Health Assessment

‫التقييم الصحي‬

Prof Dr. Salma Khadim Jehad

Dr. Ali Faris
M.Sc Hassanain Mohammed Kadhim
Lecture -1- ًٌ‫اٌّسبظشح االو‬
‫ ػجبط فبهُ زُّذ‬-: ‫رشخّخ ورشرُت اٌّسبظشح‬
Inst:-@17qnu

1 M.Sc Hassanain Mohammed Kadhim

 ‫‪Health Assessment: is the gathering of information about a patient's‬‬
‫‪physiological, psychological, sociological, and spiritual status in order to‬‬
‫‪identify actual and potential health problems‬‬
‫انتقٍٍى انصحً‪ :‬هى خًغ انًؼهىياخ حىل انحانح انفسٍىنىخٍح وانُفسٍح واالختًاػٍح وانشوحٍح نهًشٌض يٍ أخم‬ ‫نفع انتؼشٌف‬

‫تحذٌذ انًشاكم انصحٍح انفؼهٍح وانًحتًهح‪.‬‬

‫ششذ اٌزؼشَف‬
‫َىٍه هى خّغ ِؼٍىِبد ػٓ اٌسبٌه ((اٌسبٌخ شٕى َؼٍٕ زبٌخ اٌّشَط ))ِثً شٕى اٌّؼٍىِبد‬
‫ِثً اٌفغُىٌىخُخ شىْ اخّغ ِؼٍىِبد ػٓ اٌسبٌخ اٌفغُىٌىخُخ ((اٌفصبَ واالوزئبة واٌىعىاط ‪...‬اٌخ هٕه رٍٔ‬
‫ِزؼٍمبد ثبي اٌفغُىٌىخُخ ))‬
‫إٌفغُه شٕى ((هى ادسان وعٍىن اٌّشَط وفهّه واَعب االوزبة واٌ شٍ َزؼٍك ثبٌٕفظ ))‬
‫االخزّبػُه ((هى لذسد اٌّشَط ػًٍ اٌزفبػً ثُٕه وثُٓ اٌّدزّغ ))‬
‫اٌشوزُه (( هى اػبدح اٌزىىَٓ اٌشوزٍ ٌالٔغبْ واَعب ِزؼٍك ثبٌذَبٔبد ))‬
‫أذ ِٓ ػشفذ رٍٔ وٍهٓ ساذ رسذد زبٌخ اٌّشَط واَعب ساذ َغبػذن ثبٌفسص اٌطجٍ ِثً ِشَط ثٍ رىزذ‬
‫هبٌ زبٌخ فغُىٌىخُه الصَ ِزٍضِه او رىىْ ززس وَب ٔفغُزه رؼجبٔه ِب َشَذ اصػبج هبٌ زبٌخ ٔفغُه الصَ‬
‫رخٍٍ ِشربذ ززً شٕى رسصً ػًٍ افعً ٔزُده‬
‫أغشاض اٌزمُُُ اٌصسٍ ‪The purposes of the health assessment‬‬
‫ٌٍسصىي ػًٍ ثُبٔبد ٌخػ األعبط ‪ To obtain baseline data‬‬
‫)‪ To identify and manage a variety of patient problems (actual and potential‬‬
‫ٌزسذَذ وإداسح ِدّىػخ ِزٕىػخ ِٓ ِشبوً اٌّشظً (اٌفؼٍُخ واٌّسزٍّخ) ‪‬‬
‫ٌزمُُُ فؼبٌُخ اٌشػبَخ اٌزّشَعُخ ‪ To Evaluate the effectiveness of nursing care‬‬
‫ٌزؼضَض اٌؼاللخ ثُٓ اٌّّشظخ واٌّشَط ‪ To Enhance the nurse-patient relationship‬‬
‫إلصذاس األزىبَ اٌغشَشَخ ‪ To Make clinical judgments‬‬

