مدرس المادة
Abdulrahman Thiab Ahmed
المساق الجامعي
Health Assessment

Health Assessment

Part 1: Introduction and Overview to Health Assessment: 

Health assessment refers to a systematic method of collecting and analyzing data for planning patient centered care.

Purpose of physical Assessment:

  1. To collect data pertinent to the patient’s health status.

  2. To identify deviations from normal.

  3. To pinpoint actual problems.

  4. To spot factors that place the patient at risk for health problems.

  5. To supplement, confirm, or question data obtained in the nursing history.

  6. To obtain data that will help the nurse establish nursing diagnoses and plan patient care. 

  7. To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems

  • Data collection:

Types of Data:

  1. Objective data (Signs) are detectable by an observer. They can be seen, heard, felt, smelled, or measured. For example, a discoloration of skin, a blood pressure reading, the act of crying, , swollen joint, or a hand tremor.

  • Objective data can be collected by physical examination, diagnostic and laboratory test results, pertinent nursing and medical literature.

  1. Subjective data (Symptoms) are apparent only to the person affect and can be described or verified only by that person. For example, Itching, pain, and feeling worried.

  • Subjective data can collected from the client, family, significant others, health care team members, and health records.

Sources of Data:

  1. Primary (direct source): the patient; is always the best source of data. The client can usually provide subjective data that no one else can offer.

  2. Secondary (indirect source): significant others, health personnel, medical records.

Methods of Data Collection:

  1. Observation: is to gather data by using the five senses. Although nurses observe mainly through sight, all of the senses are engaged during observation.

  2. Interviewing: is a process in which understanding of a situation is gained through the collection of information from the individual who is then helped to make decisions about his health status. 

 

 

 

Guideline in conducting health assessment

  1. Preparing the patient

To ensure an accurate assessment and physical examination. The patient must be properly prepared physically and psychologically. To prepare the patient, the nurse:

  1. Prepare for patient's physical comfort, by allowing the opportunity to empty the bowel and bladder.

  2. Keep privacy while the patient changes.

  3. Help the patient assume proper positions during examination so that body parts are accessible and the patient stay comfortable.

  4. Thoroughly explain what will be done, what the patient should expect to feel, and how the patient can cooperate.

  5. Encourage patient to ask questions and mention discomfort felt during examination.

  6. Conduct the examination systematically from head to foot so as not to miss observing any system or body part.

  7. Because the body is bilaterally symmetrical, for the most part, compare findings on one side with those on the other.

  8. Preparing  equipment:

The nurse uses a variety of equipment throughout the assessment process.

Equipment and supplies needed for performing a physical examination

Equipment

Function

Incontinent sheet

Protect bed linen from getting soiled

drapes

Ensure privacy for the client.

gloves

Prevent cross infection.

Gown for patient

For easy access of different body parts.

Paper towel

Dry hands and arms and to wipe equipment.

Percussion hammer

Test various reflexes of the body.

Height/ weight scale

For measure body weight and height.

Specimen containers

Collect specific sample for laboratory evaluation.

Sphygmomanometer and cuff

Measure blood pressure.

stethoscope

Auscultator different bogy sounds

Tape measure

Measure body parts. e.g abdominal girth.

thermometer

Measure body temperature

Tongue depressor

Facilitate visualizing pharynx and tonsils.

Wrist watch with second hands

Record time of examination as needed.

Cotton applicators

Examine superficial sensation of the skin including corneal reflex.

Eye chart ( snellen chart

Test visual acuity

flashlight

Facilitate visualization for Ear, Nose, and Throat and to check corneal reflex.

Lubricant

Lubricate instrument used in rectal and vaginal examination.

Otoscope

Examine outer ear and the tympanic membrane

Laryngeal mirror

Metal instrument with mirror to inspect pharynx and oral cavity

Penlight

Flashlight to test pupillary reaction to light and assess

third, fourth, and sixth (oculomotor, trochlear, and

abducens) cranial nerves

ophthalmoscope

Examine fundus of the eye.

Sterile safety pin

Examine deep sensation of the skin.

Tuning fork

Test hearing acuity

Vaginal speculum

Facilitate vaginal examination

protoscope

Facilitate rectal examination

spirometer

Facilitate breathing examination

 

  1. Preparing the environment:

The examination room should have the following features.

  1. privacy for the patient.

  2. curtains or dividers to enclose the patient's bed.

  3. a warm comfortable temperature.

  4. proper examination clothing for the patient.

  5. adequate lighting.

  6. control of outside noises.

  7. precautions to prevent interruptions by visitors or other health care personnel.

  8. a bed or table set at examiner's waist level.

