Health Assessment

Equipment• Maintenance• Isolation precautions• Adequate number of gloves

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Preparing for the Health Assessment

Positioning • Ensures accessibility to the body part being

assessed.

Draping• Prevents chilling.• Prevents unnecessary exposure.

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Conducting the Health and Physical Assessment

Aimed at establishing a data base against which subsequent data can be compared.• Comprehensive Assessment (head to toe)• Assessment of a body part (focused)• Assessment of a body system (focused)

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Conducting the Health and Physical Assessment

Conducted in an aseptic, systematic, and efficient manner.

Requires the fewest position changes for the client.

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General Survey

Initial Observations • Client’s physical appearance• Mood and behavior• Speech patterns and voice intonations• Signs and symptoms of distress• Vital signs• Height and weight

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General Survey

Special Considerations• Elderly clients• Disabled clients• Abused clients

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Measurement of Height and Weight

Height• Height is expressed in inches (in), feet (ft),

centimeters (cm), or meters (m).• A scale for measuring height is usually

attached to a standing weight scale.• Infant’s length is measured from vertex (top)

of head to soles of feet while infant is lying with knees extended.

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Measurement of Height and Weight

Weight• Measurement of weight is expressed in

ounces (oz), pounds (lb), grams (g), or kilograms (kg).

• Daily weights should be obtained at the same time of the day, on the same scale, with the client wearing the same type of clothing.

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Measurement of Height and Weight

Weight• Types of scales available include chair,

stretcher, bed, and platform scales.• Infants are weighed on platform or cradle

scales.

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Measurement of Height and Weight

Nursing Considerations• Accurate recordings are necessary for drug

dosage calculations and evaluation of effectiveness of drug, fluid, and nutritional therapy.

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Measurement of Height and Weight

Documentation• Height and weight are recorded on the

admission assessment form.• Daily weights are usually recorded on the

vital signs record.• Measurements taken at different times or on

different scales should be recorded.

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Vital Signs

The taking of vital signs refers to measurement of the client’s body temperature (T), pulse (P) rate, respiratory (R) rate, and blood pressure (BP).

Vital signs are the first step in the physical examination.

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Vital Signs

Assessment of vital signs provides specific data regarding the client’s current condition.

Variations from baseline values may indicate potential problems with the client’s health status.

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Vital Signs

The sequence for recording vital sign measurements in the nurses’ notes is T-P-R and BP.

Vital signs are plotted on graphic forms that facilitate data comparison at a glance.

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Thermoregulation

The body’s physiological function of heat regulation to maintain a constant internal body temperature

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Physiologic Function

Thermoregulation• The heat of the body is measured in units

called degrees.• The core internal temperature of 98.6

degrees Fahrenheit (F) does not vary more than 1.4 degrees F.

• Core internal temperature is higher than the skin and external temperature.

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Thermoregulation

Heat Production• Basal Metabolic Rate (BMR)• Vasodilation• Vasoconstriction• Piloerection

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Thermoregulation

Heat Loss• Radiation• Conduction• Convection• Evaporation

Insensible Heat Loss

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Thermoregulation

Behavioral Control of Body Temperature• The person makes appropriate

environmental adjustments in response to the body’s signaling conditions of either being overheated or too cold.

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Respiration

Respiration is the act of breathing. Terms related to respiratory function are:

• External respiration• Internal respiration• Inspiration• Expiration• Vital capacity

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Respiration

Major physiological pulmonary functions are:• Ventilation• Circulation• Diffusion• Transport• Regulation

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Hemodynamic Regulation

The circulatory system transports nutrients to the tissues, removes waste products, and carries hormones from one part of the body to another.

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Hemodynamic Regulation

Systemic Circulation• Arteries• Arterioles• Capillaries• Veins• Venules

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Hemodynamic Regulation

Cardiac Cycle• Systole• Diastole

Stroke Volume Cardiac Output Compensatory Mechanisms

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Hemodynamic Regulation

Pulse• The pulse is caused by the stroke volume

ejection and distension of the walls of the aorta.

• The bounding of blood flow in an artery is palpable at various points in the body (pulse points).

