HA- IPPA

• Health assessment is an organized and systematic approach using the techniques of inspection, palpation, percussion, and auscultation to obtain baseline data on the patient, to supplement or question data obtained in the nursing history, and to obtain data that will help the nurse establish nursing diagnosis and plan of care.
• The examination room should be adequately ventilated, comfortable, quiet, private, with adequate lighting.
• The examination table should be at a height that prevents the examiner from stooping and should be equipped to raise the head up to 45 degrees.
• A bedside stand or table should be available for laying out equipment.
• Observe for signs of distress in posture, such as bending over because of abdominal pain or facial expressions, wincing or labored breathing.
• Observe the person's activities prior to assessment.
• Note body and breath odor in relation to activity level.
• Observe the person's race, sex, general physical development, nutritional state, mental alertness, affect, evidence of pain, restlessness, body position, clothes, and apparent age.
• Careful observation of the general state of the individual provides many clues about a person's body image, how they behave, and some idea of how well or ill they are.
• Note obvious signs of health or illness, including skin color and breathing.
• During health assessment, the examiner should position the patient so that both sides are easily accessible.
• The examination sequence should be performed using a head to toe sequence.
• For the abdomen, the sequence of technique should be IAPePa.
• During the examination of the abdomen, it is important to flex the patient’s knees to relax the abdominal muscles, which facilitates examination of the abdominal organs.
• The sequence of examining the quadrants: RLQ, RUQ, LUQ, LLQ should be followed.
• Abdominal palpation should be avoided among patients with tumor of the liver and tumor of the kidneys.
• Auscultation of the abdomen should be done for 5 minutes before concluding the absence of bowel sounds.
• If ophthalmoscopy is done, the room should be darkened for better illumination, and this should be explained to the client to prevent unnecessary anxiety.
• Note the color, patterns, size, location, consistency, symmetry, movement, behavior, odors or sounds.
• Use good lighting, preferably sunlight.
• Bimanual palpation involves use of both hands to envelope certain body parts.
• Abnormalities may be overlooked with dim light.
• Expose one body part at a time.
• Compare the appearance of symmetric body parts (eyes, ears, arms, hands) or both sides of any individual body part.
• The first technique involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings in the client.
• The sense of touch is used to assess the factors: texture, temperature, moisture, organ location and size, any swelling, vibration, or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.
• Palpate tender areas last.
• Observe the patient as a whole in a general survey then inspect each body system.
• The technique requires occasional use of certain instruments such as ophthalmoscope (for eye inspection), otoscope (ear inspection), penlight, nasal and vaginal speculum to facilitate viewing.
• The technique can be done using different parts of the hands as follows: fingertips for fine tactile discrimination, a grasping action of the fingers and thumb to detect the position, shape and consistency of an organ or mass, and the back of the hands and fingers for temperature.
• Light palpation involves placing your dominant hand lightly on the surface of the structure and using a circular motion to feel for easily palpable body organs and masses.
• Tapping of the patient’s skin with short, sharp strokes is used to assess underlying structures.
• Moderate palpation involves depressing the skin surface 1 - 2 cm (0.5 - 0.75 inch) with your dominant hand, and using a circular motion to feel for easily palpable body organs and masses.
• Inspection precedes palpation, percussion and auscultation because the latter can potentially alter the appearance of what is being inspected.
• Deep palpation involves placing your dominant hand on the skin surface and your non dominant hand to apply pressure, resulting in surface depression between 2.5 and 5 cm (1 and 2 inches), allowing you to feel very deep organs or structures that are covered by thick muscle.
• A female nurse assesses a female client and if a female client will be examined by a male nurse, a female nurse must be in attendance to ensure that the procedure is done in an ethical manner.
• Palpation should be done in a slow, gentle, systematic manner.
• Inspect both sides of the body for symmetry.
• Fluorescent lights can alter the true color of the skin.
• Warm hands by rubbing them together or holding them under warm water before palpating tender areas.