health assessment For B.Sc Nursing 2024 PPT

Health Assessment PPT

1. Presented By.
Sheikh Inayat Ul Rehman
2
nd
Sem B.Sc Nursing
Kidwai College Of Nursing.
Bangalore Karnataka-560029
Health Assessment (NUR 224)
1

2. Learning objectives
At the end of this module, the learner should be
able to:
1.Define the Key terms.
2.Understand the concept of physical
examination in terms of its requirements.
3.Discuss the concept of general survey in terms
of its purpose, skills, and components.
4.Discuss the four basic physical examination
techniques.
5.Identify commonly needed physical
examination equipments and their functions.

3. Physical Examination
Physical examination is a systematic approach
of collecting objective data about clients’
health status.
It employs through detailed evaluation of
clients’ all body structures, organs, or systems.
It requires the nurse to apply special
techniques, use equipments and knowledge
base, to physically expose each region of
clients’ body and examine it by looking,
listening, touching, or smelling.

4. Purpose of physical Examination
Physical examination is performed in all
health care settings, covering healthy
and sick clients.
It serves for screening, detection, and
prevention of disease.
It also provides an opportunity for health
promotion (education & counseling) as
well as the evaluation of disease process
or treatment results.

5. Component of Physical Examination:
General survey (the nurses’ initial observation
for the clients’ general appearance and
behavior).
Vital signs measurement
Height and weight measurement
Body systems examination

6. 1-Physical Appearance
Normal Range of Findings Abnormal Findings
1-Age –the person appears his or her
stated age.
Appears older, smaller, or younger, as with
chronic disease or retardation.
2-Sex –Sexual development is
appropriate for gender and age
Delayed or early puberty, or inappropriate to
gender.
3-Level of consciousness –the person is
alert and oriented, attends to your
questions and responds appropriately.
Alert.Follow commands and responds
completely and appropriately to stimuli
Lethargic. The patient is sleepy or drowsy
and will awaken and respond appropriately
to command .
Stupor. require vigorous stimulation for a
response .
Semi coma. The patient is not awake but
will respond purposefully to deep pain
Coma. The patient is completely
unresponsive.

7. 1-Physical Appearance
Normal Range of Findings Abnormal Findings
4-Skin color –color tone is even, skin
is intact with no obvious lesions
•Pallor, (loss of color)
•cyanosis, (bluish discoloration)
•jaundice Yellowish discoloration)
•lesions.
5-Facial features –symmetric with
movement.
6-No signs of acute distress are
present
•Immobile, masklike, asymmetric,
drooping.
•shortness of breath, wheezing.
•facial grimace, holding body part.
(Pain)

8. II-Body STRUCTURE
1-Stature –the height
appears within normal
range for age.
•Excessively short or tall
2-Nutritional status –the
weight appears within normal
range for height and body
build.
•Underweight
•Obese

9. II-Body STRUCTURE
3-Symmetry –body parts look equal bilaterally•Unilateral atrophy
•hypertrophy (enlargementofmuscles.)
4-Posture –the person stands comfortably
erect as appropriate for age.
•Rigid spine and neck (moves as one
unit) e.g., arthritis. Stiff and tense.

10. 5-Position –the person sits
comfortably in a chair or on
the bed or examination table,
arms relaxed at sides, head
turned to examiner.
•Leaning forward with arms
braced on chair arms (chronic
pulmonary disease).
•Sitting straight up and resists
lying down, (left-sided
congestive heart failure).
7-Physical deformities–
Absence of any congenital or
acquired defects.
Presence of deformities or
congenital defect

11. III-Mobility
1-Gait: the walk is smooth, even,
and well-balanced; and
associated movements,
(symmetric arm swing), are
present.
Limping with injury.
Difficulty stopping
2-Range of motion–the person
has full mobility for each joint.
3-Involuntary movement:
absent
Limited joint range of motion.
Paralysis –absent movement.
Movement jerky,
uncoordinated
Tics, tremors, seizers

12. IV-Behavior
1-Facial expression –the
person maintains eye contact
expressions are appropriate to
the situation.
Flat, depressed, angry, sad
anxious. However, note that
anxiety is common in ill
people.
2-Mood and affect–the
person is comfortable and
cooperative with the
examiner and interacts
pleasantly.
Hostile, distrustful,
suspicious, crying

13. Vital signs are the key physiologic measures of the person’s
general health state. The nurse obtains vital signs to:
a.Establish baseline measurement.
b.Identify physiologic problems.
c.Monitor clients’ response to therapy.
Signs range
Pulse rate 60 -100 beats/min
Respiratory rate 12 -20 breath/min
Blood pressure 100/70 to 140/90 mmHg
Temperature 36.5 -37.5 C
Pain

14. 3-Measuring Height and weight
Body mass index _Weight_(kg)____
(Height) 2
Where
 Weight is measured in kilograms.
 Height is measured in meters
BODY MASS INDEX FINDING
< 20 PERSON IS UNDER WEIGHT
=20-25 PERSON IS NORMAL WEIGHT
=25-30 PERSON IS OVERWEIGHT
 >30 PERSON IS OBESE

15. EXAMPLE:-
Calculate body mass index of person, his
weight is 98kg, his height is172 cm .
Answer steps:
Transfer height from cm to meter
=172/100=1.72m
Body mass index (BMI) = 98/(1.72)2
=33
BMI = 33 SO the person is obese.

