general health assessment

gather data about client

functional abilities & responses to illness/stresor

THE NURSE PERFORMS A

PHYSICAL EXAMINATION TO:

• establish a baseline data

• identify nursing diagnoses,collaborative problems,

or wellness diagnoses,

• monitor the status of an identified problem

• screen for health problems

• Comprehensive - interview + head to toe exam

• Focused - focused on presenting problem

• Ongoing - performed as needed to assess status, evaluates client outcomes

Head to Toe - starts at head * progresses down body

* system-related datat found throughout:

Heart sounds - chest; pulses - periphery

Body Systems - Gather system related data all at once

* may be done in a predetermined order

that mimics head-to-toe:

Nerological, cardiovascular, respiratory, gastrointestional

PREPARING YOURSELF

WHAT THE NURSE NEEDS TO KNOW

• Theoretical Knowledge (A&P techniques)

• Self-Knowledge

(skill, comfort level, willingness to seek help)

• Knowledge about client's situation

(purpose of exam, client diagnosis)

• Privacy Key (draping, use of curtains)

• Noise Control (TV/radio off)

• Temperature Control(what the client likes)

• Enable Visualization (adequate lighting, use penlight)

• Promote Client Comfort:

- Develop rapport

- explain procedure (lamens terms)

- respect cultural differences

- use proper positioning

(in this order)

• Inspection 

• Palpation (feel)

• Percussion

• Auscultation (listen)

• Olfaction (smell)

• Use of sight to gather data

• used throughout physical exam

• tools to enhance: otoscope, ophthalmoscope, penlight

• examples: skin color, gait, general appearance, behavior

• Use of touch to gather data

• begin with light pressure, moving to deep

• use caution with deep

• parts of hand used: fingertips - skin texture, swelling,& specific locations of pulsations & massesdorsum - back of hand; temperature, palm - general area of pulsation,grasping (fingers & thumb): detect position, shape and consistency of a mass

• Examples: Edema, moisture, antaomical landmarks, masses

• tapping on skin to elicit sound - direct tapping lightly with pads of fingers directly on the skin & indirect - used more frequently and requires two hands

• useful for assessing abdomen, lungs, underlying structures

• examples: distended bladder

• use of hearing to gather assessment data

• Direct - listening w/o an instrument

indirect - use of stethoscope (diaphragm - high pitched sounds, bowel/lung/heart/abdoment; bell - low-pitched sounds, heart murmurs, vascular bruit)

• sensing various body odors

• helps detect infection, poor hygiene practices

and certain disease processes

• adds information you collect through IPP&A

AGE MODIFICATIONS

INFANTS

• Parents Hold

• Attend to Safety

• teach parent normal growth and development

AGE MODIFICATIONS

TODDLERS

• allow to explore and/or sit on parent's lap

• ivasive procedure last

• Offer Choices (only 2)

AGE MODIFICATIONS

PRESCHOOL

• use doll for demonstration

• still may want parental contact

• allow child to help w/ exam

AGE MODIFICATIONS

SCHOOL-AGE CHILDREN

• Show approval, develop rapport (relationship)

• allow independence

• teach about workings of body

AGE MODIFICATIONS

ADOLESCENTS

• provide privacy

• concerned with normalcy

• use exam to teach health lifestyles

• screen for suicide risk (3rd leading cause of death)

AGE MODIFICATIONS

YOUNG & MIDDLE ADULTS

AGE MODIFICATIONS

OLDER ADULTS

• may need special positioning related to mobility

• adapt exam to vision and hearing

• assess for change in physical ability

• assess for ability to perform ADL's

• provide periods of rest as needed

BASIC COMPONENTS

GENERAL SURVEY

• appearance/behavior • grooming/hygiene

• body type/posture • mental state

• speech • vital signs • Ht/wt

begins at first contact, overall impression,

deviations lead to focused

BASIC ASSESSMENT:

SKIN (INTEGUMENTARY)

• characteristics - color, temp, moisture, texture, turgor or elasticity (hydration) , edmea (excessive amount of fluid in tissue, swelling), cancer screenings

• remember ABCDE - asymmetry, border irregularity, color variation, diameter greater than 0.5 cm, and elevation above surface

• Hair  - alopecia (hair loss), pediculosis (head lice), hirsutism (excess hair) color, texture, distribution

• Nails - brittle, color, clubbing (long term hypoxic state angle 180º), capillary refill

BASIC ASSESSMENT:

HEAD

HEENT - head, eyes, ears, nose & throat

• Skull & Face - size, shape, facial features (equal distances

Acromegaly - large head

microcephaly - small head (retardation)

TMJ - irregular jaw movement

BASIC ASSESSMENT

EYES

• external eye - blinking, lubrication

• sclera color

• pupils

PERRLA - Pupils equal, round, reactive to light, accomedation

Visual auity - distance, near side, color visual fields

internal structures - optomoscope

BASIC ASSESSMENT

EARS

external ear - hear

inner ear - otoscope

tympanic membrane (pearly, gray shiny translucent)

Hearing - weber's test sense of vibration in both ears

, Rinne's test compare air and bone conduction AC 2x as long as BC,

balance - Romberg's test - feet together, eyes closed, minimum sway

BASIC ASSESSMENT

NOSE

• smell - decreases w/ age; high rates in alzheimers

• no deviated septum

•mucus membranes pink, moist, no lesions

• need a penlight, otoscope

BASIC ASSESSMENT

MOUTH

lips, buccal mucosa, gums,palates - pink, smooth moist no lesions, uvula should rise w/ phonation (vocalization)

teeth - no cavities, no loose teeth, ability to chew well

BASIC ASSESSMENT

NECK

• musculature -sternocledomastoid and trapezius landmarks of neck

• trachea -midline

• thyroid gland - smooth firm non tender, non palable

Cervical lymph nodes - 3 chains, not palpable, small in size (no more 1 cm), mobile, soft and nontender

