final health assessment powerpoint

8/10/2019 Final Health Assessment Powerpoint

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Chapter 27: The Complete Health Assessment: Putting It All Together

Elsevier items and derived items 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

The CompleteHealth Assessment:Putting It All Together


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Objectives

Utilize knowledge of all body systems and appropriateassessment techniques to examine a client from head-to-toe.

Develop a sequence of examination that is comfortable

for both the client and practitioner.


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Complete Health Assessment

The art of arranging all the steps you have learned so far

You may have to pause and think of what comes next ratherthan just gather data

Repeated rehearsals will make it smoother

You will come to the point at which the procedure flowsnaturally

Even if you forget a step, you will be able to insert it gracefullyinto next logical place

The following sequence is one suggested route

It is intended to minimize the number of position changes forthe patient and for you

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Complete Health Assessment

(cont.) Perform all the steps listed here for a complete

examination

With experience, you will learn to strike a balance betweenwhich steps you must retain to be thorough and which cornersyou may safely cut when time is pressing

Have all equipment prepared and accessible before examination

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Sequence

Patient walks into room, sits; the examiner sits facingthe patient; the patient is in street clothes


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The Health History

Collect the history, complete or limited as visit warrants

While obtaining the history and throughout theexamination, note data on persons general appearance


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Seated Together


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Physical Examination

General appearance

Appears stated age

Level of consciousness

Skin color Nutritional status

Posture and position comfortably erect

Obvious physical deformities

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Physical Examination (cont.)

General appearance (cont.)

Mobility

Gait

Use of assistive devices

Range of motion (ROM) of joints

No involuntary movement

Able to rise from a seated position easily

Facial expression

Mood and affect Speech: articulation, pattern, content appropriate, native

language

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General appearance (cont.)

Hearing

Personal hygiene

Measurement Weight

Height

Compute body mass index

Vision using Snellens eye chart

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Standing


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Skin

Examine both hands and inspect nails

For the rest of the examination, examine skin withcorresponding regional examination

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C C


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Vital signs

Radial pulse

Respirations

Blood pressure

Temperature, if indicated

Head and face

Inspect and palpate scalp, hair, and cranium

Inspect face: expression, symmetry, CN VII

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Ch t 27 Th C l t H lth A t P tti It All T th


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Seated, Changed into Gown

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Head and face (cont.)

Palpate temporal artery, then temporomandibular joint asperson opens and closes mouth

Palpate maxillary sinuses and frontal sinuses

If tender, transilluminate the sinuses

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Eye

Test visual fields by confrontation, CN II

Test extraocular muscles: corneal light reflex, sixcardinal positions of gaze, CN III, IV, VI

Inspect external eye structures

Inspect conjunctivae, sclerae, corneas, and irides

Test pupil size for light and accommodation

Darken room

Using an ophthalmoscope, inspect ocular fundus, includingred reflex, disc, vessels, and retinal background

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Chapter 27 The Complete Health Assessment P tting It All Together


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Ear

Inspect external ear: position and alignment, skincondition, and auditory meatus

Move auricle and push tragus for tenderness

With an otoscope, inspect canal, then tympanicmembrane for color, position, landmarks, andintegrity

Test hearing using voice test; tuning fork tests, Weberand Rinne tests

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Nose

Inspect external nose for symmetry and lesions

Inspect facial symmetry, CN VII

Test the patency of each nostril

With a speculum, inspect the nares, including nasalmucosa, septum, and turbinates

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Mouth and throat

With a penlight, inspect mouth, including buccalmucosa, teeth and gums, tongue, floor of mouth,palate, and uvula

Grade tonsils, if present

Note mobility of uvula as person phonates ahh, andtest gag reflex, CN IX, and CN X

Ask the person to stick out tongue, check CN XII

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Neck

Inspect neck for symmetry, lumps, and pulsations

Palpate cervical lymph nodes

Inspect and palpate carotid pulse, one side at a time;if indicated, listen for carotid bruits

Palpate trachea in midline

Test ROM and muscle strength against yourresistance: head forward and back, head turned toeach side, and shoulder shrug, CN XI

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Neck (cont.)

Palpate thyroid gland from posterior approach

Open persons gown to expose all of back for examinationof thorax, but leave gown on shoulders and anterior chest

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Chest, posterior and lateral

Inspect the posterior chest: configuration of thoraciccage, skin characteristics, and symmetry of shouldersand muscles

Palpate: symmetric expansion; tactile fremitus; lumps ortenderness

Palpate length of spinous processes

Percuss over all lung fields, percuss using diaphragmaticexcursion

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Chest, posterior and lateral (cont.)

Percuss costovertebral angle, noting tenderness

Auscultate breath sounds; note any adventitioussounds

Move around to face patient; patient remains sitting

For a female breast examination, ask permission to lift gown todrape on shoulders, exposing anterior chest

For male, lower gown to the lap

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Chest, anterior

Inspect respirations and skin characteristics

Palpate for tactile fremitus, lumps, or tenderness

Percuss anterior lung fields

Auscultate breath sounds

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Heart

Ask person to lean forward and exhale briefly; auscultatecardiac base for any murmurs

Upper extremities

Test ROM and muscle strength of hands, arms, andshoulders

Palpate epitrochlear nodes

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Female breasts

Inspect for symmetry, mobility, and dimpling as woman liftsarms over head, pushes hands on hips, and leans forward

Inspect supraclavicular and infraclavicular areas

Help woman to lie supine with head at a flat to 30-degreeangle

Stand at persons right side

Drape gown up across shoulders and place an extra sheetacross lower abdomen

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Female breasts (cont.)

