Health Assessment / Physical assessment.pptx

It is useful for GNM-I year, B.Sc.N. Sem.-I,II students. This PPT contains Physical Assessment / Head To Toe Assessment topic of Fundamentals of Nursing subject.

1. HEALTH ASSESSMENT Prepared By- Mr. Ahmed Sodha M.Sc. (N). – M.S.N . Prepared By - Ahmed Sodha

2. HEALTH ASSESSMENT HEAD TO TOE PHYSICAL EXAMINATION Prepared By - Ahmed Sodha

3. HEALTH ASSESSMENT DEFINITION: Health assessment or clinical examination (more popularly known as a check-up) is the process by which a doctor/ Nurse investigates the body of a patient for signs of disease. Prepared By - Ahmed Sodha

4. HEALTH HISTORY PHYSICAL ASSESSMENT HEALTH ASSESSMENT Prepared By - Ahmed Sodha

5. 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. Prepared By - Ahmed Sodha

6. 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 Prepared By - Ahmed Sodha

7. 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. . Prepared By - Ahmed Sodha

8. PREPARATIONS Prepared By - Ahmed Sodha

9. 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 Prepared By - Ahmed Sodha

10. 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 Prepared By - Ahmed Sodha

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14. POSITIONS OF PATIENT 2. PRONE POSITION: 1. SUPINE POSITION: Prepared By - Ahmed Sodha

15. 3. SITTING POSITION: 4. SEMI FOWLER’s POSITION: Prepared By - Ahmed Sodha

16. 5. SIM’s POSITION: 6. KNEE-CHEST POSITION: Prepared By - Ahmed Sodha

17. 7. DORSAL RECUMBENT POSITION: 8. LITHOTOMY POSITION: Prepared By - Ahmed Sodha

18. 9. TRENDELENBERG’s POSITION: Prepared By - Ahmed Sodha

19. METHODS OF EXAMINING: 1. Inspection: A method of systematic observation. Inspection should begin with general observation of the patient progressing to specific body areas. Prepared By - Ahmed Sodha

20. 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. Prepared By - Ahmed Sodha

21. 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 Prepared By - Ahmed Sodha

22. For light palpation, press the skin gently with the tips of two or three fingers held close together. Prepared By - Ahmed Sodha

23. 3. Percussion: Tapping of the body lightly but sharply to determine consistency of tissues and/or organs through vibration `& areas of tenderness. Prepared By - Ahmed Sodha

24. 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. Prepared By - Ahmed Sodha

25. 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 Prepared By - Ahmed Sodha

26. 4. Auscultation: Process of listening for sounds over body cavities to determine presence and quality of heart, lung, and bowel sounds. Prepared By - Ahmed Sodha

27. TYPES OF AUSCULTATION Direct auscultation : use of unaided ear Indirect auscultation : use of stethoscope Prepared By - Ahmed Sodha

28. 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 . Prepared By - Ahmed Sodha

29. 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. Prepared By - Ahmed Sodha

30. iv) Body type : Trim, muscular, obese or excessively thin. Prepared By - Ahmed Sodha

31. v) Posture: Observe whether the client has a slumped, erect or bent posture. Prepared By - Ahmed Sodha

32. vi) Gait: Observe the walking pattern of the client. Not whether the movements are coordinated or uncoordinated. Prepared By - Ahmed Sodha

33. 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. Prepared By - Ahmed Sodha

34. VITAL SIGNS : Equipment Needed: A Stethoscope A Blood Pressure Cuff A Watch Displaying Seconds A Thermometer Prepared By - Ahmed Sodha

35. 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. Prepared By - Ahmed Sodha

36. 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" ). Prepared By - Ahmed Sodha

37. 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.  Prepared By - Ahmed Sodha

38. PHYSICAL EXAMINATION: Prepared By - Ahmed Sodha

39. SKILLS OF PHYSICAL EXAMINATION Prepared By - Ahmed Sodha

40. HEAD TO TOE ASSESSMENT 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 Prepared By - Ahmed Sodha

41. Cynosis Erythema Prepared By - Ahmed Sodha

42. 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. Prepared By - Ahmed Sodha

43. NORMAL NAIL SHAPE Technique : view the index finger note the angle of the nail base it should be above 160 degree. Lovibond angle Prepared By - Ahmed Sodha

44. ABNORMAL NAIL SHAPES Early clubbing Late clubbing Prepared By - Ahmed Sodha

45. Lovibond angle Window sign/ Schamroth’s sign Causes: Cardiac [infective endocarditis ] Respirotory [lung abscess, bronchogenic carcinoma, empyema thorasic , cystic fibrosis etc.] Alimentary causes: Ulcerative colitis cirrhosis of liver Prepared By - Ahmed Sodha

