Health assesment

 1. HEALTH ASSESSMENT HEAD TO TOE PHYSICAL EXAMINATION

 2. HEALTH ASSESSMENT DEFINITION: Health assessment or clinical examination
(more popularly known as a check-up) is the process by which a doctor investigates the
body of a patient for signs of disease.
 3. HEALTH HISTORY PHYSICAL ASSESSMEN T
 4. HEALTH HISTORY • A health history is the collection of subjective data that
provides a detailed profile of the patient health status. • Therapeutic communication
skill and interview technique used to gather health history. • It helps to identify actual
and potential health problem.
 5. Physical examination is an integral part of health examination and it includes head
to toe examination of the patient to rule out any deviation from the normal. PHYSICAL
EXAMINATION
 6. PURPOSE •To gather baseline data. •To confirm the alterations, disease or
inability to perform the activities of daily living. •To supplement data obtained in the
nursing history. •To make nursing diagnosis. •To make clinical judgments about the
client’s changing health status and management. •To evaluate the effectiveness of
health care. •.
 7. PREPARATIONS Comfort Position, gowning Height of examination table
Light sources Eliminate distractions Equipments: clean & in working condition
 8. INSTRUMENTS SUPPLIES PURPOSE Flash light or penlight To assist viewing of
the pharynx and cervix or to determine the reactions of the pupils of the eye Nasal
speculum to visualization of the lower and middle turbinates Opthalmoscope To
visualize the interior of the eye Otoscope To visualized the ear drum and external
auditory canal Knee hammer To test reflex
 9. INSTRUMENTS SUPPLIES PURPOSE Tuning fork To test hearing acuity and
vibratory sense. Vaginal speculum To assess cervix and vagina Cotton applicator To
obtain specimens Gloves To prevent contamination Lubricant To ease insertion of
instruments Tongue depressors To depress the tongue Stethoscope To auscultate heart,
lung, abdomen and cardiovascular sound. Thermometer To check the temperature
 13. POSITIONS OF PATIENT 2. PRONE POSITION: 1. SUPINE POSITION:
 14. 3. SITTING POSITION: 4. SEMI FOWLER’s POSITION:
 15. 5. SIM’s POSITION: 6. KNEE-CHEST POSITION:
 16. 7. DORSAL RECUMBENT POSITION: 8. LITHOTOMY POSITION:
 17. 9. TRENDELENBERG’s POSITION:
 18. METHODS OF EXAMINING: 1. Inspection: A method of systematic observation.
Inspection should begin with general observation of the patient progressing to specific
body areas.
 19. 2. Palpation: Process of examining patients by application of the hands. Used to
determine: • Consistency of tissue. • Alignment and intactness of structures. •
Symmetry of body parts. • Areas of warmth and tenderness.
 20. Parts of hands used for various palpation: Part of hand Type of palpation Finger
tips To assess texture, shape, size, consistency and palpation Dorsum of hand and
fingers To assess temperature Palm of hand To assess vibration Pinching of fingers To
assess turgor, consistency and position
 21. For light palpation, press the skin gently with the tips of two or three fingers held
close together.
 22. 3. Percussion: Tapping of the body lightly but sharply to determine consistency
of tissues and/or organs through vibration `& areas of tenderness.
 23. PERCUSSION The sounds may be: • Resonance: a low pitched and loud sound
heard over the normal lung tissues. • Hyper resonance: very loud , very low pitched
sound longer than resonance signifies emphysema. • Tympany : a drum like sound
heard over the air filled tissues such as gastric air bubble. • Dull: A medium pitched
sound with a medium duration without resonance heard over solid tissues such as heart
, liver.
 24. Percussion sound with examples: Percussion sounds Intensity Pitch Percussion
example Dullness Medium Moderate Liver Resonance Loud Low Normal lung Hyper
resonance Very loud Lower Emphysematous lung Tympany Loud Higher Puffed out
cheek , gastric air bubble
 25. 4. Auscultation: Process of listening for sounds over body cavities to determine
presence and quality of heart, lung, and bowel sounds.
 26. TYPES OF AUSCULTATION Direct auscultation: use of unaided ear Indirect
auscultation: use of stethoscope
 27. PROCESS OF HEALTH ASSESSMENT: I. GENERAL APPEARANCE & BEHAVIOR: i)
Gender and race: Certain illnesses are more likely to affect the specific gender and race.
