Health assessment

• Complete Health Assessment


  Conducted from head-to-toe assessment
• Physical Health Assessment


  Orderly collection of information concerning the patient’s health status - physical examination
• Three Types of Physical Health Assessment

  • Complete assessment
  • Examination of a body system
  • Examination of a body area
• Preparing the client


  1. Assure client during the examination by explanations at each step

  2. Put on a gown

  3. Empty bladder before the exam
• Pre-school


  1. Use short, simple explanations

  2. Allow the child to play with equipment to lessen fears

  3. A pre-school likes to help, let her hold the stethoscope for you

  4. Use games

  5. Use a slow, patient, deliberate approach

  6. Give the pre-schooler the needed feedback

  7. Compliment the child on his/her cooperation
• Toddler


  1. Let the toddler sit on the parent’s lap in all the procedure

  2. Begin by greeting the child or the accompanying parent by name

  3. Have the parent “undress” the child

  4. 1-2 yr. old children like to say “NO”. Don’t offer a choice when there is none

  5. Demonstrate a procedure to the parent first

  6. Praise the child when he or she is cooperative
• Adolescence


  1. Health teaching

  2. Communicate with some care

  3. Appraise the adolescent with the variation among teenagers on growth and development
• School-age child


  1. Break the ice with small talk

  2. Let the child undress himself

  3. Demonstrate equipment

  4. Comment on the body and how it works
• Pediatric Considerations A. Infant

  • The parent should be present

  • Maintain a warm environment

  • Timing should be 1-2 hours after feeding

  • Use a soft, crooning voice

  • Lock eyes from time to time

  • Use pacifier for crying and invasive procedures

  • Offer brightly colored toys
• Preparing the Environment

  Comfortable, warm room temperature

  Private area free of interruptions from others

  Quiet area free of distractions

  Adequate lighting

  Examination table or bed at a height that prevents stooping

  A bedside table/tray to hold the equipment needed for the examination

  Draping

  Drapes are made of paper, cloth or bed linen.

  • Drapes provide not only a degree of privacy but also warmth.
• Assessment Techniques

  ◼ INSPECTION

  ◼ PALPATION

  ◼ PERCUSSION

  ◼ AUSCULTATION ( A )

  Always follow order IPPA, except for the abdomen , (IAPP)
• INSPECTION

  Visual examination

  Use visual inspection to assess moisture, color and texture of body surfaces, as well as

  shape, position, size color and symmetry of the body.

  Lighting must be sufficient for the nurse to see clearly.

  PALPATION

  An examination of the body using the sense of touch. - warm hands and short nails

  • Inform the patient of when, where and how the touch will occur
• FINGERPADS

  Texture (hair)

  Temperature (skin)

  Vibration (joint)

  Distention (urinary bladder)

  Position, size, shape consistency, mobility (organs or masses) Pulsations

  Tenderness or Pain

  Dorsum of hand (temperature)
• PALPATION

  ◼ Light Palpation

  Use finger pads. Depress 1 cm. below surface

  Provide information on skin texture, moisture, masses, muscle guarding and tenderness ◼ Deep Palpation

  Done with two hands or one hand.

  Reveals information about position of organs, masses and their size, shape, mobility and

  consistency. Depress 4 to 5 cm below skin surface

  • Most often used in assessing abdominal and reproductive structures.
• PERCUSSION

  Striking an object against another to cause vibration that produce sound.

  Any part of the body can be percussed.

  Most commonly used for abdomen and thorax.

  • Analyze sounds by intensity, duration and pitch.
• Indirect percussion


  The striking of an object held against the body area to be examined
• Types of Percussion Technique

  • Direct percussion
  • Indirect percussion
• Components of indirect percussion


  • Pleximeter
  • Plexor
• Plexor


  The tip of the flexed middle finger of the other hand
• Pleximeter


  The middle finger of the nondominant hand, placed firmly on the client’s skin
• Indirect percussion


  1. The pleximeter is placed firmly on the client’s skin

  2. The plexor strikes the pleximeter, usually at the distal interphalangeal joint or a point between the distal and proximal joints
• Direct percussion


  Strikes the area to be percussed directly with the pads of two, three or four fingers or with the pad of the middle finger
• CHARACTERISTICS OF PERCUSSION SOUNDS Flatness:

  Is an extremely dull sound produced by most dense tissue, such as muscle or bone.

  Dullness:

  - A thudlike sound produced by dense tissue such as the liver, spleen or heart.

  Resonance:

  A hollow sound such as that produced lungs filled with air.

  Hyperresonance:

  Is not produced in the normal body.

  Tympany:

  Drumlike sound produced from an air-filled stomach.

  • Reflects the least dense tissue.
• How are sounds analyze

  Intensity (Amplitude)

  refers to the loudness or softness of a sound.

  B. Duration

  describes the time period over which a sound is heard when elicited.

  C. Pitch (Frequency)

  the highness and lowness of a sound.

  D. Quality (Timbre)

  how one perceived the sound.

  E. Location

  • is where the sound is produced and heard.
• AUSCULTATION

  • the process of listening to sounds produced within the body.
  • DIRECT OR IMMEDIATE (listening with an unaided ear)
  • INDIRECT OR MEDIATE (listening with an amplification device)