46. B. HEAD: Eyes: Examine the conjunctiva, sclera. Test pupils for irregularity, accommodation, and reaction. Evaluate visual fields and visual acuity. Prepared By - Ahmed Sodha

47. Vision Visual acuity (ability to see small detail): by snellens chart. Peripheral vision: Prepared By - Ahmed Sodha

48. Ears: Examine the pinna and peri -auricular tissues. Test auditory acuity, perform Weber and Rinne tests. Prepared By - Ahmed Sodha

49. 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. Prepared By - Ahmed Sodha

50. 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 Prepared By - Ahmed Sodha

51. 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 Prepared By - Ahmed Sodha

52. 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. [ glosopharyngeal , vagus , hypoglosal ] e. Face: Evaluation of symmetry, smile, frown, and jaw movement will provide information about motor divisions of cranial nerves V and VII. [trigeminal, facial] Prepared By - Ahmed Sodha

53. 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. Prepared By - Ahmed Sodha

54. 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 Prepared By - Ahmed Sodha

55. Thyroid : palpation for size , symmetry , tenderness and nodules. Prepared By - Ahmed Sodha

56. Trachea: P alpation for alignment and position: unequal space between trachea and sterno-cleido mastoid muscle on each side is abnormal, indicative of trachea displacement. Prepared By - Ahmed Sodha

57. CAROTID ARTERY : Palpate one carotid artery at a time just below the upper border of the thyroid cartilage. Prepared By - Ahmed Sodha

58. RESPIRATORY ASSESSMENT: Prepared By - Ahmed Sodha

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60. 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.) Prepared By - Ahmed Sodha

61. 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 . Prepared By - Ahmed Sodha

62. 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 Prepared By - Ahmed Sodha

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64. iv) Auscultation: Use the diaphragm of the stethoscope to auscultate breath sounds. Note the location and quality of the sounds you hear. Prepared By - Ahmed Sodha

65. Areas of Auscultation :                                                                                                                                                                                                                                                                                                                                                                                                                                           Prepared By - Ahmed Sodha

66. 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 . Prepared By - Ahmed Sodha

67. 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. Prepared By - Ahmed Sodha

68. 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. Prepared By - Ahmed Sodha

69. 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 2 nd intercostal space (ICS) sternal border. Pulmonary Valve – Left 2 nd ICS sternal border. Mitral Valve – Left 5 th ICS midclavicular line. Tricuspid Valve – Left 5 th ICS sternal border Prepared By - Ahmed Sodha

70. AV Valves- Tricuspid and Mitral Semilunar valves- Pulmonic and aortic Prepared By - Ahmed Sodha

71. 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.   Prepared By - Ahmed Sodha

72. ABDOMINAL ASSESSMENT Prepared By - Ahmed Sodha

73. E. ABDOMINAL ASSESSMENT: Abdomen is divided into 4 main quadrants: Right Upper Quadrant (RUQ) Right Lower Quadrant (RLQ) Left Upper Quadrant (LUQ) Left Lower Quadrant (LLQ) Prepared By - Ahmed Sodha

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75. 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. Prepared By - Ahmed Sodha

76. 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. Prepared By - Ahmed Sodha

77. 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. Prepared By - Ahmed Sodha

78. 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. Prepared By - Ahmed Sodha

79. 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. Prepared By - Ahmed Sodha

80. 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. Prepared By - Ahmed Sodha

81. GENITALIA AND RECTUM : Prepared By - Ahmed Sodha

82. 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. Prepared By - Ahmed Sodha

83. 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. Prepared By - Ahmed Sodha

84. 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. Prepared By - Ahmed Sodha

85. 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 . Prepared By - Ahmed Sodha

86. 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. Prepared By - Ahmed Sodha

87. Rombergs te st : 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. Prepared By - Ahmed Sodha

88. REFLEXES OF MUSCLES : Tests of muscle strength and assessment of common reflexes Prepared By - Ahmed Sodha

89. 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 patellar. Extension of lower leg at knee. Prepared By - Ahmed Sodha

90. Procedures Normal reflex Achilles 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 . Babinski’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. Prepared By - Ahmed Sodha

91. 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. Prepared By - Ahmed Sodha

92. 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 Prepared By - Ahmed Sodha

93. 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. Prepared By - Ahmed Sodha

94. 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. Prepared By - Ahmed Sodha

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96. 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 . Prepared By - Ahmed Sodha

97. 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. Prepared By - Ahmed Sodha

98. 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. Prepared By - Ahmed Sodha

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