2. Objectives of Health Assessment
Describe prehospital physical
examination techniques
Describe examination equipment
Describe the general approach to the
physical examination
Outline the steps of the comprehensive
physical examination
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3. Objectives
Detail the components of the mental
status examination
Identify abnormal findings in the mental
status examination
Outline steps in the general patient
survey
Distinguish between normal and
abnormal findings in the general survey
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4. Objectives
Describe examination techniques for
specific body regions
Identify normal and abnormal findings in
the body region examination
Describe examination techniques specific
to children and older adults
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5. Health Assessment
Component of Health assessment
ï¶Health History
ï¶Physical assessment
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6. Purposes
Establish a nurse- client relationship.
Gather data about the clientâs general health
status, integrating physiologic, psychological,
cognitive, socio cultural, development and
spiritual dimensions.
Identify clientâs strengths.
Identify actual and potential health problem.
Establish a base for the nursing process.
To evaluate the physiological outcome of care.
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8. Health History
Health history is a collection of subjective
and objective data that provide a detailed
profile of the clientâs health status.
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9. History Taking
IDENTIFICATION DATA OF THE PATIENT
Patient's name:-
Age: - Sex-
Hospital Name:-
File No./MLC No.:-
Source providing history:-
Date/ Time of admission-
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10. OPD No.:-
IPD No.:-
Ward-
Bed No.:-
Doctorâs Unit:-
Provisional Diagnosis-
Surgery done/Date of Surgery:-
Name of the Surgery:-
Residential Address-
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12. DETAILS OF ADMISSION:-
Arrived via wheel chair / stretcher /
ambulatory: -
LOC â Conscious / Semiconscious /
Unconscious
From admitting room / emergency room.''
home / any others:-
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13. ORIENTATION TO THE UNIT:-
Use of telephone / TV / call lights:-
Visiting hours:-
No Smoking:-
Patient is informed that hospital is not
responsible for the personal belongings: -
Yes/No
Valuable handed over to (Write relationship
With patient)
Written consent:-
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18. FAMILY INFORMATION
-Name of Family Members
-Relationship with patient
-Age
-Type of Family
-Education
-Occupation
-Marital Status
-Health Status
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19. Family Income per Year:
Family interpersonal relationship / Any
Family Disharmony:-
Family History of illness: (Hypertension,
DM, Cancer, Arthritis, etc
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20. ENVIRONMENTAL BACKGROUND
1) HOUSING
Type of house:-
Lighting :-
Ventilation:-
Water facilities:-
Sanitation:-
2) PETS/ANIMALS
3) FOOD HYGIENE PRACTICES:
4) PERSONAL HYGIENE PRACTICES:
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21. 5) COMMUNITY RESOURCES
a) Transport: -
b) Health facilities:-
c) Educational Facilities :-
PAST MEDICAL HISTORY
Hypertension, DM, Cancer, Respiratory,
Arthritis, stroke and others:
PAST SURGICAL HISTORY
PRESENT MEDICAL HISTORY;-
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23. SPECIAL ASSISTIVE DEVICES
Wheel Chair / Braces / Crutches /
Walkers / others:-
Contact lenses / Hearing aid / Prosthesis /
Glasses:-
Dentures:- Total / Partial
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24. PSYCHOSOCIAL HISTORY
Any recent stress?
Who is with the patient in the hospital?
Does the patient have anybody who will
give financial support if needed?
Who will care for the patient at home?
Calm: Yes / No
Anxious: Yes / No
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26. Inspection
Visual assessment of the patient and
surroundings
Findings that may be significant:
â Patient hygiene
â Clothing
â Eye gaze
â Body language
â Body position
â Skin color
â Odor .
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27. Nurse observe body part
Pay attention to client, watching all
movement & looking carefully at any body
part.
It help to know physical characteristics.
Quality of inspection depend on the
nurseâs willingness to spend time during a
job.
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28. If the emergency response was to the
patient's home, make a visual inspection
for
â Cleanliness
â Prescription medicines
â Illegal drug
â Weapons
â Signs of alcohol use
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29. Principles
Make sure good lighting is available.
Position and expose body parts so that all
surface can be viewed.
Inspect each area of size, shape,
colour,symmetry, position and abnormalities.
If possible, compare each area inspected with
the same area on the opposite side of the body.
Use additional light to inspect body cavities.
Do not hurry inspection. Pay attention to detail.
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30. Palpation
A technique in which the hands and fingers are
used to gather information by touch.
Palmar surface of fingers and finger pads are
used to palpate for
â Texture
â Masses
â Fluid
--And assess skin temperature
Client should be relax and positioned
comfortably because muscle tension during
palpation impair its effectiveness.
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31. Types of Palpation
Light palpation
Deep palpation
Bimanual palpation
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32. Light Palpation
The nurse apply tactile pressure slowly,
gentely and deliberately.
The nurseâs hand is placed on the part to
be examined and depressed about 1-2cm.
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33. Deep Palpation
It is done after light palpation.
It is used to detect abdominal masses.
Technique is similar to light palpation
except that the finger are held at a greater
angle to the body surface and the skin is
depressed about 4-5 cm.