‫‪M.Sc Hassanain Mohammed Kadhim‬‬ ‫نفع انُقاط‬

‫‪2‬‬
Preparation for Health assessment includes the :
 ٍ‫َشًّ اٌزسعُش ٌٍزمُُُ اٌصس‬
1- Preparation your self ‫خهض ٔفغه‬
 Proper knowledge ‫اٌّؼشفخ اٌصسُسخ‬
 Skillful ‫ِبهش‬
 Clean comfortable uniform ‫صٌ ِشَر ٔظُف‬
 Clean hand ( hand washing ) )َٓ‫َذ ٔظُفخ (غغً اٌُذ‬

3 M.Sc Hassanain Mohammed Kadhim

2- Preparation of physical environment:
)) ‫إػذاد اٌجُئخ اٌّبدَخ )) اػذاد غشفخ اٌّشَط‬
• Clean ‫َٕظف‬
• Quite ‫هذوء‬
• Warm ‫دافئ‬
• Ventilation ‫وعٍُخ رهىَخ‬
• Privacy ‫خصىصُخ‬
• Proper furniture ‫أثبس ِٕبعت‬
• Proper moisture‫اٌشغىثخ إٌّبعجخ‬
• Proper lighting ( natural & artificial) )‫اإلظبءح إٌّبعجخ (غجُؼُخ واصطٕبػُخ‬

4 M.Sc Hassanain Mohammed Kadhim

 3- Preparation of the client : ‫ردهُض اٌّشَط‬
• Identify your self ‫ػشف ػٓ ٔفغه‬
• Explain the procedure ‫اششذ اإلخشاء‬
• Provide clean gown ‫رىفُش ػجبءح او ٌجظ ٌٍّشَط ٔظُف‬
• Explain the types of position the client may take to
facilitate exam

‫اششذ أٔىاع اٌىظبئف اٌزٍ لذ َزخزهب اٌؼًُّ ٌزغهًُ االخزجبس‬

5 M.Sc Hassanain Mohammed Kadhim

 4- Preparation of the equipments:
‫ردهُض اٌّؼذاد‬

 Be sure that’s the equipments is in good condition working

well
‫رأوذ ِٓ أْ اٌّؼذاد فٍ زبٌخ خُذح ورؼًّ ثشىً خُذ‬
 Clean well arranged according to use
َ‫ٔظُفخ ِشرجخ زغت االعزخذا‬
 All infection control measures should be taken under
consideration
‫َدت ارخبر خُّغ رذاثُش ِىبفسخ اٌؼذوي فٍ االػزجبس‬

6 M.Sc Hassanain Mohammed Kadhim

 Gathering Data ‫خّغ اٌجُبٔبد‬
1- Subjective data - Said by the client (S) by using interview to
collect the following data:
:‫ ٌقىنها انؼًٍم (انؼًالء) تاستخذاو انًقاتهح ندًغ انثٍاَاخ انتانٍح‬- ‫انثٍاَاخ انزاتٍح‬
 Biographical ‫اٌغُشح اٌزارُخ‬
 Present history ٌٍ‫اٌزبسَخ اٌسب‬
 Past history ٍ‫اٌزبسَخ اٌّبظ‬
 Family history‫ربسَخ اٌؼبئٍخ‬
*Information related to life style & activities of daily living
‫ِؼٍىِبد ِزؼٍمخ ثّٕػ اٌسُبح وأٔشطخ اٌسُبح اٌُىُِخ‬
2- Objective data - Observed by the nurse (O)
)‫ اٌزٍ رّذ ِالزظزهب ِٓ لجً اٌّّشظخ (ط‬- ‫اٌجُبٔبد اٌّىظىػُخ‬

