Health Assessment: Part 1

1. NEO 111 Melanie Jorgenson, RN, BSN Health Assessment: Part 1

2. Examination Techniques • Inspection: performing deliberate, purposeful observations in a systematic manner • Palpation: using the sense of touch • Percussion: striking one object against another to produce sound • Auscultation: listening with a stethoscope to sounds produced in the body

3. Health History • Biographical data • Reason for seeking care • History of present health concern • Past medical history • Family history • Lifestyle

4. 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) Positions for Physical Examination

5. Assessments Made Using Palpation • Temperature • Turgor • Texture • Moisture • Pulsations • Vibrations • Shape and masses • Organs

6. Assessments Made Using Percussion • Location • Shape • Size of organs • Density of other underlying structures or tissues

7. Assessments and Characteristics of Sounds Determined by Auscultation • Assessments • Blood pressure • Heart sounds • Lung sounds • Bowel sounds • Characteristics of sounds • Pitch • Loudness • Quality

8. Initial Assessment Data • General survey • Height and weight • Vital signs

9. Elements of a Head-to-Toe Physical Assessment • The Head & Neck • The Eyes & Ears • The Nose & Sinuses • The Mouth & Throat • Chest and back • The Posterior and Lateral Thorax • The Anterior Thorax • The Heart

10. 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.

11. Neck and Head Assessments • Facial structures • Eyes, ears, nose, mouth, and throat • Anterior neck structures • Trachea, esophagus, thyroid glad, arteries, veins, and lymph nodes • Posterior neck areas • Upper portion of the spine

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

13. 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)

14. 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)

15. Thorax and Lung Assessments • Respiratory system • Recognizing and identifying normal and abnormal breath sounds • Components of the thorax • Lungs, rib cage, cartilage, and intercostal muscles • Assessment techniques • Inspection, palpation, percussion, and auscultation

16. Palpating the Posterior Thorax (Sequence)

17. Cardiovascular System Assessments • Functions of the system • Transports oxygen, nutrients, and other substances to the body tissues • Removes metabolic waste products to the kidneys and lungs • Assessment techniques • Careful auscultation is important to identify heart sounds

18. Documentation of Cardiac Assessment Findings • Any symptoms patient is experiencing • Vital signs • Color and temperature of skin; capillary refill of nails • Inspection findings related to carotid arteries, jugular veins, and anterior chest wall • Palpation findings related to sternoclavicular area and anterior chest wall • Auscultation findings, including rate, rhythm, pitch, and location of sounds

19. Palpating the Apical Impulse

20. Questions?

21. NEO 111 Melanie Jorgenson, RN, BSN Health Assessment: Part 2

22. Elements of a Head-to-Toe Physical Assessment – Part 2 • Neurological • Skin • Musculoskeletal • Upper and lower extremities • Abdomen

23. Neurologic & Musculoskeletal Assessment • Neurologic system • Assesses cognitive function • Evaluates sensation in the body, cranial nerves, and DTR • Musculoskeletal examination • Provides information on muscles and joints • Peripheral vascular system • Identifies condition of arteries and veins in the extremities

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

25. Integumentary Assessments • Components of the integumentary system • Skin, hair, nails, sweat glands, and sebaceous glands • Findings • Nutrition and hydration • Overall health status • Information associated with certain systemic diseases, infection, immobility, sun exposure, and allergies

26. Inspecting Overall Skin Coloration

27. 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

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

29. Abdomen Assessments • Components of the abdominal cavity • Men and women: stomach, small and large intestines, liver, gallbladder, pancreas, spleen, kidneys, urinary bladder, adrenal gland, and major blood vessels • Women: uterus, fallopian tubes, and ovaries • Assessment techniques • Order: inspection, auscultation, percussion, and palpation • Not all organs can be assessed

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

31. Questions?