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34. Bimanual Palpation
It involve using both hand to trap a
structure between them. This technique
can be used to evaluate spleen, kidney,
breast, uterus and ovary.
Sensing hand â Relax & place lightly over
the skin.
Active hand â Apply pressure to the
sensing hand.
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36. Percussion
Percussion involve tapping the body with the
fingertips to evaluate the size, border and
consistency of body organs and to
discover fluid in body cavity.
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37. Percussion
Used to evaluate
for presence of air
or fluid in body
tissues
â Sound waves
heard as
percussion tones
(resonance)
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38. Methods of Percussion
Mediate or Indirect Percussion
Immediate Percussion
Fist Percussion
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39. Mediate or Indirect Percussion
ï§ It can be performed by using the finger
on one hand as a plexor (Striking finger)
and the middle finger of the other hand as
a pleximeter (the finger being struck).
ï§ Used mainly to evaluate the abdomen or
thorax.
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40. Immediate Percussion
Used mainly to evaluate the sinus or an
infant thorax.
It can be performed by striking the surface
directly with the fingers of the hand.
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41. Fist Percussion
Used to evaluate the back and kidney for
tenderness.
It involves placing one hand flat against
the body surface and striking the back of
the hand with a clenched fist of the other
hand.
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42. Sounds Produced by Percussion
ï¶Sound : Tympany
ï¶Intensity : Loud
ï¶Pitch : High
ï¶Duration : Moderate
ï¶Quality : Drumlike
ï¶Common location : Air containing space,
enclosed area, gastric air bubble, Puffed out cheek
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43. Sounds Produced by Percussion
Sound : Resonance
Intensity : Moderate to Loud
Pitch : Low
Duration : Long
Quality : Hollow
Common location : Normal lungs
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44. Sounds Produced by Percussion
Sound : Hyper Resonance
Intensity : Very Loud
Pitch : Very Low
Duration : Longer than resonance
Quality : Booming
Common location : Emphysematous lungs
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45. Sounds Produced by Percussion
Sound : Dullness
Intensity : Soft to moderate
Pitch : High
Duration : Moderate
Quality : Thudlike
Common location : Liver
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46. Sounds Produced by Percussion
Sound : Flatness
Intensity : Soft
Pitch : High
Duration : Short
Quality : Flat
Common location : Muscle
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47. Auscultation
Auscultation is listening to sound produce by the
body.
Through auscultation the nurse note the
following characteristics of sound.
ï¶ Frequency or the number of oscillation
generated per second by a vibrating object.
ï¶ Loudness â Loud or soft
ï¶ Quality â Blowing or Gurgling
ï¶ Duration â Length of time that sound vibration
last. Short / medium / long.
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48. Auscultation
Best performed in a quiet environment
Requires a stethoscope
â Body sounds produced by movement of fluids or
gases in patient's organs or tissues
Note:
â Intensity
â Pitch
â Duration
â Quality
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49. Stethoscope
Used to evaluate sounds created by
cardiovascular, respiratory,
and gastrointestinal systems
Position stethoscope between
index and middle fingers
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50. Olfaction
While assessing a client, the nurse
should be familiar with the nature and
source of body odors.
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51. Preparation for Examination
Infection control : If patient have any
open skin lesions and any drainage. Nurse
has to maintained infection control and
avoid infection.
- use gloves
- use apron
- use mask
- use gown
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55. Psychological preparation
Explain procedure
If both are opposite sex then third person
is necessary.
Observe facial expression
Client should free from anxious feeling.
Clarify client doubt.
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56. General examination
1.Gender and race :
Example â Skin cancer is 20% higher in
white than black people. Prostate cancer
is higher in African American than white
American.
2. Age : old age people and children's are
more prone to get infection.
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57. 3. Signs of distress :
Pain, Difficulty in breathing
4. Body type : Thin, Fat
5. Posture : Standing. Upright position,
Knee flexed
6. Gait : Co-ordination proper or not, person
normally walk with the arms swinging
freely at the sides, with the head and face
leading the body.
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58. 7. Body movement :
- Movement are purposefully.
- If any part is immobile.
8. Hygiene and grooming :
- Personal hygiene maintain or not.
- Cosmetic used or not
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59. 9. Dress : culture, life style, socio economic
status. It should be appropriate according
to weather condition.
10. Body odor :
- Unpleasant odor
- Poor hygiene
- Bad breath
- Poor oral hygiene
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60. 11. Affect and mood :
- Feelingâs to other
- Emotionally expression
- Mood appropriate as per situation
12. Speech :
Pressure, tone, speed.
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61. 13. Client abuse : any problem during
growing and serious health problem during
childhood.
14. Substance abuse :
- Drugs
- Alcohol
- Smoking
- Ganja
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71. Height and Build
Descriptions include:
â Average, tall, short, lanky ( long & thin ),
muscular
May also be affected by age and lifestyle
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72. Weight
Observe general appearance
â Obese to emaciated
Recent changes may be key finding
â Recent weight loss or gain
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73. Head to toe Examination
Hair:
ï¶ Hair type :
Terminal Hair : long, thick, found on axilla
and pubic area.