Part 2: Physical Assessment & Techniques of Examination:

 

The nurse depends  on his/her  own senses and uses them  in five examination techniques that enable nurse to collect a broad range of physical data about the patients. These are:

  1. Inspection (Using Sight)

  2. Palpation   ( Using touch)

  3. Percussion (Using hearing and touch).

  4. Auscultation (Using hearing)

Inspection:

  • Inspection refers to a visual examination of the body using the sense of sight.

  • Nurses frequently use this technique to assess color, rashes, scars, body shape, facial expressions that may reflect emotions, and body structures.

  • Inspection needs to be systematic. When inspect a patient should, for instance, proceed from head to toe, observing first for general characteristics, then for specific ones.

Inspection may be direct or indirect

  • Direct inspection involves directly looking at the patient.

  • Indirect inspection involves using equipment to enhance visualization.

For example, the oto/ophthalmoscope allows better visualization of the ears and eyes.

Palpation:

  • Palpation is the examination of the body using the sense of touch. The pads of the figures are use because their concentration of nerve endings makes them highly sensitive to tactile discrimination. 

  • The nurse’s touch is gentle, hands are warm, and nails are short to prevent discomfort or injury to the patient.

Palpation is use to determine:

  • Texture; e.g., of the hair

  • Temperature, e.g., of the skin area

  • Vibration, e.g.  of a joint.

  • Position, size, consistency ,and mobility of organs or masses.

  • Presence and rate of peripheral pulses.

  • Tenderness of pain.

 There are two main types of palpation:

  1. Light (Superficial) palpation: is applying very gentle pressure with the tips and pads of fingers to a body area and then gently moving them over the area, pressing about 1⁄2 inch. Light palpation is best for assessing surface characteristics, such as temperature, texture, mobility, shape, and size. It is also useful in assessing pulses, areas of edema, and areas of tenderness.

  2. Deep palpation: is applying harder pressure with fingertips or pads over an area to a depth greater than 1⁄2 inch. Deep palpation can be single-handed or bimanual Deep palpation is used to assess organ size, detect masses, and further assess areas of tenderness. 

Percussion: 

  • Percussion is an assessment method in which the body surface is struck to elicit sounds that can be heard or vibrations that can be felt.

  • Percussion is use to determine the size and shape of internal organs by establishing their borders. It indicates whether tissue is fluid-filled, or solid. Also its use to evaluate the density of underlying tissue and to elicit tenderness.

There are two percussion techniques: 

  1. Direct Percussion: involves striking a finger or hand directly against the patient’s body to evaluate the sinus of an adult by tapping a finger over the sinus or to elicit tenderness over the kidney by striking the costovertebral angle (CVA) directly with a fist.

  2. Indirect Percussion: requires both hands and is done by different methods, depending on which body system is being assessed. 

Indirect percussion is performed by placing the distal aspect of the middle finger of the nondominant hand against the skin over the organ being percussed and striking the distal interphalangeal joint (between the cuticle and first joint) with the tip of the middle finger of the dominant hand.

The tapping produces a vibration 1.5 to 2 inches (4 to 5 cm) deep in body tissue and subsequent sound waves. Percuss two or three times in one location before moving to another. 

Percussion elicits five types of sound. These are:

  1. Resonance: A loud, long, low-pitched sound normally heard over the lung fields. is a hollow sound such as that produced by lungs filled with air.

  2. Hyper-resonance: A loud, low-pitched, and very long sound heard over lungs that are over inflated with air (as in emphysema is not produced in the normal body. Its described as booming and can be heard over an emphysematous).

  3. Dullness: is heard over the liver.

  4. Flatness: A soft, high-pitched sound of short duration normally heard over muscles and bones.

  5. Tympany: A high-pitched, loud sound of medium duration usually heard over the stomach, indicating the presence of gastric air bubbles.  is a musical or drum-like sound produced from an air-filled stomach.

Characteristics of percussion sounds:

Percussion produces sounds that vary according to the tissue being percussed. This chart lists important percussion sounds along with their characteristics and typical locations.

Intensity

Pitch

Duration

Quality

Source

Sound

Soft

High

Short

Flat

Muscle, bone

Flatness

Soft to moderate

High

Moderate

Thud like

Liver, full bladder,

pregnant uterus

Dullness

Moderate to loud

Low

Long

Hollow

Normal lung

Resonance

Loud

High

Moderate

Drum like

Gastric air bubble,

intestinal air

Tympany

Very loud

Very low

Long

Booming

Hyperinflated lung

(as in emphysema

Hyperresonance

 

Auscultation:

Auscultation is the process of listening to sounds produces within the body. Auscultation may be direct or indirect.

  • Direct auscultation is the use of the unaided ear,. E.g. to listen to a respiration wheeze or the grating of a moving joint.

  • Indirect auscultation: is the use of stethoscope, which amplifies the sounds and conveys them to the nurse's ear. A stethoscope is used primarily to listen to sounds from within the body. E.g., heart, lungs, and bowel sounds.

 

تحميل الملف
First Lac Health Assessment.pdf