Chapter 26 - Health Assessment
Types of Health Assessments
- Comprehensive - Focused - Ongoing - Emergency
Biographical Data
> May be collected by people other than the nurse > It includes the patient's name, address, and billing and insurance information. > Can also include biological sex, age and birth date, martial status, occupation, race, ethnic origin, religious preference, and the patient's primary health care provider > The source of information is also recorded > Language has been identified as the biggest barrier to health care and appears to increase the risks to patient safety
Past Health History
> May provide insight into causes of current symptoms > Alerts the nurse to certain risk factors > Includes childhood and adult illnesses, chronic health problems and treatment, and previous surgeries or hospitalizations > It should also include accidents or injuries, obstetric history, allergies, and the data of most recent immunizations > The patient should be asked about health maintenance screenings, such as routine mammograms and colorectal tests, including dates and results, as well as the use of safety measures. > Should include information about prescribed and over-the-counter medications (including vitamins, supplements, and home remedies). Should include the name, dose, route, frequency, and purpose for each medication.
Inspecting and Palpating the External Male Genitalia
> Standing or supine position > Gloves needed > Genitalia are inspected for size, placement, contour, appearance of skin, redness, edema, and discharge > Assess the location of the urinary meatus and inspect the scrotum for symmetry > Palpate the testes for size, shape, and consistency
Physical Assessment (More Info)
> Systematic collection of objective information > it is often necessary to modify the sequence, positions, and specific assessments based on the patient's age, energy level, and cognitive and physical state, as well as time constraints
Assessing Language
> The cerebral cortex controls the ability to express self through writing, words, or gestures and to understand the spoken and written word > Methods of assessment include asking the patient to name items in the room, to follow simple commands, to read a short sentence aloud, or to match printed and spoken words with appropriate pictures. > Injury to cortex can cause aphasia, which is a disorder of language ability. > Aphasia that is expressive involves the person not being able to write or speak to communicate and aphasia that is receptive is when the person cannot comprehend written or spoken words.
Emergency Health Assessment
> type of rapid focused assessment conducted when addressing a life-threatening or unstable situation > assessment of the airway, breathing, and circulation when encountering a patient with traumatic injury as a result of a motor vehicle accident is an example
Jaundice
yellow appearance of the skin
Assessing Memory
> Assess memory by asking questions that require answers demonstrating immediate recall and recall for past events. To assess immediate memory, ask the patient to repeat a series of numbers forward and backward. Start with three numbers and continue until the patient can no longer remember. Most adults can repeat a series of five to eight numbers forward (four to six backward)
Inspecting and Palpating the Joints
> Each joint is put through its full ROM to assess the degree of movement > Joint movements include flexion, extension, hyperextension, abduction, adduction, supination, and pronation > Each joint normally has full ROM, is nontender, and moves smoothly > Palpate joints for pain, swelling, nodules, and crepitation (grating sound)
Inspecting and Palpating the Muscles
> Examine the muscles by inspection and palpation of muscle groups and by testing muscle tone and strength > Look for bilateral symmetry and palpate for tenderness > Evaluate muscle tone by putting each joint through passive ROM > Assess muscle strength
Inspecting Extremities
> Inspect the skin of extremities for color, temperature, continuity, lesions, venous patterns, and edema. > The skin of the lower extremities is typically pale and cool, shiny with brown discolorations, and hairless if the patient has peripheral vascular disease. Also, the toenails are thickened.
Inspecting and Palpating the Inguinal Area
> Inspected by asking the patient to bear down > The inguinal area is usually free of bulges
Techniques of Physical Assessment
> Inspection > Palpation > Percussion > Auscultation
Instrumental Activities of Daily Living
the activities of daily living needed for independent living
Adventitious Breath Sounds (More Info)
- Wheeze = Musical or squeaking; high-pitched continuous sounds; auscultated during inspiration and expiration; air passing through narrowed airways - Rhonchi = Sonorous or coarse (snoring); low pitched, continuous sounds; auscultated during inspiration and expiration; coughing may clear the sound somewhat; air passing through or around secretions - Crackles = bubbling, crackling, popping; low to high-pitched, discontinuous sounds; auscultated during inspiration and expiration; opening of deflated small airways and alveoli; air passing through fluid in the airways - Stridor = harsh, loud, high-pitched; auscultated on inspiration; narrowing of upper airway or presence of foreign body in airway - Friction Rub = rubbing or grating; loudest over lower lateral anterior surface; auscultated during inspiration and expiration; inflamed pleura rubbing against chest wall
Bronchovesicular Breath Sounds
normal breath sounds heard over the mainstem bronchus; they are moderate blowing sounds, with inspiration equal to expiration
Vesicular Breath Sounds
normal sound of respirations heard on auscultation over peripheral lung areas
Pallor
paleness of the skin
Review of Systems
physical examination of all body systems in a systematic manner as part of the nursing assessment
Inspection
purposeful and systematic observation
Inspecting and Palpating the External Genitalia
> Ask the patient to empty her bladder > Supine position > Inspect external genitalia for color, size of labia majora and vaginal opening, lesions, and discharge > Mucous membranes are dark pink and moist > Labia should be symmetric > There may normally be a small amount of clear or whitish vaginal discharge
Bronchial Breath Sounds
those heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration
Inspecting the Abdomen
> Inspect the skin color and surface characteristics, including the umbilicus, contour, symmetry, peristalsis, pulsations, and visible masses. > The umbilicus should be centrally located and may be flat, rounded, or concave. > The abdomen should be evenly rounded or symmetric.
