Masumba Review of Health Assesment.….pdf

Health assesment which includes physical examination and common terminologies in medical surgical nursing

1. Health Assesment
•Masumba N.C
•Advcert(M&),
BscN,MPH(st),MBA (st)

2. General Objective
•By the end of this lecture students should
understand Review of Health Assessment.

3. Specific Objective
•By the end of this lecture students should
understand

4. Question
What is a
health
assessment?
•Health assessment refers to
the process of obtaining
data or information from a
patient. The information to
be collected has to be

5. Health Assessment
•Healthassessmentisaprocessinvolving
systematiccollectionandanalysisofhealth-
relatedinformationonpatientsforuseby
patients,clinicians,andhealthcareteamsto
identifyandsupportbeneficialhealthbehaviors
andmutuallyworktodirectchangesin
potentiallyharmfulhealthbehaviors.

6. Cont
•Writedowninyournotebookthemeaningof
healthassessment
•Welldone!Nowcompareyourdefinition
withtheoneinthefollowingsection.

7. Review of Health Assessment
•Two components of health assessment:
•History taking
•Physical examination

8. cont
History Taking
This is also referred to as a ‘clinical
interview’. It is a planned discussion that is
aimed at establishing the health needs and
health problems of the client. It is normally
conducted before a physical assessment.

9. Review of Health Assessment
•During history taking you should collect the
following information:
•Demographic data, e.g., age, sex, address, and
marital status
•Presenting complaints

10. Review of Health Assessment
•History of presenting illness and history of
previous illnesses
•Treatment history
•Family history
•Social and occupational history.

11. Review of Health Assessment
Demographic Data/biographical Data
•Under this heading you will need to collect and record
the following information:
•Name of client.
•Age
•Sex
•Address. (residential)

12. Review of Health Assessment
•Marital status
•Number of Children
•Next of kin
•Religion

13. Review of Health Assessment
•Denomination
•Nationality
•Tribe
•Occupation

14. Review of Health Assessment
•ThePresentingComplaint
•Thepresentingcomplaintissimplytheproblem
whichmadethepatientseekmedicalhelp.
•definethemaincomplaintanditsduration.The
timinganddurationofsymptomaticeventsis
especiallyimportantsincethechronology(order)
oftheillnesswillprovidevaluablecluestothe
pathologicalprocessunderlyingit.

15. Review of Health Assessment
•Some patients find it difficult to remember the
exact duration of their illness, especially the
elderly. Some will use events to signify the
duration. Ask when the patient last felt
perfectly well. This may help the patient to
remember earlier symptoms, which he/she
may have thought were unimportant.

16. Review of Health Assessment
•TheHistoryofthePresentIllness
•Askthepatienttotellyouthestoryoftheillness
fromthebeginning.Ideally,youshouldallowthe
patienttocontinuewithoutinterruption.Ifthe
patientisanxiousornervous,youwillneedto
usetactfulencouragement.Fortalkative
patients,trytodirecttheiraccountofevents..

17. Review of Health Assessment
•Some patients use medical terminologies without
knowing their meaning. Encourage such patients to tell
you what they actually feel to be wrong
•If the patient is accompanied by friends/relatives, always
talk to the patient first. When the patient has given you
an initial description of their symptoms, suggest that you
would like to find out more about certain aspects.

18. Cont’
•Clear up doubts about the time of onset and the
duration of the main symptoms. For symptoms that
come and go, try to find out whether the relapses and
remissions(a stage of lesser intensity ,when something
subsides or improves) are related in any way to times,
seasons or events in the patient’s life. After the
patient’s story is clearly understood, examine each
symptom in detail.

19. Cont’
•SymptomAnalysis
•Insymptomanalysis,itisimportanttoconsiderthe
courseorshapeofillness,reasonforpresentation,
andfinallyreviewofsystems.
•Forexample,toconductananalysisofpain,youneed
toconsiderthefollowingandaskyourclientthese
questions:

20. Cont’
•Onset:whendidthepainstart?
•Location:whereisthepain?
•Duration:howlonghaveyoubeenfeelingthat
pain?Whendiditstart?
•Characteristics:howisthepain?Isitstabbing?
burning?pricking?Isitlocalizedoritoriginates
fromacertainbodypartandmovestootherparts?

21. Cont’
•Aggravating factor: what worsens the pain? Is
it coughing? breathing?
•Relieving factor: what lessens/reduces the
pain?
•Treatment: what drugs or treatment are you
receiving?

