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Assessment

Assessment. Physical Assessment Part 1 Helen Harkreader, RN, PhD. Nursing Assessment. gathering information about the health status of a person identify concerns and needs that can be treated or managed by nursing care. look, listen, touch, to make an informed decision about care.

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Assessment

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  1. Assessment Physical Assessment Part 1 Helen Harkreader, RN, PhD

  2. Nursing Assessment • gathering information about the health status of a person • identify concerns and needs that can be treated or managed by nursing care. • look, listen, touch, • to make an informed decision about care.

  3. Types of Assessment • Initial • Focused • Ongoing • Shift Assessment • Emergency

  4. Health History • Reason for admission/chief complaint • Demographic information • History of present illness • Family history • Other history • Medical: diabetes, heart disease, renal disease • Surgical history

  5. Health History • It’s important to remember: • Nursing care is more concerned with • helping the person manage or function with a health problem • Not with • diagnosing and treating illnesses.

  6. Physical Exam • Usually follows history • Head to toe approach • Includes (as needed): inspection, palpation, auscultation, and percussion

  7. General Survey • How do they look overall? • What can you discern just by looking at and talking with them? • Are they oriented? • What is their mood? • How about nutritional status? • Vital signs?

  8. General Survey • As you introduce your self and establish trust with the patient your are beginning the general survey

  9. General Survey • Level of consciousness • Orientation • Confusion • Memory • Mood, affect • Signs of distress: dyspnea, anxiety

  10. Planes of the Body • Sagittal (through midline)-divides right and left; medial and lateral • Frontal plane- divides anterior and posterior • Transverse – divides top to bottom through pelvis; superior and inferior • Proximal and distal

  11. Inspection • Visual examination - looking • Color, shape, size, symmetry, position and movement • Good lighting is very important

  12. Palpation • Assessment through touch • Temperature, moisture, texture, tenderness, masses, and edema • May be light or deep, one hand or two • Make sure your hands are clean and fingernails short!

  13. Percussion • Short, sharp strikes to the body surface to produce palpable vibrations and sounds • Maybe direct (one hand) or indirect (two hands) • Can detect size, shape, density and location of structures

  14. Auscultation • Listening to the sounds in the body (usually with a stethoscope) • Used to listen to lung sounds, heart sounds and abdominal sounds • Keep your stethoscope clean!

  15. HEENT • Head, Eyes, Ears, Nose, Throat • Look at distribution of hair. Are there any lumps on the head? Discolorations? • Is head normal size? Upright? Are the facial structures symmetrical in shape?

  16. HEENT • Basically a Cranial nerve assessment • You do not need to check each cranial nerve at this point, but be aware of what they are and how to assess them.

  17. HEENT • Does the mouth droop? • Talk to the patient. Do all the facial muscles move together? • Can the person see and hear well? • Pupils equal, round and reactive to light and accommodation. • What does this mean? • Check the eye muscle function. Have the patient follow your finger to all eight positions. • Inspect the ear and assess hearing by talking to the patient

  18. Cranial Nerves • examine sensation and movement of the face: the facial nerve--CN VII and the trigeminal nerve--CN V • List the function of each cranial nerve. Which ones are used for swallowing?

  19. Other HEENT • Check the nose for abnormalities • If warranted, palpate the sinuses for tenderness • Look at mouth and neck. Take a look at the tongue. Are there white patches? Red patches? • Check range of motion for the neck (gently!). • Look at the neck for jugular vein distention. This could indicate a heart problem.

  20. Other HEENT • Where are these structures? • Lymph nodes • Jugular veins • Carotid arteries • Trachea • Trapezius and sternocleidomastoid

  21. Other HEENT • To assess the lymph nodes, place both hands on the neck at the same time and palpate using the pads of your fingers. • Normal: not palpable or smooth, firm, less than 1 cm, mobile, and nontender

  22. Head and Neck • size, symmetry, position and movement of head • temporomandibular joint

  23. Skin • Inspection • Intact, free of lesions • Pink toned or underlying healthy glow • Palpation • Warm, cold, moist, dry • Lesion: Hard, firm, feels like fluid • Movable, fixed, attached to underlying structures

  24. Skin Color • cyanosis (central, peripheral, circumoral), • jaundice, • pink tone, glowing, ashen • pallor, • erythema

  25. Skin • Turgor • Moisture • Temperature

  26. Skin Disruptions • macules, papules, nodules • vesicles, bulla • scales, plaque, patches (vitiligo) • petechiae, necrosis, keloid • linear, annular

  27. Describing Lesions • Size, color, type (primary, secondary), location, distribution • local vs. generalized • Annular, linear • Abrasion, laceration

  28. Hair • Distribution • Texture • Cleanliness, grooming • Scalp for lesions • Infestations

  29. Nails • Capillary refill • Abnormal shape • Clubbing

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