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Hemodynamic Regulation

Blood Pressure • Measurement of pressure pulsations exerted

against the blood vessel walls during systole and diastole

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Blood Pressure

Systolic Pressure • Maximum pressure exerted against arterial

walls during systole

Diastolic Pressure • Pressure remaining in the arterial system

during diastole

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Hemodynamic Regulation

Hemodynamic regulators for blood pressure control are:• Blood volume• Cardiac output• Peripheral vascular resistance• Viscosity

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Factors Influencing Vital Signs

Age Gender Heredity Race Lifestyle Environment

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Factors Influencing Vital Signs

Medications Pain Exercise Anxiety and Stress Postural Changes Diurnal (daily) Variations

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Assessing Body Temperature

Temperature Scales• Centigrade or Fahrenheit scales are used to

measure temperature.• Glass or electronic thermometers are used.

Temperature Sites• Oral• Rectal• Axillary

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Assessing Body Temperature

Alterations in Body Temperature• Pyrexia• Hyperthermia• Heat Exhaustion• Heat Stroke• Hypothermia• Frostbite

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Assessing Pulse

Sites• The most accessible peripheral sites are the

radial and carotid sites.• The carotid site should always be used to

assess the pulse in a cardiac emergency.

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Assessing Pulse

A peripheral pulse is palpated by placing the first two fingers on the pulse point with moderate pressure.

A Doppler ultrasound stethoscope is used on superficial pulse points.

A stethoscope is used to auscultate the heart’s rate and rhythm.

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Assessing Pulse

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Assessing Pulse

A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate.

Pulse Characteristics• Pulse quality• Pulse rate (bradycardia, tachycardia)• Pulse rhythm (dysrhythmias)• Pulse volume

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Assessing Pulse

Nursing Considerations• An irregular pulse rate, if not previously

documented, should be reported immediately.

• Clients on certain cardiac medications may need to monitor their pulse rate.

• Routine exercise lowers resting and activity pulses.

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Assessing Respirations

Sites• Observation of chest wall expansion and

bilateral symmetrical movement of the thorax

• Placement of back of hand next to client’s nose and mouth to feel expired air

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Assessing Respirations

Rate is counted by number of breaths taken per minute.

Observation of thoracic and abdominal movements includes:• Depth, rhythm, and symmetry• Costal (thoracic) breathing• Diaphragmatic breathing

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Assessing Respirations

A stethoscope is used to auscultate breath sounds throughout the respiratory system.

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Assessing Respirations

Dyspnea, Bradypnea, tachypnea, apnea Hypoventilation Hyperventilation

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Assessing Respiratory Function

Cyanosis• Bluish appearance in the nail beds, lips, and

skin• Reduced oxygen levels in the arterial blood

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Assessing Respiratory Function

Clients with respiratory alterations require additional nursing assessment.• Pulse oximetry • Apnea monitor

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Assessing Respiratory Function

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Assessing Blood Pressure

The direct method of measuring blood pressure requires an invasive procedure.

The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed.

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Assessing Blood Pressure

The most common site for indirect measurement is the client’s arm over the brachial artery.

Accurate measurement requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity.

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Assessing Blood Pressure

Korotkoff sounds are five distinct phases of sound heard with a stethoscope during auscultation.

The forearm or leg sites can be palpated to obtain a systolic reading when the brachial artery is inaccessible.

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Assessing Blood Pressure

Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure.

Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg.

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Assessing Blood Pressure

Orthostatic Hypotension (postural hypotension)• Sudden drop in systolic pressure when client

moves from a lying to a sitting to a standing position

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Assessing Blood Pressure

False Readings• Clients who have recently eaten, ambulated,

or experienced an emotional upset• Improper cuff width• Improper technique in deflating cuff• Improper positioning of extremity• Failure to recognize an auscultatory gap

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The Physical Examination

Techniques• Inspection• Palpation• Percussion• Auscultation

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Integumentary System

Skin Hair and Scalp Nails

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Skin Assessment

Skin assessment provides a noninvasive window to observe the body’s physiological functions.