Lithotomy
> the patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and the heels in stirrups > Used to assess female genitalia and rectum
Prone
> the patient lies flat on the abdomen with the head turned to one side > used to asses the hip joint and the posterior thorax
Body Mass Index (BMI)
ratio of height to weight
Supine
> the patient lies flat on the back with legs extended and knees slightly flexed > facilitates abdominal muscle relaxation and is used to assess vital signs and the head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses.
Erythema
redness of the skin
Functional Health Assessment (More Info)
> A functional health assessment focuses on the effects of health or illness on a patient's quality of life, including the strengths of the patient and areas the need to improve > Assess the patient's ability to perform ADLs > Assess the patient's ability to perform iADLs (housekeeping, meal preparation, management of finances, and transportation)
Health History (More Info)
> A health history is a subjective collection of data that provides a detailed profile of the patient's health status. > The patient is the primary source of data > The nurse should adapt questions to the individual patient, omitting questions that do not apply and adding questions that seem pertinent, based on the setting, situation, the individual patient, and ongoing information as the health assessment proceeds.
Review of Systems (More Info)
> A series of questions about all body systems that helps to reveal concerns or problems as part of the health history > These questions are commonly incorporated into the physical examination of each region > Many questions also relate to one or more body systems
Assessing the Cardiovascular and Peripheral Vascular Systems
> Assessment includes the heart and extremities > HEALTH HISTORY: History of chest pain, palpitations, or dizziness; swelling in the ankles or feet; number of pillows used to sleep; type and amount of medications; history of heart defect, rheumatic fever, or chest or heart surgery; personal and family history of hypertension, myocardial infarction, coronary artery disease, high blood cholesterol levels, or diabetes mellitus; history of smoking; type and amount of exercise; usual foods eaten per day; changes in color or temperature of extremities; history of pain in the legs when sleeping; history of blood clots or sores on the legs that do not heal > PHYSICAL ASSESSMENT: Techniques used include inspection, palpation, and auscultation. The necessary equipment includes a stethoscope, a blood pressure cuff, and a watch. The patient may be in a sitting or supine position. - Peripheral vascular assessment includes measuring the blood pressure and assessing the skin and perfusion of the extremities and the peripheral pulses. Assessments are made by inspection and palpation, with the patient sitting or supine. > VARIATIONS in INFANTS/CHILDREN: Visible cardiac pulsation if the chest wall is thin, sinus dysrhythmia (the rate increases with inspiration and decreases with expiration), presence of S3, more rapid heart rate > VARIATIONS in OLDER ADULTS: Difficult to palpate apical pulse, difficult to palpate distal arteries, more prominent and tortuous blood vessels (varicosities common), increased systolic and diastolic blood pressure, widening pulse pressure
Assessing Neurovascular Status
> Assessment of neurovascular status is an important nursing intervention leading to early identification of neurovascular impairment and timely intervention. > Musculoskeletal trauma, crush injuries, orthopedic surgery, and external pressure from a cast or tight-fitting bandage can cause damage to blood vessels and nerves. > This can lead to diminished perfusion and severe ischemia
Auscultating Bowel Sounds and Vascular Sounds
> Auscultation is used to assess bowel sounds and vascular sounds. Warm the stethoscope. > Using light pressure, place the diaphragm on the right lower quadrant. Move to the right upper, the left upper, and then the left lower. Listen for bowel sounds and note their frequency and character (they usually occur every 5 to 34 seconds). > Before noting them as absent, listen for 2 minutes. > Using the bell, the nurse should auscultate over the abdominal aorta, femoral arteries, and iliac arteries for bruits.
Level of Consciousness
> Awake and Alert: fully awake; oriented to person, place, and time; responds t all stimuli, including verbal commands > Lethargic: appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patient's name > Stuporous: unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements > Comatose: cannot be aroused, even with the use of painful stimuli; may have some reflex activity; if no reflexes present, is in a deep coma
Reason for Seeking Health Care
> Chief Complaint > The reason for requesting care is a statement in the patient's own words that describes the patient's reason for seeking care. > Can be acquired using an open-ended question > The nurse should try to record whatever the person has to stay in the person's exact words. Avoid paraphrasing or interpreting
Assessing Female Genitalia
> Consists of the mons pubis, labia majora and minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and urethral opening > Assessed for lesions, discharge, masses, and enlargement of internal organs. > Rectum and anus may be assessed during this part of the examination > HEALTH HISTORY: Menstrual history, sexual history, pain with intercourse or difficulty achieving orgasm, number of pregnancies and live births, history of sexually transmitted infection, use of contraceptives, frequency of pelvic examinations and pap smears, history of vaginal discharge, itching, or pain on urination, use of hormones and tobacco > PHYSICAL ASSESSMENT: Assess the genitalia by inspection and palpation. > VARIATIONS IN INFANT/CHILDREN: Enlarged labia and clitoris, breast enlargement, vaginal discharge in girls, pubic hair and breast development, menstruation begins about 2.5 years after puberty begins, irregular menstrual cycle for first 2 years > VARIATIONS in OLDER ADULT: decreased size of labia and clitoris, decreased amount of pubic hair, decreased vaginal secretions, pail, thin, and dry vaginal mucosa
