Health Assessment

• Cephalocaudal assessment


  Assessment from head to toe for adults
• Least invasive to more invasive areas


  Assessment approach for pediatrics
• Symmetrical Assessment


  • Assessing left and right sides
• Don't palpate abdomen due to risk of rupturing AAA or spreading Wilms tumor
• Head, Face, Neck, and Lymphatics Assessment

  1. Collection of Subjective Data

  2. Equipment use

  3. Explain procedure

  4. Provide privacy

  5. Position client comfortably
• Head and Face Assessment

  • Inspect for head size, shape, and configuration
  • Palpate head for consistency
• Neck Assessment


  • Inspect neck position, symmetry, and presence of lumps/masses
  • Inspect movement of thyroid and cricoid cartilage and thyroid gland
  • Inspect cervical vertebrae
  • Inspect neck range of motion
  • Palpate trachea
  • Palpate thyroid gland

  
• Lymphadenopathy


  Enlarged lymph nodes exceeding 1 cm, can be caused by acute/chronic inflammation, infection, malignancy, or autoimmune disorder
• Lymph node locations


  • Preauricular
  • Postauricular
  • Occipital
  • Tonsillar
  • Submandibular
  • Submental
  • Superficial cervical
  • Posterior cervical
  • Deep cervical chain
  • Supraclavicular

  
• Head is symmetrically round, hard and smooth without lesions or bumps. Face is oval, smooth and symmetric. Temporal artery is elastic and non-tender. Temporomandibular joint has full range of motion without tenderness. Neck is symmetric with centered head position and no bulging masses. C7 is visible and palpable with neck flexed. Has smooth, controlled, full range of motion of neck. Thyroid gland is nonvisible but palpable when swallowing. Trachea is in midline. Lymph nodes are nonpalpable except for a few deep cervical less than 1 cm bilaterally.

  
• Assessment of the Eyes

  1. Collection of Subjective Data

  2. Equipment use

  3. Explain procedure

  4. Provide privacy

  5. Position client comfortably
• Visual Acuity Test


  Tests visual acuity at 20 feet
• Extraocular Muscle Function Test

  • Corneal Reflex
  • Cover Test
  • Six Cardinal Position of Gaze
• Proper eye alignment has light reflection equally centered on both pupils. Unequal reflection may indicate eye misalignment disorders.
• External Eye Structure


  • Inspect eyelids and lashes (width, position, ability to close, direction, color, swelling, lesions, discharge)
• Eye examination


  1. 2-14 inches from the patient's face

  2. Have the patient follow your penlight in the following directions (always start in the midline): right upper to left lower, left upper to right lower, right side to left side

  3. Observe the client's eye movement
• Normal eye movement


  Smooth and symmetrical movement of the eyes as they track the penlight throughout all six directions
• Abnormal eye movement


  Involuntary shaking of the eyes called nystagmus
• Inspection of external eye structure

  1. Inspect eyelids and lashes (width and position of palpebral fissures) ability to close eyelids, direction of eyelids in comparison with eyeball, color, swelling, lesions, or discharge

  2. Inspect positioning eyeballs (alignment in sockets, protruding, or sunken)

  3. Inspect bulbar conjunctiva and sclera (clarity, color, and texture)

  4. Inspect the palpebral conjunctiva (eversion of upper eyelid is usually performed only with complaints of eye pain or sensation of something in the eye)
• Eyelids and lashes are present, able to close eyelids, and the direction of eyelids is aligned with the eyeball. No swelling, lesion, or discharge observed.
• Eye balls must be symmetrically aligned in socket without protruding or sinking
• Bulbar conjunctiva is clear, moist and smooth, sclera is white and underlying structures are clearly visible
• Eversion of upper eyelid

  1. Don gloves

  2. Inspect the upper palpebral conjunctiva by everting the upper eyelid while the client is looking down with eyes slightly open

  3. Use of cotton tipped applicator for everting the upper eyelids

  4. Palpebral conjunctiva is free from swelling, trauma and foreign bodies
• Inspection of lacrimal apparatus

  1. Inspect lacrimal apparatus over the lacrimal glands (lateral aspect of the upper eyelid) and the puncta (medial aspect of the upper eyelid). Observe for swelling, redness, or drainage

  2. Palpate the lacrimal apparatus, noting drainage from the puncta while palpating the nasolacrimal duct
• No swelling or redness, no drainage when palpating the nasolacrimal duct
• No swelling or redness, no drainage during inspection and palpation the nasolacrimal duct
• Inspection of cornea and lens

  Shine light to determine transparency
• Transparent, no opacities
• Inspection of iris and pupil

  Observe for shape, color of the iris and size and shape of the pupil
• Iris is round, flat, evenly colored, PERRLA
• PERRLA


  Pupils are equal, round, reactive to light and accommodation
• Test pupillary reaction to light

  In a darkened room, have client focused on a distant object, shine a light obliquely into the pupil, observe the pupil's reaction to light - normally pupils constrict
• Test accommodation of pupils

  Shift gaze from far to near, normally pupils constrict
• By shifting gaze from far to near, normally pupils constrict
• Use of finger or pencil, asked client to focus as you move from about 12-15 inches and closer towards the eye
• Equipment: Penlight, 512 Htz Tuning Fork, Watch with a second hand
• Assessment of the outer ears/auricle/pinna

  Inspect for equal size bilaterally, smooth skin with no lesions, consistent color with facial color, no discharge, no tenderness on the auricle and mastoid process
• Ears are equal in size bilaterally, skin is smooth with no lesions, color is consistent with the facial color, no discharge is present, no tenderness on the auricle and mastoid process
• Hearing and equilibrium tests

  1. Whisper test

  2. Weber test

  3. Rinne test

  4. Romberg test
• Explain procedure to the client, provide privacy, position the client comfortably