2. Preparing for the Health
Assessment
Environment
• Ensure privacy
• Quiet, warm room
• Special needs of the client
• Surface for placement of equipment
drjma 27-2
3. Preparing for the Health
Assessment
Equipment
• Maintenance
• Isolation precautions
• Adequate number of gloves
drjma 27-3
4. Preparing for the Health
Assessment
Positioning
• Ensures accessibility to the body part being
assessed.
Draping
• Prevents chilling.
• Prevents unnecessary exposure.
drjma 27-4
5. Conducting the Health and
Physical Assessment
Aimed at establishing a data base
against which subsequent data can be
compared.
• Comprehensive Assessment (head to toe)
• Assessment of a body part (focused)
• Assessment of a body system (focused)
drjma 27-5
6. Conducting the Health and
Physical Assessment
Conducted in an aseptic, systematic, and
efficient manner.
Requires the fewest position changes for
the client.
drjma 27-6
7. General Survey
Initial Observations
• Client’s physical appearance
• Mood and behavior
• Speech patterns and voice intonations
• Signs and symptoms of distress
• Vital signs
• Height and weight
drjma 27-7
8. General Survey
Special Considerations
• Elderly clients
• Disabled clients
• Abused clients
drjma 27-8
9. Measurement of Height and
Weight
Height
• Height is expressed in inches (in), feet (ft),
centimeters (cm), or meters (m).
• A scale for measuring height is usually
attached to a standing weight scale.
• Infant’s length is measured from vertex (top)
of head to soles of feet while infant is lying
with knees extended.
drjma 27-9
10. Measurement of Height and
Weight
Weight
• Measurement of weight is expressed in
ounces (oz), pounds (lb), grams (g), or
kilograms (kg).
• Daily weights should be obtained at the
same time of the day, on the same scale,
with the client wearing the same type of
clothing.
drjma 27-10
11. Measurement of Height and
Weight
Weight
• Types of scales available include chair,
stretcher, bed, and platform scales.
• Infants are weighed on platform or cradle
scales.
drjma 27-11
12. Measurement of Height and
Weight
Nursing Considerations
• Accurate recordings are necessary for drug
dosage calculations and evaluation of
effectiveness of drug, fluid, and nutritional
therapy.
drjma 27-12
13. Measurement of Height and
Weight
Documentation
• Height and weight are recorded on the
admission assessment form.
• Daily weights are usually recorded on the
vital signs record.
• Measurements taken at different times or on
different scales should be recorded.
drjma 27-13
14. Vital Signs
The taking of vital signs refers to
measurement of the client’s body
temperature (T), pulse (P) rate,
respiratory (R) rate, and blood pressure
(BP).
Vital signs are the first step in the
physical examination.
drjma 27-14
15. Vital Signs
Assessment of vital signs provides
specific data regarding the client’s
current condition.
Variations from baseline values may
indicate potential problems with the
client’s health status.
drjma 27-15
16. Vital Signs
The sequence for recording vital sign
measurements in the nurses’ notes is T-
P-R and BP.
Vital signs are plotted on graphic forms
that facilitate data comparison at a
glance.
drjma 27-16
17. Thermoregulation
The body’s physiological function of heat
regulation to maintain a constant internal
body temperature
drjma 27-17
18. Physiologic Function
Thermoregulation
• The heat of the body is measured in units
called degrees.
• The core internal temperature of 98.6
degrees Fahrenheit (F) does not vary more
than 1.4 degrees F.
• Core internal temperature is higher than the
skin and external temperature.
drjma 27-18
20. Thermoregulation
Heat Loss
• Radiation
• Conduction
• Convection
• Evaporation
Insensible Heat Loss
drjma 27-20
21. Thermoregulation
Behavioral Control of Body Temperature
• The person makes appropriate
environmental adjustments in response to
the body’s signaling conditions of either
being overheated or too cold.
drjma 27-21
22. Respiration
Respiration is the act of breathing.