22. Cont’
•you may use this mnemonic OLDCARTS. meaning
•O–Onset of illness
•L–Location
•D–Duration
•C–Characteristics
•A–Aggravating factors
•R–Relieving factor
•T–Treatment
•S–Severity of the condition

23. Cont’
•TheHistoryofPreviousIllness
•Anevaluationoftheprevioushistorywillhelp
youtogetaninsightaboutthehealthstatusof
thepatientupuntilnow.
•shouldincludeallimportantillnesses,operations
andinjuriesfrominfancytothepresent

24. Cont’
•The Family History
•It is important to evaluate the family history of
your client. Evaluation of family history will help
you to determine the health of the immediate
family members. It will also help you to know
whether your client is at risk of developing
certain conditions which run in families.

25. Cont’
•Note the patient’s position in the family and
the age of the siblings/children, if any. Record
the state of health, important illnesses and
the cause of death of immediate relatives.
Inquire about hereditary disorders in the
family. Ask if there is any family member with
similar symptoms.

26. Cont’
•The Social History
•The patient’s physical and emotional environment, including
their surroundings both at home and work, are essential
components of the history when assessing the effect of the
illness on the patient and on the family. Ask your patient
questions such as; what do you do during your spare time?
Do you take alcohol? Smoke? Exercise?

27. Cont’
•Occupational History
•Certain occupations may predispose to conditions such
as prolonged exposure to radiation may lead to
cancers. Ask your client whether s/he has been:
noxious substances at work, number of work hours,
nature of work e.g. secretary, director, underground
mine worker, street vendor, bar man, shop assistant or
nursery nurse etc.

28. Cont’
•8. Menstrual History
A.MenstrualHistory
•menstruation, i.e., the last normal menstrual
period, regularity, duration, amount of flow,
dysmenorrhea, menstrual tension, history of
oral contraception use.
•

29. Cont’
B.ObstetricHistory
•experienceofchildbirth,includingabortions,
numberofpregnancies,deliverieswhether
normalorhadcomplications,healthduring
pregnancyandwhetherthosechildrenare
aliveortheyaredead.

30. Physical
Examination

31. Physical Examination
What is
physical
examination?

32. What is physical examination?
Aphysicalexaminationistheprocessofcollecting
observabledatabythenurseusingtechniques
ofinspection,palpation,percussionand
auscultation.Duringaphysicalexamination,you
areexpectedtouseyoursenses,thatissight,
smell,touchandhearingtogatherdata

33. physical examination
•Agoodphysicalexaminationrequiresa
cooperativepatientandaquiet,warmand
well-litroom.Daylightisbetterthanartificial
light,whichmaymaskchangesinskincolour,
forexample,thefaintyellowtingeofslight
jaundice.

34. Physical examination?
•Aftertakingthehistoryofthepatient,itis
importanttoconductaroutinephysical
examination.Toconductacomprehensive
physicalexamination,thepatientmaybe
requiredtoexposesomesensitivepartsofthe
bodydependingontheconditionandwhich
partsaretobeexamined.

35. Physical examination
•This may disturb the patient as it might border
on their privacy. You will need to explain to
the patient the importance of the examination
and reassure him/her of privacy to put the
patient at ease and to gain their cooperation.

36. Physical Examination
•Be gentle and avoid tiring and exposing the
patient unnecessarily. In acutely ill patients, it
may be necessary to postpone a routine
examination and to perform only the
examination necessary for a provisional
diagnosis and treatment. The history and
physical examinations are complementary.

37. Physical Examination
•Makethepatientrelaxregardlessofthe
circumstances.Foracompleteexamination,the
patientshouldbeaskedtoundress,butshould
becoveredwithabedsheet/blanket.The
patientmaybepermittedtokeepthe
underwearon,butremembertoexaminethe
buttocksandthegenitaliaaswell.

38. Physical Examination
•A chaperone (a person who accompanies or looks
after another person or group) should be present
when a male nurse is examining a female patient
and during rectal and vaginal examinations, both
to reassure the patient and to protect the nurse
from subsequent accusations of improper
conduct.

39. Physical Examination
•There are four major techniques used in
performing physical examination. These are:
•Inspection
•Palpation
•Percussion
•Auscultation

40. Cont’
–Inspection
•Inspectionisthevisualexaminationofapartorregionof
thebodytoassessnormalconditionsordeviationsfrom
normal.Inspectionismorethanjustlooking.This
techniqueisdeliberate,systematic,andfocused.Youare
requiredtocomparewhatyoucanseewiththeknown,
generalcharacteristicsofthebodypartsbeinginspected.