Assessing the Abdomen
> Contains the stomach, the small intestine, the large intestine, the liver, the gallbladder, the pancreas, the spleen, the kidneys, and the urinary bladder. > HEALTH HISTORY: History of abdominal pain, indigestion, nausea, vomiting, constipation or diarrhea, food allergies, or lactose intolerance; food intake; usual bowel and bladder elimination patterns; history of gastrointestinal disorders; urinary tract disorders; history of abdominal surgery or trauma; amount of alcohol ingestion; menstrual history > PHYSICAL ASSESSMENT: Use a warm stethoscope and ensure that lighting is adequate. Ask the patient to empty the bladder. Place patient in supine position. The four quadrants of the abdomen are right upper, right lower, left upper, and left lower. - The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after because they stimulate bowel sounds. - Ask the patient to breathe slowly and deeply through the mouth during the examination to promote relaxation. Ask the patient to identify painful areas of the abdomen and explain that you will assess these at the end of the examination. > VARIATIONS in INFANTS/CHILDREN: Umbilical cord in newborns (dries and falls off within the first few weeks of life); potbelly; visible peristaltic waves > VARIATIONS in OLDER ADULTS: Decreased bowel sounds, decreased abdominal tone, fat accumulation on the abdomen and hips
Components of Health History
> Demographic information > The reason the patient is seeking health care > Present health or history of present health concern > Past health history > Family history > Functional health > Psychosocial and lifestyle factors > Review of systems
Positioning
> During positioning, it is important to consider the patient's age, culture, health status, mobility, physical condition, energy level, and privacy > Positioning patients who are weak or have physical limitations may require assistance > Uncomfortable or embarrassing positions should not be maintained for long periods > The assessment should be organized so that several body systems can be assessed with the patient in one position, this minimizing unneeded and possibly tiring movements.
Assessing the Thorax
> INSPECTING: Observe the patient's chest for color, shape or contour, breathing patterns, and muscle development. The shape or contour should have a downward equal slope at the rib cage. The chest should be symmetric. The transverse diameter should be greater than the anteroposterior diameter. Respirations should be smooth and even. > PALPATING: It is used to detect areas of sensitivity, chest expansion during respirations, and vibrations (fremitus). Use the palmar surface of the hands to palpate the anterior and posterior thoracic landmarks for temperature, moisture, muscular development, and any tenderness or masses. Chest expansion is determined by placing the hands over the posterior chest wall, with the fingers at the level of T9 or T10. Ask the patient to take a deep breath, and observe the movement of your thumbs. Movement should be symmetrical. > AUSCULTATION: It is used to detect airflow within the respiratory tract. Ask the patient to breath slowly and deeply through the mouth. Place the warmed diaphragm of the stethoscope over the thoracic landmarks and auscultate breath sounds in the same sequential patterns are used for palpation. Listen for pitch, duration, and intensity of sounds. - Bronchial breath sounds = heard over the larynx and trachea; high-pitched and harsh blowing sounds; sound on expiration being longer than inspiration - Bronchovesicular breath sounds = heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration - Vesicular breath sounds are soft, low-pitched, whispering sounds, heard over most of the lung fields; the sound on inspiration is longer than expiration - Adventitious breath sounds (added, abnormal sounds) are not normally heard in the lungs. They are commonly caused by air moving through moisture, mucus, or narrowed airways. Sputum of coughs should be assessed for color, consistency, and amount.
Assessing the Neck and Precordium
> INSPECTION: Observe the neck and precordium (the portion of the body over the heart and lower thorax, encompassing the aortic, pulmonic, triscuspid, and apical areas, and Erb's point) for visible pulsations. Pulsations are usually absent, except for the apical impulse. Inspect the epigastric area at the tip of the sternum for pulsation of the abdominal aorta. Pulsations in areas other than the apical impulse are abnormal. > PALPATION: Warm your hands, if necessary. Palpate the carotid artery medial to the sternomastoid muscle in the neck between the jaw and clavicle. Palpate one at a time to avoid obstructing both arteries simultaneously, reducing blood flow to the brain and potentially causing dizziness or loss of consciousness. Note the strength and grade it. Normal findings include equal pulses bilaterally, with a strength of +2. Abnormal findings include an absent, weak, thready pulse or a forceful or bounding pulse. To palpate, use the palmar surface of the hand with four fingers held together, and gently palpate the precordium for pulsations. Palpate the cardiac landmarks, including the apical impulse. Note the size, duration, force, and location in relationship to the midclavicular line. > AUSCULTATION (CAROTID ARTERIES): Use the bell of the stethoscope. Listen for bruits, which are abnormal "swooshing or blowing" sounds heard over a blood vessel. They may be caused by blood that is swirling in the vessel rather than the normal smooth flow. A bruit may be heard in the presence of stenosis (narrowing) or occulsion of the artery. It may also be caused by abnormal dilation of a vessel.