Eg. Risk of having skin cancer is 20% higher in whites than in blacks.
 28. ii) Age: Age influences the normal physical characteristics. iii) Signs of distress:
There may be obvious signs and symptoms indicating pain, difficulty in breathing or
anxiety.
 29. iv) Body type: Trim, muscular, obese or excessively thin.
 30. v) Posture: Observe whether the client has a slumped, erect or bent posture.
 31. vi) Gait: Observe the walking pattern of the client. Not whether the movements
are coordinated or uncoordinated.
 32. vii) Body movements: Note for any tremors involving the extremities. viii)
Hygiene and grooming: Note the appearance of hair, skin and finger nails. Also observe
for the clothing. ix) Affect and mood: Affect is a person’s feelings as they appear to
others. x) Speech: An abnormal pace may be caused by emotions and neurological
impairments. xi) Substance abuse: Check for the history of substance abuse.
 33. VITAL SIGNS: Equipment Needed: • A Stethoscope • A Blood Pressure Cuff • A
Watch Displaying Seconds • A Thermometer
 34. 1. Temperature:Temperature can be measured is several different ways: • Oral
• Axillary • Aural • Rectal. 2. Respiration: In adults, normal resting respiratory rate is
between 16-24 breaths/minute.
 35. 3. Pulse: A normal adult heart rate is between 60 and 100 beats per minute. A
pulse greater than 100 beats/minute is defined to be tachycardia. Pulse less than 60
beats/minute is defined to be bradycardia. 4. Blood Pressure: Record the blood pressure
as systolic over diastolic (Eg. "120/70" ).
 36. HEIGHT, WEIGHT AND CIRCUMFERENCE: • A person’s general level of health
can be reflected in the ratio of height to weight. • Weight is a routine measure during
health visits. • A client’s weight will normally vary daily because of fluid loss or
retention. • Progressive weight gain is ` expected during pregnancy. • Head, chest and
abdominal circumference should be assessed in case of infants.
 37. PHYSICAL EXAMINATION:
 38. Look (Inspection) Listen (auscultation) Feel (palpation) Tap (percussion)
Smell (olfaction) SKILLS OF PHYSICAL EXAMINATION
 39. HEAD TO TOE ASSESSMENT A. THE INTEGUMENT: The integument includes skin,
hair and nails. The examination begins with a generalized inspection using a good
source of lighting. 1. SKIN: Assessment of the skin involves inspection and palpation. •
Pallor/Jaundice • Cyanosis • Erythema • Edema
 40. • Cynosis Erythema
 41. 2. HAIR: Inspect the hairs for colour, alopecia (hair loss) and the cleanliness of the
scalp. 3. NAILS: Nails are inspected for nail plate shape, angle between the nail and the
nail bed, nail texture, nail bed colour and the intactness of the tissues around the nails.
Clubbing is a condition in which the angle between the nail and nail bed is 180 degree
or greater. It may be caused by long term lack of oxygen.
 42. NORMAL NAIL SHAPE • Technique: view the index finger note the angle of the
nail base it should be above 160 degree.
 43. • ABNORMAL NAIL SHAPES Early clubbing Late clubbing
 44. B. HEAD: a. Eyes: Examine the conjunctiva, sclera. Test pupils for irregularity,
accommodation, and reaction. Evaluate visual fields and visual acuity.
 45. Vision Visual activity(ability to see small detail): by snellens chart. Peripheral
vision:
 46. b. Ears: Examine the pinna and peri-auricular tissues. Test auditory acuity,
perform Weber and Rinne tests.
 47. EARS Examination of ears: Pull the ears backward and upward. Instrument used:
Auto scope • External ears: Crusts, discharges, lesions etc. • Tympanic membrane:
Normally it is shiny, translucent, with a pearl grey color. See for any perforation, lesions,
bulging. • Hearing: There are 3 ways for testing the hearing.
 48. Weber's test It is used to assess the conductive hearing loss. Technique: Place a
vibrating tuning fork in the midline of the persons skull and ask if he can hear the
sounds same in both the ears or better in one ear. Result : The person should hear the
tone produced by bone conduction equally in both ears, is the positive test result
 49. Rinne test This is a test to compare the air conduction and the bone conduction
sounds. Technique: Place the stem of the vibrating tuning fork on persons mastoid
process and ask him or her to signal when the sound disappears note the time in
seconds. Invert the tuning fork so the vibrating end is near the ear canal he should hear
the sound. Note the time in seconds. Results : AC : BC = 2 : 1
 50. c. Nose: Connect the nasal speculum to the otoscope and examine the nares,
noting the condition of the mucosa, septum and turbinate's. d. Mouth: Examine the oral
mucosa, the tongue and teeth. Evaluate the function of cranial nerves IX, X, and XII. e.