Terms related to respiratory function are:
• External respiration
• Internal respiration
• Inspiration
• Expiration
• Vital capacity
drjma 27-22
23. Respiration
Major physiological pulmonary functions
are:
• Ventilation
• Circulation
• Diffusion
• Transport
• Regulation
drjma 27-23
24. Hemodynamic Regulation
The circulatory system transports
nutrients to the tissues, removes waste
products, and carries hormones from one
part of the body to another.
drjma 27-24
27. Hemodynamic Regulation
Pulse
• The pulse is caused by the stroke volume
ejection and distension of the walls of the
aorta.
• The bounding of blood flow in an artery is
palpable at various points in the body (pulse
points).
drjma 27-27
28. Hemodynamic Regulation
Blood Pressure
• Measurement of pressure pulsations exerted
against the blood vessel walls during systole
and diastole
drjma 27-28
29. Blood Pressure
Systolic Pressure
• Maximum pressure exerted against arterial
walls during systole
Diastolic Pressure
• Pressure remaining in the arterial system
during diastole
drjma 27-29
33. Assessing Body Temperature
Temperature Scales
• Centigrade or Fahrenheit scales are used to
measure temperature.
• Glass or electronic thermometers are used.
Temperature Sites
• Oral
• Rectal
• Axillary
drjma 27-33
34. Assessing Body Temperature
Alterations in Body Temperature
• Pyrexia
• Hyperthermia
• Heat Exhaustion
• Heat Stroke
• Hypothermia
• Frostbite
drjma 27-34
35. Assessing Pulse
Sites
• The most accessible peripheral sites are the
radial and carotid sites.
• The carotid site should always be used to
assess the pulse in a cardiac emergency.
drjma 27-35
36. Assessing Pulse
A peripheral pulse is palpated by placing
the first two fingers on the pulse point
with moderate pressure.
A Doppler ultrasound stethoscope is
used on superficial pulse points.
A stethoscope is used to auscultate the
heart’s rate and rhythm.
drjma 27-36
38. Assessing Pulse
A pulse deficit occurs when the apical
pulse rate is greater than the radial pulse
rate.
Pulse Characteristics
• Pulse quality
• Pulse rate (bradycardia, tachycardia)
• Pulse rhythm (dysrhythmias)
• Pulse volume
drjma 27-38
39. Assessing Pulse
Nursing Considerations
• An irregular pulse rate, if not previously
documented, should be reported
immediately.
• Clients on certain cardiac medications may
need to monitor their pulse rate.
• Routine exercise lowers resting and activity
pulses.
drjma 27-39
40. Assessing Respirations
Sites
• Observation of chest wall expansion and
bilateral symmetrical movement of the
thorax
• Placement of back of hand next to client’s
nose and mouth to feel expired air
drjma 27-40
41. Assessing Respirations
Rate is counted by number of breaths
taken per minute.
Observation of thoracic and abdominal
movements includes:
• Depth, rhythm, and symmetry
• Costal (thoracic) breathing
• Diaphragmatic breathing
drjma 27-41
42. Assessing Respirations
A stethoscope is used to auscultate
breath sounds throughout the respiratory
system.
drjma 27-42
44. Assessing Respiratory Function
Cyanosis
• Bluish appearance in the nail beds, lips, and
skin
• Reduced oxygen levels in the arterial blood
drjma 27-44
47. Assessing Blood Pressure
The direct method of measuring blood
pressure requires an invasive procedure.
The indirect method requires use of the
sphygmomanometer and stethoscope for
auscultation and palpation as needed.
drjma 27-47
48. Assessing Blood Pressure
The most common site for indirect
measurement is the client’s arm over the
brachial artery.
Accurate measurement requires the
correct width of the blood pressure cuff
as determined by the circumference of
the client’s extremity.
drjma 27-48
49. Assessing Blood Pressure
Korotkoff sounds are five distinct phases
of sound heard with a stethoscope during
auscultation.
The forearm or leg sites can be palpated
to obtain a systolic reading when the
brachial artery is inaccessible.
drjma 27-49
50. Assessing Blood Pressure
Hypotension refers to a systolic blood
pressure less than 90 mm Hg or 20 to 30
mm Hg below the client’s normal systolic
pressure.