Assessing the Neurological System
> Includes cerebral function, cranial nerve function, cerebellar function, motor and sensory function, and reflexes > Normally the patient is alert and responsive, has full sensory function, and all muscle groups are bilaterally strong. > HEALTH HISTORY: History of numbness, tingling, tremors, seizures, headaches, dizziness, trauma to the head or spine, high blood pressure, stroke, changes in the ability to hear, see, taste, or smell, loss of ability to control bladder and bowel, history of smoking, history of chronic alcohol use, history of diabetes or cardiovascular disease, use of prescription and over-the-counter medications > PHYSICAL ASSESSMENT: Evaluate the cerebral function by observing the patient's behavior throughout the health history interview and physical assessment. Assess the patient's mental status, memory, emotional status, cognitive abilities, and behavior. Evaluate cerebellar function by assessing motor skills, coordination, and balance. Assess the sensory system by having the patient identify various sensory stimuli, and evaluate the reflexes by contraction of specific muscles. - Equipment includes a visual acuity chart, a penlight, a sharp object, cotton balls, a tongue depressor, and familiar objects. > VARIATIONS in INFANTS/CHILDREN: Positive Babinski sign (normal in children less than 2 years old), grasp reflex, motor control develops in head, neck, trunk, and extremities sequence > VARIATIONS in OLDER ADULTS: Slower thought processes and verbal responses; decreased sensory ability; slower coordination and voluntary movements; decreased reflex responses; appearance of confusion in unfamiliar surroundings; slower gait, with a wider base and flexed hips and knees
Assessing the Musculoskeletal System
> Includes the bones, muscles, cartilage, ligaments, tendons, and joints > Health history information is used to evaluate the patient's ability to carry out ADLs and to collect data about areas such as pain, stiffness, and ability to move. Physical examination provides information about posture, gait, bone size and structure, joint ROM, and muscle strength. - Normally, the joints are bilaterally equal in size, shape, and color. > HEALTH HISTORY: History of trauma, arthritis, or neurologic disorder, history of pain or swelling in the muscles/joints, frequency and type of usual exercise, dietary intake of calcium, history of any surgery on muscles or joints, history of smoking, history of alcohol intake > PHYSICAL ASSESSMENT: Positions include standing, sitting, and supine. > VARIATIONS in INFANTS/CHILDREN: C-shaped curve of spine at birth; the anterior cervical curve develops at about 3 to 4 months of age, and the anterior lumbar curve develops between 12 and 18 months of age; lordosis (an exaggerated lumbar curve); pronation of the feet in children between 12 and 30 months of age; genu varum (bowleg) for 1 year after learning to walk > VARIATIONS in OLDER ADULTS: Loss of muscle mass and strength, decreased ROM, kyphosis, decreased height, osteoarthritic changes in joints
Assessing the Head and Neck
> Includes the skull, face, eyes, ears, nose and sinuses, mouth and pharynx, trachea, thyroid gland, and lymph nodes. > If the patient smokes, include a discussion about ways to stop smoking in the care plan. Note headaches or dizziness. > Assessment of this system provides data about the shape and structure of cranial bones, function of special senses, nasal and oral structures, and any swelling or pain in the lymph nodes in the neck. > HEALTH HISTORY: Includes changes in vision and hearing, history of glasses or hearing aids, allergies, history of chronic illnesses, exposure to harmful substances or noises, history of smoking and drug use, presence of body piercings and tattoos, history of eye or ear infections, history of head trauma, and oral and dental care practices. > INSPECTING/PALPATING THE HEAD AND FACE: Inspect for size and shape. The head and face should be in proportion to each other and symmetric. Abnormal findings include lack of symmetry or unusual size or contour of the skill. Inspect the face for color, symmetry, and distribution of facial hair. The location, amount, duration, and timing of abnormalities should be noted. > INSPECTING THE EYES: Assess the structures and functions of the eyes using a penlight and the Snellen chart. Inspection is the primary assessment technique used. It includes the external eye structures, visual acuity, extraocular movements, and peripheral vision. The eyes, eyebrows, eyelids, eyelashes, lacrimal glands, pupils, and iris should be examined for symmetry and position. The pupils are normally black, equal in size, round, and smooth. The pupils should also be assessed for reaction to light and accommodation and for convergence. - Visual acuity is measured using the Snellen chart. Patients should stand 20ft away from the chart and read the lines, starting with both eyes and ending with only one. The extraocular movements should be assessed using the cardinal fields of vision for coordination and alignment. Normally both eyes move together, are coordinated, and are parallel. This assesses for retinal function and optic nerve function. Patient should sit or stand approximately 2 feet away. > INSPECTING and PALPATING the EARS: Assess the external ear by inspection and palpation. An otoscope is used by advanced professionals for viewing the inner ear. - Inspect the external ear for shape, size, and lesions. The external surfaces of the ear should be smooth, and the shape and size of the ears should be symmetric and proportional to the head. Inspect the visible portion of the ear canal. Note the presence of cerumen, edema, discharge, or foreign bodies. The external ear should be palpated for pain, edema, or presence of lesions. - Hearing screening tests that are proven to be useful include the whisper test, audiometer, and self-report questionnaires. When using the whisper test, assess one ear at a time. Stand 1-2 ft away from the patient, standing behind him/her. - Assessment of the nose includes examining the external nose, the nares, and the turbinates. The nose should be inspected, and the sinuses should be inspected and palpated. The nose can be assessed for patency by occluding on nostril at a time and asking the patient to inhale and exhale through the nose. Examine the nasal mucosa with a penlight. It is usually moist