16. 4-Body systems examination
Body systemsexamination is the systematic
objectiveevaluation of client’s body structures,
parts, and organs, using the examiners’ sense

17. Review client health history
Prepare equipment
Examine client in a warm & quiet room
Examine client in well-lighted room
Consider patients’ privacy and comfort
Practice and adhere to standard precaution of Infection
control
Explain procedure to client & reassure client along the
examination. Begin examination with the patient in
sitting position( if possible). This facilitates front and
back examination
Use appropriate Draping, such that only body part being
examined is exposed

18. Physical examination equipments:
Ophthalmoscope
Otoscope
Tuning fork
Nasal speculum
Percussion hammer
Snellen
chart

19. Basic Physical examination techniques
Physical examination utilizes four techniques
Inspection
Palpation
Percussion
Auscultation

20. 1.Inspection
means Observing the client in a close, focused manner
using vision, and smell senses.
*It begins during the first contact with client and
continues throughout the assessment
*It provides information about body parts’: color, size,
location, movement, texture, symmetry, odor, and
sound

21. 2.Palpation
Palpation is the use of hands and fingers to
feel different body parts for data collection.
The nurse uses pads of the fingers and palms
to touch and feel the patient’s body parts
with his hands to examine:
size texture
location
tenderness
body temperature
lumps or masses

22. Types of palpation
1.Light palpation
Using the flat part of the right hand or the
pads of the fingers, not the fingertips
The fingers should be together
Depress the skin 1 to 2 cm with your finger
pads, usually the lightest touch possible.

23. Light palpation

24. 2.Deep palpation
Used to determine organ size as well as the presence
of abdominal masses
The flat portion of the right hand is placed on the
abdomen
Depress the skin 4 to 5 cm with firm, deep pressure.
Pressure should be applied to the abdomen gently but
steadily
The patient should be instructed to breathe quietly
through the mouth and to keep arms at the sides

25. 3.Percussion
A methods of “ striking” of body parts
during physical examination with fingers to
evaluate the size, consistency, borders and
presence of fluid in body organs
Percussion of a body part produces a sound
that indicates the type of tissue within the
organ
It is particularly important in examining
the chest and abdomen

26. Methods of Percussion
1.Direct percussion:
Using one or two fingers, tap directly on the
body part. Ask the patient to tell you which
areas are painful and watch his/her face for
signs of discomfort.
Direct percussionis commonly used to assess
an adult patient's sinuses for tenderness.

27. 2.Indirect Percussion
Press the distal part of the middle finger (pleximeter) of your
nondominanthand firmly on the body part(left hand).
Keep the rest of your hand off the body surface.
 Flex the wrist of your dominant hand.
Using the middle finger (plexoror striking finger) of your
dominant hand, tap quickly and directly over the point where
your other middle finger touches the patient's skin. The
motion of the striking finger should come from the wrist and
not from the elbow
Deliver 2 -3 quick taps and listen carefully.

28. Types of sounds
Sound Quality of
sound
Where it is
heard
Source
Tympany DrumlikesoundOver enclosed
air
Puffed-out
cheek, air in
bowel
Resonance Hollow sound Over areas of
part air and solid
Normal lung
Hyper
resonance
Booming soundOver air (child’s lungs) N
(adult) Lung with
emphysema
Dullness Thudlike soundOver solid areaLiver, spleen
Flatness Flat sound Over dense
tissue
Thigh Muscle,
bone, over
tumor

29. 4.Auscultation
A method used to “listen” to the body sounds.
Various body systems like heart, lungs, and
abdominal organshave characterized sounds
Bowel, breath, heart, and blood movement
sound are heard using a stethoscope
It is important to know the normal sound to
distinguish from abnormal sound

30. Types of auscultation
1.Direct auscultation:
* Uses the ear alone to listen, such as when
listening to the grating of a moving joint.
* Sounds are audiblewithoutstethoscope
2.Indirect auscultation:
sounds are audible withstethoscope
3.Bell for low pitched sound and diaphragm
for high pitched sound

31. Question?
31