7 M.Sc Hassanain Mohammed Kadhim

 -Objective data - Observed by the nurse (O)
)‫ اٌزٍ رّذ ِالزظزهب ِٓ لجً اٌّّشظخ (ط‬- ‫اٌجُبٔبد اٌّىظىػُخ‬
 Physical Examination: collection of objective data by using many
techniques such as: The order of techniques is as follows
ً‫ تشتٍة انتقٍُاخ ػهى انُحى انتان‬:‫ خًغ انثٍاَاخ انًىضىػٍح تاستخذاو تقٍُاخ ػذٌذج يثم‬:ًَ‫انفحص انثذ‬
1-Inspection ُُٕٓ‫فسص ِٓ خالي اٌؼ‬
2-Palpatio ) ‫خظ ( ٌّظ‬
3-Percussion ‫غشق‬
4-Auscultation ‫اٌغّغ‬
 A. Inspection :critical observation *always first* * ‫ انًالحظح انُقذٌح * دائًا أوال‬:‫ انُظش‬- ‫أنف‬
 1. Take time to “observe” with eyes, nose ‫خز ولزه فٍ "اٌّالزظخ" ثبٌؼُُٕٓ واألٔف‬
 2. Use good lighting ‫اعزخذَ إظبءح خُذح‬
 3. Look at color, size, shape, symmetry, position
‫أظش إًٌ اٌٍىْ واٌسدُ واٌشىً واٌزّبثً واٌّىظغ‬
 4. Observe for odors from skin, breath, wound ‫سالت سوائر اٌدٍذ وإٌفظ واٌدشوذ‬

8 M.Sc Hassanain Mohammed Kadhim

 B. Palpation : touch ( finger tips , dorsal surface of the hand & palm )
)‫ اٌٍّظ (أغشاف األصبثغ واٌغطر اٌظهشٌ ٌٍُذ وسازخ اٌُذ‬:‫اٌدظ‬
Type of palpation :- ‫أٔىاع اٌدظ‬
1- light palpation ( 1– 2 cm) )ُ‫ ع‬2-1( ‫خظ اٌعىء‬

*Pulse ‫خظ إٌجط‬ * temp ‫خظ ِؤلذ‬ * texture ‫خظ االٔغدخ‬

* moisture ُ‫ِؼشفخ سغىثخ اٌدغ‬ * pain ٌُ‫ٌّظ ِٕطمخ اال‬ tendernessْ‫اٌشلخ واٌسٕب‬

9 M.Sc Hassanain Mohammed Kadhim

 2- Deep palpation =( 4- 5 cm )to assess mass and organs

3- Bimanual using two hand (5-8) cm to assess organs

10 M.Sc Hassanain Mohammed Kadhim

 -Organ assessment ‫رمُُُ األػعبء‬
*Size ‫ِمبط‬
*Shape ً‫شى‬
-Mass assessment ‫رمُُُ اٌىزٍخ‬
*Size ‫ِمبط‬
*Shape ً‫شى‬
*Location ‫ِىلغ‬
*Consistency ‫رٕبعك‬
*Boarder ‫ثىسدس‬
*Mobility ً‫إِىبُٔخ اٌزٕم‬
*Painful ٌُ‫ِؤ‬

11 M.Sc Hassanain Mohammed Kadhim

 C. Percussion : sounds produced by tapping body surface
‫ األصىاخ انصادسج ػٍ انُقش ػهى سطح اندسى‬:‫ اإلٌقاع‬-‫ج‬
 Type of percussion ‫ٔىع اإلَمبع‬
1- direct percussion ----- sinus only ‫ اٌدُىة األٔفُخ فمػ‬----- ‫لشع ِجبشش‬
2- indirect percussion ‫لشع غُش ِجبشش‬
3- blunt percussion ---- liver & spleen ‫ اٌىجذ واٌطسبي‬---- ‫لشع زبد‬
*Produces different sounds depending on underlying structures
‫ٌُتح أصىاتًا يختهفح اػتًادًا ػهى انهٍاكم األساسٍح‬
1- Resonance ( air ) ---- lung --- normal ‫ غجُؼُخ‬--- ‫ اٌشئخ‬---- )‫اٌشُٔٓ (اٌهىاء‬
2- Hyper- resonance ( to much air ) abnormal ( emphazema)
)‫فشغ اٌشُٔٓ (ٌىثُش ِٓ اٌهىاء) غُش غجُؼٍ (دثمخ‬
3- Flatness ------ bone & muscle ‫ اٌؼظبَ واٌؼعالد‬------ ‫رغطُر‬
4- Dullness( fluid ) ----- liver & spleen ‫ اٌىجذ واٌطسبي‬----- )ً‫رشست (عىائ‬
5- Drum( tympanic)---- stomach ‫ ِؼذح‬---- )‫غجٍخ (غجٍخ‬