and dark red. - Palpate the maxillary and frontal sinuses. There should not be any pain. - The mouth and pharynx include the lips, tongue, teeth, gums, hard and soft palate, salivary gland, tonsillar pillars, and tonsils. It should be assessed using a penlight, tongue blade, gloves, and a 4x4 in gauze sponge. Wear gloves when assessing the mouth and use the gauze to hold the tongue for palpation. The lips should be pink, moist, and free of swelling. - Assessments of the neck include the trachea, lymph nodes, and thyroid gland. Assess the neck with the patient sitting and the neck slightly hyper extended, if possible. Ask the patient to tilt the head backward, forward, and side to side to assess range of motion. The neck should be symmetric, with smooth and controlled ROM. Assess the neck for venous distension. Palpation of the thyroid is usually done by advanced providers. When inspecting the trachea, focus on the position in the neck. It should be midline and symmetrical. When inspecting the thyroid gland (lower portion of the neck), focus on its position and size. It should be symmetrical. Ask the patient to swallow. Abnormal findings include asymmetry, enlargement, lumps, and bulging. - When assessing the lymph nodes, they should be palpated for enlargement, tenderness, and mobility. The nodes are generally not palpable, but if they are, they should be small, mobile, smooth, and nontender. If they are palpable, note the location, size, consistency, mobility, and tenderness. Enlarged lymph nodes (lymphadenopathy) may indicate infection, autoimmune disorders, or metastasis of cancer. > VARIATIONS IN INFANTS/CHILDREN: Closing of posterior fontanel at 8 weeks of age; soft anterior fontanel at about 19 months of age, gazing at and following bright objects by 1 month of age, focusing with both eyes by 6 months of age, pupils at the inner folds (pseudostrabismus), and startle reflex in newborns > VARIATIONS in OLDER ADULTS: Impaired near vision (presbyopia), decreased color vision and peripheral vision, decreased adaptation to light and dark, a white ring around the cornea, entropion (eyelid turns inward) and ectropion (eyelid turns outward), hearing loss (presbycusis), elongated ear lobes, decreased neck ROM, small and more easily palpated lymph glands
Family History
> Information about a person's family history will provide information about diseases and conditions for which an individual patient may be at increased risk. > Certain disorders have genetic links > Information regarding contact with family members with communicable diseases or environmental hazards can provide clues to the patient's current health or risk factors for health issues > This information can also identify important topics for health teaching and counseling.
Inspecting the Breasts
> Inspect the breasts for size, shape, symmetry, color, texture, and skin lesions > Breasts should be relatively symmetric > Shape should be round and smooth, with no depressions or puckering > Soft > Inspect areola and nipples for size and shape and nipples for discharge, crusting, and inversion
Assessing the Breasts and Axillae
> Men are also at risk for breast disease > Each breast has a lymphatic network that drains into the underlying axilla > Physical assessment of the breasts and axilla is primarily conducted to identify any lumps in the breasts and/or enlargement or pain in axillary lymph nodes. > Research does not show a clear benefit of physical breast exams > HEALTH HISTORY: History of pain, lumps, swelling, redness, changes in size, dimpling in the breasts, and discharge from the breast; family history of breast cancer; history of breast disease, biopsy, or surgery; menstrual and pregnancy history; use of hormones or oral contraceptives; knowledge related to breast self-awareness; most recent mammogram PHYSICAL ASSESSMENT: Involves both inspection and palpation. The patient can be sitting or lying supine. > VARIATIONS in INFANTS/CHILDREN: Breast enlargement and a white discharge from the nipples (2 weeks old), female breast growth beginning at 10 to 11 years of age, temporary enlargement of one or both breasts in pubescent boys > VARIATIONS IN OLDER ADULTS: Granular, pendulous breasts in women
Assessing Mental Status
> Mental status assessment includes level of consciousness, level of awareness, behavior and appearance, memory, and language. > On initial contact, begin to evaluate the patient's orientation to person, place, and time, as well as cognitive abilities and affect. > Observe the patient's appearance, general behavior, ability to speak clearly, and their ability to respond to questions. > Assess the patient's overall appearance. > Glasgow Coma Scale is a standardized assessment tool that assesses level of consciousness. Limitations include the inability to assess the verbal score after the patient has been intubated; a lack of assessment of respiration and brainstem reflexes; inability to assess a possible developing vegetative state; and inability to recognize pseudocoma. Max score is 15. > FOUR (Full Outline of Un-Responsiveness) score coma scale is a further improvement on previous scales for classifiying and communicating impaired consciousness. It does not include assessment of verbal response.
Assessing Motor and Sensory Function
> Motor ability is evaluated by assessing balance, gait, and coordination > Sensory function is assessed by testing sensory discrimination to pain, light touch, vibrations > Inspecting Balance and Gait: Evaluate balance and gait by having the patient walk across the room on the toes, on the heels, and heel to toe. Observe posture balance, and arm and leg movements. Posture should be erect, with slight swaying in the standing position. > Assessing Motor Function and Coordination: Evaluate motor function and coordination by having the patient rapidly touch each finger with the thumb, rapidly pat the hand on the thigh, and tap the foot on the floor. Limitations may be due to a disease of the upper motor neurons or cerebellum. > Assessing Sensory Perception: Test sensory perception by evaluating the patient's response to pain, light touch, and normal shapes. With the patient's eyes closed, randomly touch the skin on the upper and lower extremities and the trunk with a sharp object and a soft object. Should go from distal to proximal. Another method is asking the patient to close the eyes and identify familiar objects.