Face: Evaluation of symmetry, smile, frown, and jaw movement will provide information
about motor divisions of cranial nerves V and VII.
 51. C. Neck: Palpate the neck with emphasis on the salivary glands, lymph nodes,
and thyroid. Look for tracheal deviation. Identify the carotid arteries and auscultate for
bruits.
 52. • Lymph nodes are assessed by palpating with the pad of the finger for
enlargement , tenderness and mobility . • Normally nodes are not palpable. If palpable
they should be small, mobile, smooth and non tender. LYMPH NODES
 53. Thyroid : palpation for size , symmetry , tenderness and nodules.
 54. Trachea: Palpation for alignment and position: unequal space between trachea
and sterno-cleido mastoid muscle on each side is abnormal, indicative of trachea
displacement.
 55. CAROTID ARTERY : Palpate one carotid artery at a time just below the upper
border of the thyroid cartilage.
 56. RESPIRATORY ASSESSMENT:
 58. Funnel chest (Pectus excavatum describes an abnormal formation of the rib cage
that gives the chest a caved-in or sunken appearance.) Pigeon chest (Pectus carinatum,
is a deformity of the chest characterized by a protrusion of the sternum and ribs.)
 59. D. CHEST AND LUNGS: i) Inspection: • Observe the rate, rhythm, depth, and effort
of breathing. • Listen for abnormal sounds such as wheezes. • Observe for retractions.
ii) Palpation: • Identify any areas of tenderness. • Assess expansion and symmetry of
the chest. • Check for tactile fremitus.
 60. iii) Percussion: Percuss from side to side and top to bottom . Categorize what
you hear as normal, dull, or hyper resonant. INTERPRETATION:Percussion Notes and
Their Meaning:Flat or Dull Pleural Effusion or Lobar Pneumonia Normal Healthy Lung or
Bronchitis Hyper resonant Emphysema or Pneumothorax
 62. iv) Auscultation: Use the diaphragm of the stethoscope to auscultate breath
sounds. Note the location and quality of the sounds you hear.
 63. Areas of Auscultation :
 64. ABNORMAL BREATH SOUNDS : Crepts : fine, short interrupted sound heard
during inspiration and expiration. Example : Respiratory distress. Rhonchi : low pitched
continuous musical sound heard during expiration and clears with coughing. Example :
Pneumonia. Wheeze : high pitched continuous musical sound heard during inspiration or
expiration and does not clear with coughing. Example : Pneumonia . Pleural friction
Rub : grating type of sound heard during inspiration and does not clear with coughing,
example : Empyema .
 65. CARDIAC ASSESSMENT: • Inspection of the Heart The chest wall and
epigastrium is inspected while the client is in supine position. Observe for pulsation and
heaves or lifts. Normal Findings: • There should be no lift or heaves.
 66. PALPATION OF THE HEART The entire pre-cordium (anterior surface of the body
covering the heart and lower thorax) is palpated methodically using the palms and the
fingers, beginning at the apex, moving to the left sternal border , and then to the base
of the heart. NORMAL FINDINGS: • No, palpable pulsation over the aortic, pulmonary,
and mitral valves. • Apical pulsation can be felt on palpation. • There should be no
noted abnormal heaves, and thrills felt over the apex.
 67. Percussion of the Heart • The technique of percussion is of limited value in
cardiac assessment. It can be used to determine borders of cardiac dullness.
Auscultation of the Heart • Aortic valve – Right 2nd intercostal space (ICS) sternal
border. • Pulmonary Valve – Left 2nd ICS sternal border. • Mitral Valve – Left 5th ICS
midclavicular line. • Tricuspid Valve – Left 5th ICS sternal border
 68. AV Valves- Tricuspid and Mitral Semilunar valves- Pulmonic and aortic
 69. Auscultating the heart – Auscultate the heart in all anatomic areas aortic,
pulmonic, tricuspid and mitral. – Listen for the S1 and S2 sounds (S1 closure of AV
valves; S2 closure of semi-lunar valve). – Listen for abnormal heart sounds e.g. S3, S4,
and Murmurs. – Count heart rate at the apical pulse for one full minute. Normal
Findings: • S1 & S2 can be heard at all anatomic site. • No abnormal heart sounds is
heard (e.g. Murmurs, S3 & S4). • Cardiac rate ranges from 60 – 100 beats per min.