12 M.Sc Hassanain Mohammed Kadhim

13 M.Sc Hassanain Mohammed Kadhim
 D. Auscultation : listening to sounds produced by the body by
using stethoscope
‫ االستًاع إنى األصىاخ انتً ٌصذسها اندسى تاستخذاو سًاػح انطثٍة‬:‫ انتسًغ‬-‫د‬

 1. Flat diaphragm picks up high-pitched respiratory sounds

best ( high density sound ).
‫ٌهتقظ انحداب انحاخض انًسطح أصىاخ اندهاص انتُفسً ػانٍح انُثشج تشكم أفضم‬
.)‫(صىخ ػانً انكثافح‬

 2. Bell picks up low pitched sounds such as heart murmurs (

low density sound ).
‫ ٌهتقظ اندشط األصىاخ انًُخفضح انحذج يثم انُفخاخ انقهثٍح (صىخ يُخفض‬.2
.)‫انكثافح‬

14 M.Sc Hassanain Mohammed Kadhim

 Instrumentation used in assessment
ُُُ‫األخهضح اٌّغزخذِخ فٍ اٌزم‬

Instruments, or “equipments” used during physical assessment should be readily accessible,

clean, in proper working order.
.‫ٌدة أٌ تكىٌ األدواخ أو "انًؼذاخ" انًستخذيح أثُاء انتقٍٍى انًادي سههح انًُال وَظٍفح وفً َظاو ػًم يُاسة‬
1-Ophthalmoscope: "lighted instrument for visualization of the eye".
."ٍٍ‫ "أداج يضاءج نتصىس انؼ‬:ٍٍ‫يُظاس انؼ‬
2-Otoscope: for examination of the ear. .ٌ‫ نفحص األر‬:ٌ‫يُظاس األر‬
3-Snellen eye chart: TO exam visual acuity . .‫ نفحص حذج انثصش‬:ٍٍ‫يخطظ ػٍٍ سٍُه‬
4-Nasal speculum: used for assessment of the nose. .‫ ٌستخذو نتقٍٍى األَف‬:‫يُظاس األَف‬
5-Vaginal speculum: examination of the vaginal canal and cervix.

.‫ فحص قُاج انًهثم وػُق انشحى‬:ً‫يُظاس يهثه‬

6-Tuning fork: for testing auditory function and vibratory perception.
.‫ الختثاس انىظٍفح انسًؼٍح واإلدساك االهتضاصي‬:‫انشىكح انشَاَح‬
7-Percussion hammer: “reflex hammer” used to test reflexes and determine tissue density.
‫ "انًطشقح االَؼكاسٍح" تُستخذو الختثاس انًُؼكساخ وتحذٌذ كثافح األَسدح‬:‫يطشقح اإلٌقاع‬

M.Sc Hassanain Mohammed Kadhim 15

 General Appearance OR General survey
َ‫اٌّظهش اٌؼبَ أو اٌّغر اٌؼب‬
1- Body Built (weight & height) )‫ثٍٕ اٌدغُ (اٌىصْ واٌطىي‬
Normal ----- even , proper to age & life style
‫ ِٕبعت ٌٍؼّش ؤّػ اٌسُبح‬----- ٌ‫ػبد‬
Abnormal ------ excessive thin OR obese
‫ إٌسبفخ اٌّفشغخ أو اٌغّٕخ‬------ ٍ‫غُش غجُؼ‬
2- Personal hygiene & grooming ( cleanliness & grooming )
)‫انُظافح انشخصٍح وانؼُاٌح انشخصٍح (انُظافح وانؼُاٌح‬
Normal ------ clean & neat ‫ ٔظُف وأُٔك‬------ ٌ‫ػبد‬
Abnormal ----- dirty and unkempt
‫ لزسح وغُش ِهزثخ‬----- ٍ‫غُش غجُؼ‬