41. Palpation
•Palpationistheexaminationofthebodywithtouch.
Theuseoflightanddeeppalpationcanyield
informationrelatedtomasses,pulsations,organ
enlargement,tendernessorpain,swelling,muscular
spasmorrigidity,elasticity,vibrationofvoicesounds,
crepitus,moisture,anddifferencesintexture.

42. Cont’
•During your practical class, you will learn that different
parts of the hand are more sensitive for specific
assessments. For example, the tips of the fingers are
used to palpate lymph nodes, the dorsa of hands and
fingers are used to assess temperatures, and the
palmarsurface is best suited for feeling vibrations.

43. Cont’
–Percussion
•Percussionisanassessmenttechniqueinvolvingtheproductionof
soundtoobtaininformationabouttheunderlyingarea.The
percussionsoundmaybeproduceddirectlyorindirectly.Direct
percussionisperformedbydirectlytappingthebodywithoneor
twofingerstoelicitasound.Indirect,ormediated,percussionisthe
morecommontechnique.Themiddlefinger(pleximeter)ofthe
non-dominanthandisplacedfirmlyagainstthebodysurface

44. Cont’
•.Thetipofthemiddlefingerofthedominanthand
(plexor)strikesthedistalphalanxorthedistal
interphalangealjointofthepleximeterfinger.A
relaxedwristandrapidstrikeproducethebest
sounds.Thesoundsandthevibrationsproducedare
evaluatedrelativetotheunderlyingstructures.
Deviationfromanexpectedsoundmayindicatea
problem.

45. Cont’
•Forexample,theusualpercussionsoundinthe
rightlowerquadrantoftheabdomenistympany.
Dullnessinthisareamayindicateaproblemthat
shouldbeinvestigated.Youwilllearnmoreabout
thespecificpercussionsoundsofvariousbody
partsandregionslaterinthiscourse.

46. Cont’
–Auscultation
•Auscultationislisteningtosoundsproducedby
thebodytoassessnormalconditionsand
deviationsfromnormal.Auscultationisusually
indirect,usingastethoscopetoclarifysoundsby
blockingoutextraneoussounds.

47. Cont’
•Thebellofthestethoscopeismoresensitiveto
low-pitchedsounds.Thediaphragmofthe
stethoscopeismoresensitivetohigh-pitched
sounds.Auscultationisparticularlyusefulin
evaluatingsoundsfromtheheart,lungs,
abdomen,andvascularsystem.

48. Cont’
•Physicalassessmenttechniquesareusually
performedinthefollowingsequence:
inspection,palpation,percussion,and
auscultation.
•Theonlyexceptiontothissequenceisan
abdominalexamination.Inthissituation,the
sequenceisinspection,auscultation,percussion,
andpalpation

49. Cont’
•An Outline for Screening Physical Examination
•General
•General appearance (does the patient look
healthy, unwell or ill, well cared for or
neglected?)
•Mental state
•Expression and emotional state
•Build and posture

50. Cont’
•Nutrition,obesity,oedema
•Skincolour,cyanosis,pallor,jaundice,pigmentation
•Bodyhair
•Deformities,swellings
•Temperature,pulse,respirationrate
•Featuresofendocrinedisease,e.g.hyperlipidaemia,
acromegaly,Cushing’ssyndrome.

51. Cont’
•Hair:Textureandgrooming
•Eyes:Simpletestsofvisualacuity:compareone
eyeagainsttheother
•Exophthalmosorenophthalmos
•Ptosis(Droopingoftheuppereyeliddueto
paralysisordisease,orasacongenitalconditions)

52. Cont’
•Conjunctivae:anaemia,jaundiceorinflammation
•Pupils:size,equality,regularity,reactiontolight,
accommodation
•Eyemovement:nystagmus,strabismus
•Ophthalmoscopicexaminationofthefundiand
ocularchambers

53. Cont’
•Face
•Facial symmetry or asymmetry
•Jaw movements
•Rash
•Features of endocrine disease or
hyperlipidaemia

54. Cont’
•Mouth and pharynx (a touch and tongue
depressor should be used)
•Breath odours
•Lips: colour and eruptions
•Tongue: protrusion and appearance

55. Cont’
•Teethandgums(ifpatienthasdentures,notice
whethertheyfitandaskwhethertheyarewornfor
mealsoronlyforcosmeticreasons)
•Buccalmucousmembrane:colourand
pigmentation
•Pharynx(movementofsoftpalate,stateoftonsils)

56. •Neck
•Movement, pain and range
•Veins
•Lymphatic glands
•Thyroid
•Carotid pulses and bruits
•

57. •Upperlimbs
•Generalexaminationofhandsandarms
•Fingernails:clubbingorkoilonychias
•Pulse:rate,rhythm,volumeandcharacter
•Stateorarterialwallsofradialsandbrachials
•Axillae:lymphglands