 70. ABDOMINALASSESSMENT
 71. E. ABDOMINALASSESSMENT: Abdomen is divided into 4 main quadrants: •
Right Upper Quadrant (RUQ) • Right Lower Quadrant (RLQ) • Left Upper Quadrant (LUQ)
• Left Lower Quadrant (LLQ)
 73. i) Inspection: • Look for scars, striae, hernias, vascular changes, lesions, or
rashes, movement associated with peristalsis or pulsations. • Note the abdominal
contour. Is it flat, scaphoid, or protuberant? ii) Auscultation: • Place the diaphragm
lightly on the abdomen, listen for bowel sounds. • Listen for bruits over the renal
arteries, iliac arteries, and aorta.
 74. iii) Percussion: • Percuss in all four quadrants using proper technique. •
Categorize what you hear as tympanitic or dull. Tympany is normally present over most
of the abdomen in the supine position. Unusual dullness may be a clue to an underlying
abdominal mass.
 75. Liver Span • Percuss downward from the chest in the right mid-clavicular line
until you detect the top edge of liver dullness. • Percuss upward from the abdomen in
the same line until you detect the bottom edge of liver dullness. • Measure the liver
span between these two points. This measurement should be 6-12 cm in a normal adult.
 76. Splenic Dullness • Percuss the lowest costal interspace in the left anterior
axillary line. This area is normally tympanitic. • Ask the patient to take a deep breath
and percuss this area again. Dullness in this area is a sign of splenic enlargement.
 77. vi) Palpation: Palpation of the Liver a. Standard Method: • Place your fingers just
below the right costal margin and press firmly. • Ask the patient to take a deep breath.
• You may feel the edge of the liver press against your fingers. Or it may slide under
your hand as the patient exhales. A normal liver is not tender.
 78. b. Alternate Method: • This method is useful when the patient is obese or when
the examiner is small compared to the patient. • Stand by the patient's chest. • "Hook"
your fingers just below the costal margin and press firmly. • Ask the patient to take a
deep breath. • You may feel the edge of the liver press against your fingers.
 79. GENITALIAAND RECTUM: Providing privacy Not prolonging the examination
Warming instruments i.e. vaginal speculum Using lubricants to minimize discomfort
Wear gloves during genital & rectal examination Empty the bladder before examination
 80. Male genitals • Inspect the skin of glance penis. Observe for any lesions, color,
discharge or inflammation. • Assess secondary sex characteristics , observe the penis
and testes for size and shape, color, texture of scrotal skin symmetry and the
distribution of pubic hair , position of meatus and circumcision. • Palpate the penis
using your thumb and first two fingers. Note any tenderness or nodules. Normally,
testes feel firm and not hard with similar consistency.
 81. Female genitalia • Female genitalia is examined by inspection and palpation. •
Inspect the external genitalia. Separate the labia and inspect the labia minora, clitoris,
urethral orifice and vaginal opening. • Observe for inflammation, discharge, ulceration,
varicose veins, swelling and nodules. • In internal inspection, observe cervix for color,
position, bleeding.
 82. EXTREMITIES: Upper and lower Extremities are assessed for size and symmetry ,
various patterns , colour and texture of skin and nail beds , hair distribution on hands ,
lower legs , feet and toes . Observe for pigmentation , rashes , scars , ulcers and
edema.
 83. HOMAN’S SIGN • Test for homan’s sign, an indicator of phlebitis in which pain and
soreness are present in the calf area when the foot is dorsiflexed .The person’s
dorsiflexed leg is supported from calf with your non dominant hand . Note any pain or
soreness in the calf area. If present this would be a positive homan’s sign ,indicating the
possibility of phlebitis .
 84. MOTOR SYSTEM: Inspect the voluntary muscles for atrophy, fasciculation
(uncontrollable twitching)and involuntary movements. In addition assess gait ,
Romberg's sign for muscle strength and coordination. Gait : is a person’s style of
walking. To assess gait, instruct the person to walk across the room, turn and walk back
towards you . Observe the persons balance and posture . Ataxia is an uncoordinated
gait that result from cerebellar disease or intoxication.