Palpate each breast, lifting same side arm up over head

Include the tail of Spence and areola

Palpate each nipple for discharge

Support persons arm and palpate axilla and regional lymphnodes

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C apte e Co p ete ea t ssess e t utt g t oget e


Male breasts

Inspect and palpate while palpating anterior chest wall

Supporting each arm, palpate axilla and regional nodes

Neck vessels Inspect each side of neck for a jugular venous pulse,

turning persons head slightly to other side

Estimate jugular venous pressure, if indicated

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Heart

Inspect precordium for any pulsations or heave (lift)

Palpate apical impulse and note location

Palpate precordium for any abnormal thrill

Auscultate apical rate and rhythm

Auscultate with the diaphragm of stethoscope tostudy heart sounds, inching from apex up to base, orvice versa

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p p g g


Heart (cont.)

Auscultate heart sounds with the bell of stethoscope,again inching through all locations

Turn person over to left side while again auscultating

apex with bell

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p p g g

Person Supine



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Abdomen

Inspect for contour, symmetry, skin characteristics,umbilicus, and pulsations

Auscultate bowel sounds

Auscultate for vascular sounds over aorta and renalarteries

Percuss all quadrants

Percuss height of liver span in right midclavicular line

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Abdomen (cont.)

Percuss location of spleen

Palpate using light palpation in all quadrants, then deeppalpation in all quadrants

Palpate for liver, spleen, kidneys, and aorta

Test abdominal reflexes, if indicated

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Inguinal area

Palpate each groin for femoral pulse and inguinal nodes; liftdrape to expose legs

Lower extremities

Inspect for symmetry, skin characteristics, and hairdistribution

Palpate pulses, including popliteal, posterior tibial,and dorsalis pedis pulses

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Lower Extremities(cont.)

Palpate for temperature and pretibial edema

Separate toes and inspect

Test ROM and muscle strength of hips, knees, ankles,and feet

Ask person to sit up and to dangle legs off bed or table; keepgown on and drape over lap

Musculoskeletal

Note muscle strength as person sits up

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Neurologic

Test cerebellar function of the upper extremities usingfinger-to-nose test or rapid-alternating-movements test

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Patient Sits Up and Dangles

Legs

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Neurologic (cont.)

Test cerebellar function of lower extremities by askingperson to run each heel down opposite shin

Elicit deep tendon reflexes: biceps, triceps, brachioradialis,

patellar, and Achilles Test the Babinski reflex

Ask person to stand with gown on; stand close to person

Lower extremities

Inspect legs for varicose veins

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Musculoskeletal

Ask person to walk across room in his or her regular walk,turn, then walk back toward you, in heel-to-toe fashion

Ask person to walk on toes for a few steps, then to walk on

heels for a few steps Stand close and check Rombergs sign

Ask person to hold edge of bed and to perform a shallowknee bend, one for each leg

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Deferred

Male genitalia

Rectum

Female genitalia

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Patient Stands Up

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Musculoskeletal (cont.)

Stand behind and check the spine as person touches toes

Stabilize pelvis and test ROM of spine as personhyperextends, rotates, and laterally bends

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Tell patient you are finished with examination and thatyou will leave room as he or she gets dressed

Return to discuss examination and further plans and toanswer any questions

Thank person for his or her time For hospitalized person, return bed and any room

equipment to way you found it

Make sure call light and telephone are within easy reach

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Critical Thinking Exercises

Discuss any developmental, age, socioeconomic, andcultural considerations that should be considered duringthe assessment. Relate expected (normal) findings tothose described and discuss any additional assessmentsthat might be needed before a diagnosis or decision can

be made. Identify one nursing diagnosis for any actualor potential problem.

A.M. has come to the health care provider complainingof legs wounds that have persisted for 4 weeks. A.M.works on a production line and is on his feet all day. On

examination, the wounds are irregular with a bright redwound base and are not especially painful. There is amoderate to heavy exudate and peripheral edema.


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be made. Identify one relevant nursing diagnosis for anyactual or potential problem identified.

J.J., age 54, has come for a periodic health evaluation.He had an AMI a year ago and is being treated withmedication for hypertension. Interview reveals a change

in his condition with the following symptoms: increase inthe number of pillows he sleeps on at night from 2 to 4,decrease in activity tolerance, a dry, hacking cough, anda decrease in appetite.


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Jimmy Carter comes to the clinic accompanied by hiswife. He is alert but disoriented to time, place andperson. His wife says that his confusion just started

yesterday. How would you proceed with his neurologicevaluation?


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R.D., age 72 years, has come to the health center at therequest of her son whom she recently visited in aneighboring state. Interview reveals increasing fatigue,

weakness, anorexia, and constipation. History includes avaginal hysterectomy at age 40 years, a vein ligation at35 years, and 2 term pregnancies that resulted in livebirths. R.D. has been widowed for 12 years andcurrently lives alone. Both children live in another state.On examination her abdomen is distended and hard.


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H.N. has come into the Emergency Department withepistaxis of 2 hours duration. Vital signs are:

BP 96/60, HR 76, RR 16, T 97 F

Patient states that normal BP is 116/70.

(Is the VS change significant? Is it a problem?)

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