neo 111 melanie jorgenson, rn, bsn. inspection: performing deliberate, purposeful observations in a...

Health Assessment: Part 1

NEO 111Melanie Jorgenson, RN, BSN

Examination Techniques

Inspection: performing deliberate, purposeful observations in a systematic manner

Palpation: using the sense of touch

Percussion: striking one object against another to produce sound

Auscultation: listening with a stethoscope to sounds produced in the body

Health History

Biographical data

Reason for seeking care

History of present health concern

Past medical history

Family history

Lifestyle

Positions for Physical Examination

Sitting (to examine head, back, lungs, breast, heart, extremities)

Supine (to examine head, neck, lungs, breast, abdomen, heart, extremities)

Sims (to examine rectum and vagina)

Knee-chest (to examine rectum)

Dorsal recumbent (to examine head, neck, lungs, breast, heart)

Prone (to examine posterior thorax, lungs, hip)

Lithotomy (to examine female genitalia, rectum, genital tract)

Assessments Made Using Palpation

Temperature

Turgor

Texture

Moisture

Pulsations

Vibrations

Shape and masses

Organs

Assessments Made Using Percussion

Location

Shape

Size of organs

Density of other underlying structures or tissues

Assessments and Characteristics of Sounds Determined by Auscultation

Assessments Blood pressure Heart sounds Lung sounds Bowel sounds

Characteristics of sounds Pitch Loudness Quality

Initial Assessment Data

General survey

Height and weight

Vital signs

Elements of a Head-to-Toe Physical Assessment

The Head & Neck The Eyes & Ears The Nose & Sinuses The Mouth & Throat

Chest and back The Posterior and Lateral Thorax The Anterior Thorax The Heart

Height and Weight Measurements

As important as assessing the client’s vital signs.

Routinely taken on admission to acute care facilities and on visits to physicians’ offices, clinics, and other health care settings.

Neck and Head Assessments

Facial structures Eyes, ears, nose, mouth, and throat

Anterior neck structures Trachea, esophagus, thyroid glad,

arteries, veins, and lymph nodes Posterior neck areas

Upper portion of the spine

Thoracic Assessment

Focuses on:

Cardiovascular status.

Respiratory status.

Wounds, scars, drains, tubes, dressings.

Breasts.

Types of Normal Breath Sounds

Bronchial (loud and high-pitched with a hollow quality)

Bronchovesicular (medium-pitched and blowing)

Vesicular (soft, breezy, and low-pitched)

Terms Pertaining to Breath Sounds

Adventitious breath sounds (abnormal)

Sibilant wheezes (high-pitched, whistling)

Sonorous wheezes (low-pitched snoring)

Crackles (popping sounds heard on inhalation or exhalation

Pleural friction rub (low-pitched grating sound heard on inhalation or exhalation)

Stridor (high-pitched, harsh sound heard on inspiration while trachea or larynx is obstructed)

Thorax and Lung Assessments

Respiratory system Recognizing and identifying normal and

abnormal breath sounds Components of the thorax

Lungs, rib cage, cartilage, and intercostal muscles

Assessment techniques Inspection, palpation, percussion, and

auscultation

Palpating the Posterior Thorax (Sequence)

Cardiovascular System Assessments

Functions of the system Transports oxygen, nutrients, and other

substances to the body tissues Removes metabolic waste products to

the kidneys and lungs Assessment techniques

Careful auscultation is important to identify heart sounds

Documentation of Cardiac Assessment Findings

Any symptoms patient is experiencing Vital signs Color and temperature of skin; capillary refill

of nails Inspection findings related to carotid

arteries, jugular veins, and anterior chest wall

Palpation findings related to sternoclavicular area and anterior chest wall

Auscultation findings, including rate, rhythm, pitch, and location of sounds

Palpating the Apical Impulse

Questions?

Health Assessment: Part 2

NEO 111Melanie Jorgenson, RN, BSN

Elements of a Head-to-Toe Physical Assessment – Part 2

Neurological

Skin

Musculoskeletal

Upper and lower extremities

Abdomen

Neurologic & Musculoskeletal Assessment

Neurologic system Assesses cognitive function Evaluates sensation in the body, cranial

nerves, and DTR Musculoskeletal examination

Provides information on muscles and joints

Peripheral vascular system Identifies condition of arteries and veins

in the extremities

Neurological Assessment

Focuses on:

Level of consciousness

Pupil response

Hand grasps

Foot pushes

Integumentary Assessments

Components of the integumentary system Skin, hair, nails, sweat glands, and

sebaceous glands Findings

Nutrition and hydration Overall health status Information associated with certain

systemic diseases, infection, immobility, sun exposure, and allergies

Inspecting Overall Skin Coloration

Musculoskeletal and Extremity Assessment

Through observation of client gait and overall range of movement, the nurse is able to obtain some knowledge of the symmetry and strength of muscles

Abdominal Assessment

Focuses on gastrointestinal and genitourinary status

Includes use of inspection, auscultation, percussion, and palpation within the four quadrants of the abdomen to establish bowel function and status

Abdomen Assessments

Components of the abdominal cavity Men and women: stomach, small and large

intestines, liver, gallbladder, pancreas, spleen, kidneys, urinary bladder, adrenal gland, and major blood vessels

Women: uterus, fallopian tubes, and ovaries Assessment techniques

Order: inspection, auscultation, percussion, and palpation

Not all organs can be assessed

Assessment of Wounds, Drains, Tubes, and Dressings

The nurse must maintain accurate documentation of the amount of drainage, color, or other changes

Questions?