 85. Rombergs test : Rombergs test is a test of sensory equilibrium. Instruct the person
to stand with the feet together and eyes open . Note the persons balance .Then have
the person close the eyes. Normally you will observe only minimal swaying . A positive
test will suggest cerebellar ataxia.
 86. REFLEXES OF MUSCLES: Tests of muscle strength and assessment of common
reflexes
 87. Type Procedure Normal reflex Deep tendon reflexes Biceps Flex the client’s
arm at elbow with palms down. Place your thumb in antecubital fossa at the base of
biceps tendon . Strike the thumb with the reflex hammer . Flexion of arm at elbow.
Triceps Flex the client’s elbow , holding arm across the chest , or hold the upper arm
horizontally and allow the lower arm to go limp. Strike triceps tendon just above the
elbow . Extension at elbow. Patellar Make the client sit with legs hanging freely over the
 side of the bed or chair or have the client lie supine and support knee in a flexed
position . Briskly tap patellar tendon just below Extension of lower leg at knee.
 88. Procedures Normal reflex Achille s Make the client assume the same position
as for patellar reflex. Slightly dorsiflex the client’s ankle by grasping toes in the palm of
your hand . Strike achilles tendon just above the heel. Plantar flexion of foot . Babins
ki’s Have the client lie supine with legs straight and feet relaxed . Take the handle end
of the reflex hammer and stroke lateral aspect of the sole from the heel to the ball of
the foot , curving across the ball of the foot toward the big toe. Bending of toe
downwards.
 89. Maneuvers to assess muscle strength: Muscle group Maneuver Neck Place your
hand firmly against the client’s upper jaw .ask the client to turn head laterally against
resistance. Shoulder Place your hand over the midline of the client’s shoulder , exerting
firm pressure . Have the client raise shoulder against resistance. Elbow, Biceps, Triceps.
Pull down the forearm as the client attempts to flex the arm. As the client’s arm is
flexed ,apply pressure against the forearm .ask the client to straighten his/her arm. Hip ,
Quadriceps When the client is sitting apply downward pressure to thigh . Ask the client
to raise his leg up from the table. The client sits, holding shin of the flexed leg . Ask him
to straighten his leg against the resistance.
 90. MUSCLE STRENGTH To grade or quantify muscle strength, assess the patient as
follow: Grade Description 0/5 No muscle movement 1/5 Visible muscle movement, but
no movement at the joint 2/5 Movement at the joint, but not against gravity 3/5
Movement against gravity, but not against added resistance 4/5 Movement against
resistance, but less than normal 5/5 Normal strength
 91. SENSORY SYSTEM: • Light touch/ superficial pain: Using a wisp of cotton and a
safety pin alternatively , touch the distal and proximal portions of the upper and lower
extremities. • The temperature test can be done by asking the patient to touch and
identify the hot and cold test tube filled with hot and cold water respectively. • Vibration
is assessed by tapping a tuning fork and placing it firmly on a person’s inter-phallengial
joint of the finger and great toe. Ask the patient to describe the sensation and to
identify when the sensation ends.
 92. • Two point discrimination: When assessing two point discrimination , touch the
person alternatively with one or two safety pins on a particular body part, such as the
finger pads . ask the patient if one or two sensations are felt. • Point localization is
assessed by touching various parts of the person’s body with a wisp of cotton. The
person is instructed to open the eyes after having felt the touch and point to the area.
 94. CONSCIOUSNESS Assessment of consciousness begins with noting whether the
client is awake and alert . If the person has altered the level of consciousness , assess
whether the person is demonstrating stupor or coma . Glasgow coma scale to be
maintained for the patient with altered sensorium and in that three points are observed:
eye open response, verbal response and motor response .
 95. AFTER CARE: When the physical examination is over, remove the drape & help
the person to put on cloths. Be sure the patient is safe and comfortable. DISMANTLING
OF ARTICLES: Articles should be sent for sterilization. Disposable articles should be
immediately disposed off and replacement of all the articles should be done to the area
specified.
 96. POINTS TO BE REMEMBER: • Ensure that adequate privacy is provided during the
observation. • Always take help in case of pediatric /unconscious patient /
uncooperative patient . • Ensure adequate light. • Inform the patient / relatives before
and after the physical examination . • Record all the observations and preserve in safe
custody . • Inform any abnormal findings to senior nurse/doctor