Assessing the Rectum and Anus
> Not assessed in all patients > Usually performed by advanced professionals > Provides information about normal patterns of bowel elimination and identifies risks for illness and health behaviors > HEALTH HISTORY: bowel patterns, history of blood or mucus in the stool, family history of polyps, colon or rectal cancer, or prostate cancer, history of hemorrhoids, frequency of DREs, history of anal intercourse > PHYSICAL ASSESSMENT: Inspection and palpation. Gloves needed. Knee-chest or side-lying position. Inspection is used to assess the anal area. > VARIATIONS in INFANTS/CHILDREN: not performed in young children or adolescents > VARIATIONS in OLDER ADULTS: Anus is darker in color and hemorrhoids
Palpating the Bones
> Palpate the bones for normal contour and prominence and for bilateral symmetry
Palpating the Breasts and Axillae
> Palpate the breasts in each of the four quadrants for lumps > Palpate the nipple and areola and gently compress the nipple between the thumb and forefinger to assess for discharge > The breast tissue should be smooth and fire > Palpate for lymph nodes. Palpable lymph nodes are an abnormal finding.
Preparing the Environment for a Health Assessment
> Privacy and respect for the patient are primary concerns when conducting a health assessment > In an outpatient setting, such as a clinic, separate examination rooms provide a quiet, private space for assessment > Prepare the examination room before the health assessment is conducted by preparing the examination table, providing a gown and drape for the patient, and gathering instruments and special supplies needed for the assessment > In a hospital or community-based facility, the health assessment usually takes place in a patient's room. (If the area is open to others, an enclosure with a curtain or screen is essential.) > The room should be warm enough to prevent chilling, and the area or room should be adequately lit. > When patients are assessed in their home, it should be performed in the patient's bedroom or another private area. Direct the patient to a private dressing area or to a comfortable area in the home and ask the patient to change into a gown, if possible. > For all settings, if necessary, assist the patient with undressing. > Ask the patient to empty the bladder before the examination to promote patient comfort during the assessment and to facilitate assessment of the abdomen by the nurse.
Abnormal Skin Colors
> Redness (Erythema) = facial area, skin on body; caused by blushing, alcohol intake, fever, injury trauma, infection > Bluish (cyanosis) = exposed areas, including ears, lips, inside of mouth, hands and feet, and nail beds; caused by cold environment, cardiac or respiratory disease > Yellowish (jaundice) = all skin, mucous membranes, sclera; caused by liver disease > Paleness (pallor) = exposed areas, including the face and lips, conjuctivae, the mucous membranes; caused by anemia (decreased hemoglobin) and shock (decreased blood volume) > Vitiligo (whitish patch areas on the skin) = all skin areas, lips, nail beds, and conjunctivae; caused by depigmentation (congenital or autoimmune conditions) > Tanned or Brown = sun-exposed areas; caused by overexposure and pregnancy
Equipment
> Should be readily accessible, clean, and in proper working order > Should be warmed > Includes a thermometer, sphygmomanometer (blood pressure), scale, penlight, stethoscope, metric tape measure and ruler, eye chart (Snellen)
Assessing Muscle Strength
> Shoulder Flexion > Elbow Extension and Flexion > Wrist Extension > Grip (patient squeezes examiner's index and middle fingers) > Hip Flexion > Knee Flexion and Extension > Ankle Plantar Flexion and Dorsiflexion
Positions for Assessment
> Standing > Sitting > Supine > Dorsal Recumbent > Sims Position > Prone > Lithotomy > Knee-Chest
Performing a General Survey
> The first component of the physical assessment, beginning with the first moment of patient contact and continuing throughout the nurse-patient relationship. > Overall impression of the patient > Includes observing the patient's overall appearance and behavior, taking vital signs, measuring height, weight, and waist circumference, and calculating the body mass index. > HEALTH HISTORY: Ask about history regarding changes in weight, pain or discomfort, and sleeping patterns as well as difficulty sleeping. > APPEARANCE and BEHAVIOR: Observe the patient's body build, posture, and gait. Note proportion of height to weight, which provides insight into nutritional status. Observe posture and movements. In addition to this, observe hygiene and grooming, cognitive processes (speech), and facial expressions. > HEIGHT & WEIGHT: Have patient remove shoes and heavy clothing when taking weight. The height of infants under 2 should be measured when they are in the recumbent position. Weight infants without clothing and children in their underwear. Weights should be obtained at the same time each day; with the patient wearing the same clothing and using the same scale. > BMI = indicator of obesity or malnutrition; assesses nutritional status.