58. •Bloodpressure
•Muscles:musclewasting,fasciculation
•Testsforpower,tone,reflexesandco-ordination
•Cutaneoussensation:checkallmodalitiesto
excluderootornervelesions
•Joints:movement,painandswelling

59. Cont’
•Positionoftracheabypalpation
•Lookforandpalpateapexbeat
•Palpateoverpericardiumforthrills
•Palpaterespiratorymovements

60. Cont’
•Estimatetactilevocalfremitus
•Percussthelungs
•Auscultatetheheartsounds
•Estimatevocalresonance,cervicalandaxillary
glands

61. Cont’
•Thorax
•Anteriorlyandlaterally
•Typeofchest,asymmetryifany
•Breastsandnipples
•Respiration:rate,depthandcharacter
•Pulsation
•Dilatedvessels

62. Cont’
•Posteriorly(patient sitting)
•Inspect and palpate respiratory movement
•Estimate tactile vocal fremitus
•Percussthe lung resonance

63. Cont’
•Auscultatethe breath sounds
•Estimate vocal resonance
•Note movements and deformities of the spine
•Palpate from behind: cervical glands, thyroid
•Look for sacral oedema

64. Cont’
•Abdomen
•Inspection: size, distension, symmetry
•Abdominal wall: movement, scars, dilated vessels
•Visible peristalsis or pulsation
•Pubic hair
•Hernialorifices
•Palpation: tenderness, rigidity, hyperaesthesia,
splashing, masses, liver, gallbladder, spleen, kidneys,
bladder
•Abdominal reflexes
•Rectal examination when indicated

65. Cont’
•Lower limbs
•General examination of legs and feet
•Stance, balance and gait
•Oedema
•Varicose veins

66. Cont’
•Muscles:musclewasting,fasciculation
•Testsforpower,tones,reflexes(includingplantar
response)andco-ordination
•Joints:movements,painandswelling
•Peripheralpulses
•Temperatureoffeet

67. Unit Summary
•In this unit you have learnt about the
principles of medical/surgical nursing such as,
autonomy, confidentiality, fidelity, justice,
respect for persons, sanctity of life,
beneficence and so on

68. Unit Summary
•.Youhavealsolearntthenatureofdiseases
andseenthattheymayoccurnaturallyor
artificially.Diseasemayormaynotcausesigns
andsymptoms,dependingonthedegreeof
severity.Thecausesofdiseaseareseveraland
includeknowncausessuchasbiological
agents,physicalagents,chemicals,
deficienciesandunknowncauses.

69. Unit Summary
•Further,wehavediscussedthenursingmanagementofa
patientundergoingsurgery.Wehopeyoucanremember
yourroleduringpreoperative,intraoperativeandpost-
operativecareandhowtopreventcomplications.Always
remembertokeepthepatientinformedandreassuredat
eachphase.

70. Unit Summary
•Finally,wealsolookedathealthassessment
whichwasdefinedasprocessofobtaining
datafromthepatient.Inourhealth
assessmentwelookedattwomainwaysof
obtainingdatawhichare;historytakingand
physicalexamination.

71. Unit Summary
•Under History taking we reviewed the types of data
that should be obtained from the patient, such as
demographic/ biographic, present complaint, history
of previous illness, social history, occupational
history, menstrual and obstetric history. Under the
physical examination discussed four main
techniques, namely, inspection, palpation,
percussion and auscultation.

72. Unit,
•We hope you have enjoyed this unit interesting
and that you have learnt something new. In the
next unit you will learn about conditions of the
digestive system. But before then, test your
understanding of this unit by completing the
following self-assessment test.

74. References
•BasavanthappaB.T,(2005),MedicalSurgicalNursing,New
Delhi,JaypeeBrothers,India.
•Berkow.R,etal(1997),TheMerckManualofMedical
Information,MerckResearchLaboratories,NewJersey.
•LewisS.M,HeitkemperM.M,andDirksen.S.R,(2011).
Medical-SurgicalNursingAssessmentandManagement
ofClinicalProblems,6
th
edition,MosbyCorporation,
Philadelphia.
•StephenR.Bloom(1995),TooheysMedicine,Atextbook
forstudentsintheHealthCareProfessionals.Edinburgh,
NewYork,ChurchillLivingstone
•BillingsD.M.etal.(1982).Medical-SurgicalNursing–
CommonHealthproblemsofAdultsandChildrenacross
theLifeSpan.TheC.V.MosbyCompany,St.Louis,London.