BASIC ASSESSMENT

BREASTS

size & shape - varies among women; 1 slightly larger (usually)

nipple characteristics - if retracting or unnormal discharge

tissue - pallpate (self breast exams)

include axillae

BASIC ASSESSMENT

LUNGS

breath sounds - make sure not over bone

bronchial - high pitched, loud, tubular expiration longer than inspiration over trachea on anterior chest below nape of neck on posterior chest

bronchovesicular - midpitched, equal inspiration and expiratory phase 1st & 2nd ICS adjacent to sternum

vesicular - soft, lowpitched, breezy lenghty inspir and shor expiration.

Diminished - poor inspiration effort

adventitious - crackles, etc

BASIC ASSESSMENT

CHEST

rises and falls w/ respiration

symmetrical

diameter expands up to 3 inches w/ deep inspiration

chest shape non barrel (COPD)

BASIC ASSESSMENT

CARDIOVASCULAR

Inpsection - PMI (Point Maximal impulse located at the 5th ICS space to left of sternum along midclavicular line less than 7 yrs between 3rd & 4th)

Palpation - Thrill (assessing turbulant blood flow  associated w/ murmur)

sounds - aunt polly takes meds (aortic, pulmonic, tricuspid, mitral)

S1 - lub closure of valves between atria and ventricles, marks beginning of systole

S2 - (dub) closure of semilunar valves (between ventricles and great arteries exiting heart) marks beginning of diastole, higher in pitch

S3 - immeiately heard after S2 gallop cadence follows rhythm of word KenTUcky normal young children adolescene sitting or lying 3rd trimester of pregnancy

S4 - heard b4 S1 rythm follows FLOrida. normal in trained athletes and older clients coronory artery disease hypertension and plmonic stenosis

murmurs - additional sounds produced by turblent flow through the heart

BASIC ASSESSMENT

VESSELS

• central vessels

   * carotid - palpate pulsation, special precautions, ausculate for bruit (abnormal sound blood flows over arteries)

• jugular veins - superficial and deep, flat in upright position distend when lies down JVD (juglar venous distention) seen when right side of heart congested due to inadequate pump function)

Peripheral vessels - blood pressure, peripheral pulses (arteries) signs of inadequate oxygenation (cyanosis skin shiny tout)

varicosites - rope like destended veins

BASIC ASSESSMENT

ABDOMEN

different order palpate last

inspect - symetrical left & right no distension aorta pulsating don't palpate

ausculate- for bowel sounds if distorted don't palpate

percuss -

palpate - distor bowel sounds if do lightest tough to deeper area hurts do last

BASIC ASSESSMENT

BONES, MUSCLES, JOINTS

body shape/symmetry - posture, gait, spinal curvature

balance - romberg's test

coordination - finger-tumb opposition, movement

Joint mobility - color change (inflammation, infection erythema, swelling), deformity, crepitus (2 types chest tube and joints creaking), ROM

Muscle strength - ROM, resistance,

BASIC ASSESSMENT

NEUROLOGICAL

cereberal functions - level of consciousness (glascow comma scale achieve highest 15), arousal, response to verbal, tactile and painful stimuli, orientation - time place, person,

Mental status/cognitive functions - behavior, appearance, response to stimuli, speech, memory, communication, judgment

cranial nerve assessment -

reflexes automatic responses, responses on graded scale

motor/cerebellar function - important for movement coordination, tone, posture, equilibrium proprioception (aware of body parts and functions)

sensory functions - light touch, light pain, temp, vibration, position sense, stereongnosis (ability to recognize object by touch), graphesthesia (ability to recognize symbols, outlines etc written on skin) 2 pt, discrimination - able to tell when someone touches u on2 parts of body, what each part is) extinction (no touch)

olfactor - sensory, smell

optic - sensory visual acuity fields and ocular fundi

oculomotor - motor, EOM, pupil size

trochlea - motor, EOM

trigeminal - 3 branches, sensory & motor, corneal reflex, facial sensation, jaw movement

abducens - motor, EOM

facial - motor sensory, facial movement

acoustic - sensory, hearing equilibrium

glassopharyngeal - motor sensory swallowing, gag response, tongue movement, taste

vagus - motor sensory, sensation of pharynx & Larnyx, motor activity swallowing vocal cords

spinal accessory - motor, head movement and shoulder elevation

hypoglossal - motor tongue movement

BASIC ASSESSMENT

GENITOURINARY ASSESSMENT

Male - includes reproductive information (had children or not, are fertile)

external genitalia - penis, urethral opening, scrotum, lymph nodes, puic hair, Male TSE (self exam)

Examine for hernia - no hard knodules or cysts

female external genitalia - labia, clitoris, urethral opening, vaginal orifice, pubic hair, lymph nodes,

Check for pregnancy, UTI or STIs

other - Kidnesy (CVA tenderness), bladder (palpate abdomen, bladder scan) NP/MD responsible for anus, rcutm prostrate exam

NP/MD resonsible for pelvic exam

peri cares - look for hemorrhoids, rectal bleeding incontincence

catheter insertion/care - clean daily, assess for lesions, skin ulcerations, presence of yeast, abnormal draingage, assess for S/S UTI, Incontinence