Assessing the Integument
> The integument system is comprised of the skin, nails, hair, and scalp. > Assesses for skin cancer and provides a base for teaching skin cancer prevention. > Warning signs of Melanoma: asymmetry, uneven borders, colored, large in diameter, changes in size, shape, or color. > HEALTH HISTORY: History of rashes, lesions, change in color, itching, bruising, bleeding, allergies, exposure to sun and sunburn history, bathing routines and products, moles, exposure to harmful chemicals, degree of mobility, foods and liquids consumed, cultural practices related to the skin. > TECHNIQUES: Inspection and Palpation > Wear gloves during palpation if there are lesions or lice in the hair. > Palpate for temperature, moisture, turgor, and texture; inspect for color, vascularity, and lesions > INSPECTING SKIN COLOR: When assessing for skin conditions, it is easier to assess for people with light skin tones instead of darker ones. For erythema, use temperature for people with darker skin tones (warmer). INSPECTING SKIN VASCULARITY: Vascularity, bleeding, or bruising signs may be related to a cardiovascular, hematologic, or liver dysfunction. > PALPATING SKIN TEMPERATURE, TEXTURE, MOISTURE, TURGOR: The skin is normal warm and dry. In dehydrated patients, the texture is dry, loose, and wrinkled. Decreased skin turgor may be a normal finding in older adults. It is usually a sign of dehydration. > INSPECTING the NAILS: Inspect the nails for shape, angle, texture, and color. Nails should be convex and follow the natural curve of the finger. Nails should be smooth, firm, and nontender. > INSPECTING THE HAIR AND SCALP: Hair is found everywhere except for the palms of the hands, soles of the feet, and parts of the genitalia. Assess the hair for color, texture, and distribution. > VARIATIONS in INFANTS/CHILDREN: Jaundice and milia (whiteheads) in newborns, fine downy hair for the first 2 weeks of life, smooth thin skin at birth, pubic hair development during puberty > VARIATIONS in OLDER ADULTS: Wrinkles, dryness, scaling, decreased turgor, raised dark areas, flat and brown age spots, small and round red spots, fine and brittle gray/white hair, hair loss, course facial hair in women, thick and yellow toenails
Assessing Male Genitalia
> The male genitalia include the penis, testicles, epididymis, scrotum, prostate gland, and seminal vesicles. > HEALTH HISTORY: frequency of digital rectal examinations, frequency of testicular self-examination, use of contraceptives, occupational exposure to chemicals, sexual history, history of sexually transmitted infection, history of discharge from the penis, difficulty with urination, history of erectile dysfunction, pain with intercourse. > VARIATIONS in INFANTS/CHILDREN: Breast enlargement, development of pubic hair and enlargement of the scrotum, testes, and penis occurs at puberty, spontaneous nocturnal emission of seminal fluid > VARIATIONS in OLDER ADULT: Decreased penis size, decreased pubic hair, decreased size and firmness of testes
Palpating the Abdomen
> The pads of the fingers are used to palpate with a light, gentle dipping motion of approximately 1cm. > Watch the patients face for signs of pain. > Note muscular resistance, tenderness, enlargement of the organs, or masses. > Abdomen should be soft, relaxed, and free of tenderness.
Knee-Chest
> The patient kneels, with the body at a 90-degree angle to the hips, back straight, arms above the head. > Used to assess the anus and rectum
Sims Position
> The patient lies on either side with the lower arm below the body and the upper arm flexed at the shoulder and elbow > Both knees are flexed, with the upper leg more acutely flexed > Used to assess the rectum or vagina
Sitting
> The patient may sit in a chair or on the side of the bed. They may also remain in bed with head elevated. > Allows for visualization of the upper body, facilitates full lung expansion, and is used to assess vital signs and the head, neck, anterior and posterior thorax, lungs, heart, breasts, and upper extremities.
Inspection (More Info)
> The process of performing deliberate, purposeful observations in a systematic manner > Closely observe visually, but also use hearing and smell to gather data throughout the assessment > Assess details of the patient's appearance, behavior, and movement > Begins with the initial patient contact and continues through the entire assessment > Assesses color, texture, and moisture > Involves inspecting each area of the body for size, color, shape, position, movement, and symmetry
Assessing Thorax and Lungs
> This system comprises the lungs, rib cage, cartilage, and intercostal muscles. > Physical examination provides data about the bony structures of the thorax, respiratory effort, chest expansion, and breath sounds. > HEALTH HISTORY: History of trauma to the ribs or lung surgery, number of pillows used when sleeping, history of chest pain with deep breathing, history of persistent cough, allergies, environment exposure to chemicals and smoke, history of smoking, history of lung disease, history of frequent or chronic respiratory infections > PHYSICAL ASSESSMENT: Assessment requires a stethoscope and watch. Make sure that the environment is warm and adequately lit. Techniques used in this assessment include inspection, palpation, percussion, and auscultation. The patient may be in a sitting or supine position. > VARIATIONS in INFANTS/CHILDREN: Louder breath sounds on auscultation, more rapid respiratory rate, use of abdominal muscles during respiration > VARIATIONS in OLDER ADULTS: Increased anteroposterior chest diameter, increase in the dorsal spinal curve (kyphosis), decreased thoracic expansion, and use of accessory muscles to exhale
Assessing Level of Awareness
> Time, place, and person > People who have impaired awareness first lose time orientation, followed by place and then person.
Dorsal Recumbent
> the patient lies on the back with legs separated, knees flexed, and the soles of the feet on the bed > Used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. > Should not be used for abdominal assessment because it causes contraction of the abdominal muscles.
Standing
> the patient stands erect > should not be used for patients who are weak, dizzy, or prone to fall > used to assess posture, balance, and gait
Preparing for a Physical Examination
> Try to think of ways to make the patient comfortable and relaxed > Think of the appropriate and essential components of the examination for the individual patient and circumstances, as well as the sequence of the examination (what order will be used to assess the areas required by the examination). > Adjust the light and environment (good lighting and a quiet environment) > Gather and check equipment > Assist the patient to the appropriate position to start the examination > Assist the patient to the appropriate position to start the examination > Use proper hand hygiene techniques and standard precautions when performing physical examinations
Palpating Peripheral Pulses and Capillary Refill
> Use the pads of the index and middle fingers to palpate peripheral pulses for amplitude and symmetry. > Palpate, carefully and one at a time, the carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses. > These should be strong and equal bilaterally > Using your thumb and forefinger, squeeze the patient's fingernail or toenail until it blanches (turns white). Release the pressure and observe the time it takes for normal color to return. It should be less than 3 seconds.
