Health assessment

• The cross-referencecard icon on some cards in the Head-to-Toe Assessment section of the deck indicates which card or cards in the Reference Guide section to use for more information on a key aspect of the Assessment.
• Placing all four side rails on a patient's bed poses a safety risk for patients who will attempt to get out of bed on their own.
• Thank the patient for their time.
• Perform hand hygiene upon exiting.
• Throughout the deck, key facts are highlighted with a magnifyingglass.
• The Head-to-Toe Assessment section of the deck helps nurses and nursing students understand the key steps in performing a comprehensive head-to-toe patient assessment.
• The deck provides information on what to assess and how to assess each component of a complete head-to-toe assessment.
• The General Survey, Vital Signs, Pain Assessment, Skin and Nail Assessment, Head, Face, Neck, Lymphatics, Eyes, Ears, Nose, Mouth/Throat, Posterior and Anterior Chest, Neck Vessels and Heart, Abdomen, Musculoskeletal System, and Nervous System are all physical assessment components.
• Physical assessment components include Inspection, Palpation, Percussion, and Auscultation.
• Inspection in physical assessment involves the use of touch to assess for temperature, turgor, texture, moisture, vibrations, shape, size.
• Palpation in physical assessment involves the use of touch to assess for most tender areas.
• Percussion in physical assessment involves tapping on a person's skin to assess location, size, density of tissues.
• Auscultation in physical assessment involves listening with a stethoscope to assess pitch, loudness, quality and duration of bod sounds.
• Normal order for physical assessment is Inspect, Palpate, Percuss, Auscultate.
• Anterior Chest Inspection involves assessing for use of accessory muscles, retractions, shortness of breath, symmetry, visible pulsations, and tenderness.
• Heart Inspection involves observing for lifts and heaves, palpating across the precordium for thrills, and auscultating with diaphragm and bell.
• Palpation of the abdomen involves palpating each quadrant and assessing for muscle guarding, rigidity, masses, and tenderness.
• Percuss for CVA (costovertebral angle) tenderness.
• Percussion of the anterior chest involves percussing the chest wall.
• Auscultation of the anterior chest involves listening to breath sounds.
• Abdomen Auscultation involves auscultating bowel sounds in all four quadrants: RLQ, RUQ, LUO, LLQ, and using the bell to listen for bruits over the abdominal aorta.
• Palpate tender areas LAST.
• Abdomen Inspection involves assessing the contour of the abdomen, the umbilicus, for lesions, scars, striae, distention, visible pulsations, and symmetry.
• Palpation of the anterior chest involves palpating for symmetrical chest expansion, tenderness and masses, and assessing for tactile fremitus.
• Neck Vessels Inspection involves assessing for Jugular Venous Distention (JVD) and palpating each carotid pulse (one at a time).
• Posterior Chest Auscultation involves listening to all lung sounds using the diaphragm of the stethoscope in a "S" pattern.
• Percussion of the abdomen involves percussing the liver for size.
• Abdominal assessment order is Inspect, Auscultate, Percuss, Palpate to avoid altering bowel sounds.
• Beginning an assessment involves performing hand hygiene, making your presence known, introducing yourself and stating your job title, and documenting the assessment.
• Body Structure/Mobility in a health assessment involves assessing gait, posture, range of motion, use of assistive devices, nutritional status, and obvious deformities.
• Respirations in a health assessment can be assessed for rate, depth, and rhythm.
• Health Assessment General Survey includes observations regarding Physical Appearance, Body Structure/Mobility, Behavior, and Vital Signs such as temperature, pulse, and respirations.
• Determine if the patient has allergies.
• Temperature in a health assessment can be taken orally, temporal, tympanic, axillary, or rectally.
• Identify the patient using two patient identifiers such as name, date of birth, MRN#.
• Explain the reason for the assessment.
• Physical Appearance in a health assessment includes assessing the level of consciousness, age, gender expression, facial features, signs of distress.
• Vital Signs in a health assessment include temperature, pulse, and respirations.
• Pulse in a health assessment can be assessed radially or apically and a pulse deficit can be calculated.
• Tell the patient why you are there and how long it will take.