Vellus Hair : small, soft, found all over
body except palm or sole.
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80. Discharges:
Eye alignment:
Eye brows:
Eye lids:
Use of glasses or contact lenses:
Corneal reflex
Lacrimal function
Ophthalmoscope used to see any
abnormalities in eyes
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84. Mucus colour:
Patency of Nair:
Epistaxis:
Discharge:
Polypâs:
DNS:
Pen light and nasal speculum is used to
see nose
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87. Dryness
Smoothness
Crack lips With mouth closed the nurse
view the lips from end to end.
Remove lipstick before examination of lips.
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89. Upper molar should rest directly on the
lower molar with upper incisors slightly
overriding the lower incisors.
Dental caries â discoloration of the enamel
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91. Oral mucosa
Color: Pinkish red
moist/dry:
Ulcer:
Lesion:
Leuckoplakia: thick white patches because
of smoking and alcohol.
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92. Tongue
The client first relax the mouth and sticks the
tongue out halfway.
Slightly rough on the top surface and smooth
along the lateral margin.
Under surface of the tongue and floor of the
mouth are highly vascular.
Observe for cyst, lesions, swelling and nodule
on the back side of tongue.
Examination of tongue : Protrude the tongue,
grasp the tip and gently pulls it to one side.
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94. Palate
Extend the Head backward and open the mouth
and inspect hard palate & soft palate
Hard palate: Anterior part of palate
Shape: Dome shape
Colour: Whitish
Soft palate: Posterior part of palate
Shape: âCâ shape
Colour: Light pink
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95. Pharynx
Procedure : Extend his neck slightly, open
the mouth widely and say âahâ. Place
tongue depressor on the middle third of
tongue. Use penlight for inspection.
Inspect for edema, ulcer, inflammation,
lesions.
Gag reflex
Dysphagia
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96. Neck
Examine the anatomical position of neck.
Function of sternocleidomastoid muscle :
the nurse ask the client to flex the neck
with the chin to the chest.
Function of the trapezius muscles :
movement of the head sideway so that the
ear moves toward the shoulder.
Neck should move freely without any pain.
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97. Movement of neck :
Stiff ness:
Swelling:
Neck muscle:
ROM:
Lymph nodes : With the clientâs chin raised
and head tilted slightly, the nurse first
inspect the area where lymph nodes are
distributed.
Inspect for size, shape, inflammation and
mobility.
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98. Thyroid gland
It lies anterior lower neck, in front of neck and
both side of trachea.
Inspect for visible mass of thyroid gland,
symmetry and fullness at the base of neck.
Give water then see for bulging of the gland.
Palpation : Client flex the neck forward and
laterally toward the side being examined. The
client hold a cup of water and take a sip to
swallow.
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99. Anterior Part : using the pads of the index
and middle finger, the nurse palpate the
left lobe with the right hand and right lobe
with left hand.
Posterior Part : Both hand of the nurse are
keep around the neck with two finger of
each hand on the side of trachea.
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100. Breast
Female:
â Symmetry
â Pain:
â Lump:
â Discharge:
â Swelling:
â Trauma:
â History of breast disease:
â Surgery:
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104. Cardio vascular system
Apical pulse: To find the apical pulse the nurse
locate the 5th ICS just to the left to the sternum
and move the fingers laterally, just medial to the
left mid- clavicular line.
Redial: RtâŠâŠâŠâŠâŠ.. LtâŠâŠâŠâŠâŠ.
Heart rate:
Rhythm:
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105. Perfusion:
Edema: because of heart failure
Site of edema:
Cyanosis or Pallor: Because of MI
Fatigue: Because of decrease cardiac
output
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109. Urine last voided:
Catheter present:
Any other:
Male
â Opening of penis:
â Penile Discharge:
If âYesâ describe
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125. Biceps
Identify biceps tendon have patient flex
elbow against resistance while you palpate
antecubital fossa
Place arm so itâs bent ~ 90 degrees
Place one of your fingers on tendon and
strike it.
Reflex : Flexion of arm at elbow.
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127. Triceps
Flex clientâs arm at elbow, holding arm
across chest or hold upper arm
horizontally. Strike triceps tendon just
above elbow.
Reflex : Extension at elbow.
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129. Patellar
Have client sit with leg hanging freely over
side of table. Tap patellar tendon just
below patella.
Reflex : Extension of lower leg.
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131. Achilles
Have client assume same position as for
patellar reflex. Slightly dorsiflex clientâs
ankle by grasping toes in palm of your
hand. Strike Achilles tendon just above
heel at ankle malleolus.
Reflex : Planter flexion of foot.
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133. Planter:
Have client lie supine with legs straight
and feet relaxed. Take handle end of
reflex hammer and stroke lateral aspect of
sole from heel to ball of foot, curving
across ball of foot toward big toe.
Reflex : Planter flexion of all toes.
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135. Gluteal:
Have client assume side lying position.
Spread buttocks apart and lightly stimulate
perineal area with cotton applicator.
Reflex : Contraction of anal sphincter
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