Auscultating Heart Sounds
> Used to determine the heart sounds caused by closure of the heart values > Begin by asking the patient to breath normally, then auscultate the cardiac landmarks. Use the diaphragm for high-pitched sounds, then the bell for low-pitched sounds. > Extra heart sounds are often heard when the patient has anemia or heart disease. > S3 = a third heart sound that follows S2 "lub-dub-dee". Best heard with the bell at the mitral area. It is considered normal in children and yojng adults. > S4 = fourth heart beat that occurs right before S1. "dee-lub-dub". It is normal in older adults. > Heart murmurs are extra heart sounds caused by some disruption of blood flow through the heart. > S2 is higher pitched and shorter than S1.
Palpation (More Info)
> Uses the sense of touch > Assesses skin temperature, turgor, texture, moisture, as well as vibrations within the body, and the shape or structures within the body > The dorsum (back) surfaces of the hand and fingers are used for gross measure of temperature > The palmar (front) surfaces of the fingers and fingerpads are used to assess firmness, contour, shape, tenderness, and consistency. The fingerpads are best at fine discrimination. > The fingerpads should be used to locate pulses, lymph nodes, and other small lumps, and to assess skin texture and edema. > Vibration is palpated best with the ulnar, or outside, surface of the hand. > When palpating, the nurse's hand should be warmed and the fingernails short. > Areas of tenderness should be palpated last > Light Palpation = 1 cm (0.5 in) > Moderate Palpation = 1 to 2 cm (0.5 in to 0.75 in) > Deep Palpation = 2+ cm (0.75in+) > Deep palpation carriers risk of internal injury, but should only be performed by advanced professionals.
Psychosocial and Lifestyle Factors
> When discussing a patient's lifestyle choices, it is important to be nonjudgemental and explain why you need to know certain information > Consider assessing these factors at the end of the interview because these issues may naturally arise during the review of systems. Also, at this time, a trusting relationship has been established. > Ask the patient about his/her social support and network of available assistance. > Ask the patient about his/her level of activity and exercise, sleep and rest, and nutrition. > Obtain information related to the patient's interpersonal relationships and resources; values, beliefs, and spiritual resources; self-esteem and self-concept; and coping and stress management > Question the patient regarding personal habits, including the use of alcohol, illicit drugs and tobacco; exposure to environmental and occupational hazards; intimate partner and family violence; sexual history and orientation; and mental health
History of Present Health Concern
> When taking the patient's history of present health concern, be sure to explore the symptoms thoroughly > The nurse should encourage the patient to describe and explain any symptoms > The description should include information regarding the onset of the problem, location, duration, intensity, quality/description, relieving/exacerbating factors, associated factors, past occurrences, any treatments, and how the problem has affected the patient
Ongoing Partial Health Assessment
> also known as follow-up assessment > it is one that is conducted at regular intervals during care of the patient > concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions.
Focused Health Assessment
> assessment is conducted to assess a specific problem > focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient
Comprehensive Health Assessment
> broad health assessment that includes a complete health history and physical assessment > it is usually conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessments
Functional Health Assessment
> focuses on the effects of health or illness on a patients quality of life, including the strengths and weakness of the patients. Assess ability to preform ADL's and instrument ADL's (IADL's) such as house keeping. meal prep, finance managements, and transportation.
Draping
> prevents unnecessary exposure, provides privacy, and keeps the patient warm during the physical assessment > drapes may be paper, cloth, or bed linens > when conducting the assessment, expose only the body parts being assessed to maintain the patient's modesty and comfort
Auscultation (More Info)
> the act of listening with a stethoscope to sounds produced within the body > it is performed by placing the stethoscope diaphragm or bell against the body part being assessed > during auscultation, the body part being assessed should be exposed and should be listened to in a quiet environment > The characteristics of sound coming from a stethoscope should be pitch (high or low), loudness (soft to loud), quality (gurgling/swishing), and duration (short, medium, or long)
Percussion (More Info)
> the act of striking one object against another to produce sound > the fingertips are used to tap the body over body tissues to produce vibrations and sound waves > the characteristics of the sounds produced are used to assess the location, shape, size, and density of tissues. > abnormal sounds suggest alteration of tissues or the presence of a mass > percussion is an advanced assessment skill, usually performed by advanced practice professionals
Activities of Daily Living (ADLs)
self-care activities such as eating, bathing, dressing, and toileting
Petechiae
small, purplish hemorrhagic spots on the skin that do not blanch with applied pressure
Physical Assessment
systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems.
Turgor
tension of the skin determined by its hydration
Health History
a collection of subjective information that provides information about the patient's health status
Waist Circumference
a numerical measurement of the waist, used to assess an individual's abdominal fat and establish ideal body weight
Adventitious Breath Sounds
abnormal breath sound heard over the lungs
Edema
accumulation of fluid in extracellular spaces
Percussion
act of striking one object against another for the purpose of producing a sound; used to assess the location, shape, size, and density of body tissues
Diaphoresis
an excessive amount of perspiration, such as when the entire skin is moist
Precordium
anterior surface of the chest wall overlying the heart and its related structures
Cyanosis
bluish coloring of the skin and mucous membranes
Ecchymosis
collection of blood in subcutaneous tissues that causes a purplish discoloration
Auscultation
listening for sounds within the body
Palpation
method of examining by feeling a part of the body with the fingers or hand