Hypertension refers to a persistent
systolic pressure greater than 135 to 140
mm Hg and a diastolic pressure greater
than 90 mm Hg.
drjma 27-50
51. Assessing Blood Pressure
Orthostatic Hypotension (postural
hypotension)
• Sudden drop in systolic pressure when client
moves from a lying to a sitting to a standing
position
drjma 27-51
52. Assessing Blood Pressure
False Readings
• Clients who have recently eaten, ambulated,
or experienced an emotional upset
• Improper cuff width
• Improper technique in deflating cuff
• Improper positioning of extremity
• Failure to recognize an auscultatory gap
drjma 27-52
55. Skin Assessment
Skin assessment provides a noninvasive
window to observe the body’s
physiological functions.
drjma 27-55
56. Skin Assessment
Color
Lesions
Moisture
Temperature
Texture
Mobility and Turgor
Edema
drjma 27-56
57. Integumentary System
Hair
• The amount and texture of hair vary with
age, sex, race and body part.
• Vellus
• Terminal hair
The scalp should be smooth, clean,
intact, and free of lumps or tender areas.
drjma 27-57
59. Physical Examination
Head
• Skull and face assessment involves
inspection and palpation.
• The client’s face has its own unique
characteristics related to race, state of
health, emotions, environment.
drjma 27-59
60. Physical Assessment
Eyes
• Conjunctive and sclera are assessed for
color, redness, swelling, exudate, foreign
bodies
• Visual acuity
• Fundoscopy
drjma 27-60
61. Physical Assessment
Ears
• Auditory screening
• Inspection and palpation of external ear
• Placement, symmetry
• Otoscopic assessment
Nose and Sinuses
• Inspection and palpation
• Use of a penlight
drjma 27-61
62. Physical Examination
Mouth and Pharynx
• Breath
• Lips
• Tongue
• Buccal mucosa
• Gums and teeth
• Hard and soft palate
• Pharynx
drjma 27-62
63. Physical Examination
Neck
• Neck muscles
• Lymph nodes of head and neck
• Thyroid gland
• Trachea
drjma 27-63
64. Physical Examination
Thorax and Lungs
• Landmarks for inspection, auscultation, and
percussion
• Anterior and posterior examination
• Shape and symmetry
• Thoracic expansion
• Tactile fremitus
drjma 27-64
65. Thorax and Lungs
Auscultation of Normal Breath Sounds
• Vesicular sounds
• Bronchovesicular sounds
• Bronchial sounds
drjma 27-65
67. Heart and Vascular System
Heart
• Landmarks for inspection, palpation,
auscultation
• Heart sounds
• Palpation for thrills and heaves
• Abnormal auscultatory findings
- Murmurs
- Bruits
drjma 27-67
68. Heart and Vascular System
Vascular System
• Blood perfusion of peripheral vessels
- Peripheral pulses compared bilaterally
- Skin temperature, color
drjma 27-68
70. Breasts and Axillae
Palpation of four quadrants of breasts
Palpation of supraclavicular,
infraclavicular, and axillary nodes
Education and encouragement of
questions about breast self-examination
(BSE)
Breast cancer can also occur in males.
drjma 27-70
73. Abdomen
Auscultation
• All four quadrants in a systematic fashion
• Beginning with the RLQ
- Tympany
- Dullness
- Bruits
- Hyperactive or hypoactive bowel sounds
drjma 27-73
75. Abdomen
Light palpation in all four quadrants
beginning with the RLQ
• Resistance
• Tenderness
• Rebound tenderness
• Organ enlargement
drjma 27-75
76. Female Genitalia and Anus
Cultural Considerations
Inspection and Palpation
• Mons pubis and vulva
• Labia majora, labia minora
• Clitoris
• Urethral meatus and vaginal introitus
• Perineum and anus
drjma 27-76
77. Male Genitalia, Anus, and
Rectum
Testes and male gonads
Seminal vesicles and bulbourethral
glands
Epididymis, vas deferens, ejaculatory
ducts
Scrotum, penis, spermatic cord
Anorectral exam including the prostate
Monthly testicular self-examination (TSE)
drjma 27-77
78. Musculoskeletal System
Inspection
Palpation
Range of Motion (ROM)
Bilateral Comparison
drjma 27-78