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Skin Assessment

Color Lesions Moisture Temperature Texture Mobility and Turgor Edema

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Integumentary System

Hair• The amount and texture of hair vary with

age, sex, race and body part.• Vellus• Terminal hair

The scalp should be smooth, clean, intact, and free of lumps or tender areas.

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Integumentary System

Nails• Clubbing• Koilonychia (spoon nail)• Beau’s line • Paronchia

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Physical Examination

Head• Skull and face assessment involves

inspection and palpation. • The client’s face has its own unique

characteristics related to race, state of health, emotions, environment.

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Physical Assessment

Eyes• Conjunctive and sclera are assessed for

color, redness, swelling, exudate, foreign bodies

• Visual acuity• Fundoscopy

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Physical Assessment

Ears• Auditory screening• Inspection and palpation of external ear• Placement, symmetry• Otoscopic assessment

Nose and Sinuses• Inspection and palpation• Use of a penlight

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Physical Examination

Mouth and Pharynx• Breath• Lips• Tongue• Buccal mucosa• Gums and teeth• Hard and soft palate• Pharynx

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Physical Examination

Neck• Neck muscles• Lymph nodes of head and neck• Thyroid gland• Trachea

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Physical Examination

Thorax and Lungs• Landmarks for inspection, auscultation, and

percussion• Anterior and posterior examination• Shape and symmetry• Thoracic expansion• Tactile fremitus

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Thorax and Lungs

Auscultation of Normal Breath Sounds• Vesicular sounds• Bronchovesicular sounds• Bronchial sounds

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Thorax and Lungs.

Auscultation of Adventitious Breath Sounds• Crackles• Rhonchi• Wheezes• Pleural friction rub• Stridor

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Heart and Vascular System

Heart• Landmarks for inspection, palpation,

auscultation• Heart sounds• Palpation for thrills and heaves• Abnormal auscultatory findings

- Murmurs- Bruits

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Heart and Vascular System

Vascular System• Blood perfusion of peripheral vessels

- Peripheral pulses compared bilaterally- Skin temperature, color

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Physical Examination

Lymphatic System• Lymphatic drainage• Lymph nodes

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Breasts and Axillae

Palpation of four quadrants of breasts Palpation of supraclavicular,

infraclavicular, and axillary nodes Education and encouragement of

questions about breast self-examination (BSE)

Breast cancer can also occur in males.

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Breasts and Axillae

Drainage patterns of the left breast.

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Abdomen

Inspection • Contour • Symmetry• Umbilicus• Surface motion• Scars

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Abdomen

Auscultation • All four quadrants in a systematic fashion• Beginning with the RLQ

- Tympany- Dullness- Bruits- Hyperactive or hypoactive bowel sounds

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Abdominal Quadrants

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Abdomen

Light palpation in all four quadrants beginning with the RLQ• Resistance• Tenderness• Rebound tenderness• Organ enlargement

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Female Genitalia and Anus

Cultural Considerations Inspection and Palpation

• Mons pubis and vulva• Labia majora, labia minora• Clitoris • Urethral meatus and vaginal introitus• Perineum and anus

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Male Genitalia, Anus, and Rectum

Testes and male gonads Seminal vesicles and bulbourethral

glands Epididymis, vas deferens, ejaculatory

ducts Scrotum, penis, spermatic cord Anorectral exam including the prostate Monthly testicular self-examination (TSE)

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Musculoskeletal System

Inspection Palpation Range of Motion (ROM) Bilateral Comparison

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Musculoskeletal System

Muscle• Hypertrophy• Atrophy• Hypertonicity• Hypotonicity

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Musculoskeletal System

Joints• Arthritis• Osteoarthritis• Crepitus

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Neurologic System

Mental Status • Physical appearance and behavior• Communication• Level of consciousness

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Mental Status

Cognitive Abilities and Mentation• Attention• Memory• Judgment, insight• Spatial perception• Calculation• Abstraction• Thought process and content

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Neurological Assessment

Sensory Assessment• Exteroceptive sensations• Proprioceptive sensations• Cortical sensations• Dermatome map

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Neurological Assessment

Cranial Nerves Assessment Motor Assessment Cerebellar Assessment Reflex Assessment