16 M.Sc Hassanain Mohammed Kadhim

3- Odor ‫سائسخ‬
Normal ------ no body odor related to working or activity , with out
breathing odor
‫ ثذوْ سائسخ رٕفظ‬، ‫ ال رىخذ سائسخ ٌٍدغُ ِزؼٍمخ ثبٌؼًّ أو إٌشبغ‬------ ٍ‫غجُؼ‬
Abnormal ----- foul odor or ammonia odor or acetone odor
ْ‫ سائسخ وشَهخ أو سائسخ األِىُٔب أو سائسخ األعُزى‬----- ٍ‫غُش غجُؼ‬
4- Dressing ‫ظّبدح‬
Normal ----- proper for occasion ‫ ِٕبعت ٌٍّٕبعجخ‬----- ٌ‫ػبد‬
Proper for situation ‫ِٕبعت ٌٍىظغ‬
Proper for weather ‫ِٕبعت ٌٍطمظ‬
Abnormal ----- not proper for occasion ‫ ٌُظ ِٕبعجًب ٌٍّٕبعجخ‬----- ٍ‫غُش غجُؼ‬
Not proper for situation ‫غُش ِٕبعت ٌٍىظغ‬
Not proper for weather ‫غُش ِٕبعت ٌٍطمظ‬

17 M.Sc Hassanain Mohammed Kadhim

 5- Posture & gait ( setting & standing )
)‫انًىقف وانًشً (انىضغ وانىقىف‬
Normal ---- relaxes & erect , coordinated movement
‫ زشوخ ِٕغمخ‬، ‫ َشربذ وَٕزصت‬------ ٌ‫ػبد‬
Abnormal ----- band , shrank movement , not coordinated
‫ غُش ِٕغمخ‬، ‫ رمٍص اٌسشوخ‬، ‫ اٌفشلخ‬----- ٍ‫غُش غجُؼ‬
6- Attitude ‫عٍىن‬
Normal ---- cooperative ٍٔ‫ رؼبو‬---- ٌ‫ػبد‬
Abnormal ----- not cooperative ( withdrawn)or ( hostile)
)ٍ‫ غُش ِزؼبوْ (ِٕغست) أو (ػذائ‬----- ٍ‫غُش غجُؼ‬

18 M.Sc Hassanain Mohammed Kadhim

 7- Speech ‫خطبة‬
Normal ---- clear , understand able , moderate pace
‫ وعشػخ ِؼزذٌخ‬، ‫ فهُ لبدس‬، ‫ واظر‬---- ٌ‫ػبد‬
Abnormal ----- not understandable , rapid pace or slow pace
‫ أو إَمبع عشَغ أو ثطٍء‬، َ‫ غُش ِفهى‬----- ٍ‫غُش غجُؼ‬

8- Thought ‫فىش‬
Normal ----- logic , sequence has sense of reality & clear
‫ اٌزغٍغً ٌه إزغبط ثبٌىالغ وواظر‬، ‫ ِٕطك‬----- ٌ‫ػبد‬
Abnormal ----- illogical , flitting of idea or confuse
‫ فىشح أو اسرجبن‬، ٍ‫ غُش ِٕطم‬----- ٍ‫غُش غجُؼ‬

19 M.Sc Hassanain Mohammed Kadhim

 ‫ثشٔبِح ِغر ٌٍجبسوىد‬

ُُ‫ِهبساد رم‬ ٍ‫ششذ اظبفٍ اخٕج‬ Red Laser

‫صسٍ ٌٍشاط‬ ‫ٌفهُ اٌّىظىع‬

Thank you
20 M.Sc Hassanain Mohammed Kadhim