Chapter 27 Health Assessment Copyright 2004 by Delmar

Chapter 27 Health Assessment Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

Preparing for the Health Assessment § Environment • • Ensure privacy Quiet, warm room Special needs of the client Surface for placement of equipment Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 2

Preparing for the Health Assessment § Equipment • Maintenance • Isolation precautions • Adequate number of gloves Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 3

Preparing for the Health Assessment § Positioning • Ensures accessibility to the body part being assessed. § Draping • Prevents chilling. • Prevents unnecessary exposure. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 4

Conducting the Health and Physical Assessment § Aimed at establishing a data base against which subsequent data can be compared. • Comprehensive Assessment (head to toe) • Assessment of a body part (focused) • Assessment of a body system (focused) Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 5

Conducting the Health and Physical Assessment § Conducted in an aseptic, systematic, and efficient manner. § Requires the fewest position changes for the client. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 6

General Survey § Initial Observations • • • Client’s physical appearance Mood and behavior Speech patterns and voice intonations Signs and symptoms of distress Vital signs Height and weight Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 7

General Survey § Special Considerations • Elderly clients • Disabled clients • Abused clients Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 8

Measurement of Height and Weight § Height • Height is expressed in inches (in), feet (ft), centimeters (cm), or meters (m). • A scale for measuring height is usually attached to a standing weight scale. • Infant’s length is measured from vertex (top) of head to soles of feet while infant is lying with knees extended. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 9

Measurement of Height and Weight § Weight • Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg). • Daily weights should be obtained at the same time of the day, on the same scale, with the client wearing the same type of clothing. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 10

Measurement of Height and Weight § Weight • Types of scales available include chair, stretcher, bed, and platform scales. • Infants are weighed on platform or cradle scales. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 11

Measurement of Height and Weight § Nursing Considerations • Accurate recordings are necessary for drug dosage calculations and evaluation of effectiveness of drug, fluid, and nutritional therapy. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 12

Measurement of Height and Weight § Documentation • Height and weight are recorded on the admission assessment form. • Daily weights are usually recorded on the vital signs record. • Measurements taken at different times or on different scales should be recorded. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 13

Vital Signs § The taking of vital signs refers to measurement of the client’s body temperature (T), pulse (P) rate, respiratory (R) rate, and blood pressure (BP). § Vital signs are the first step in the physical examination. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 14

Vital Signs § Assessment of vital signs provides specific data regarding the client’s current condition. § Variations from baseline values may indicate potential problems with the client’s health status. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 15

Vital Signs § The sequence for recording vital sign measurements in the nurses’ notes is T-P -R and BP. § Vital signs are plotted on graphic forms that facilitate data comparison at a glance. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 16

Thermoregulation § The body’s physiological function of heat regulation to maintain a constant internal body temperature Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 17

Physiologic Function § Thermoregulation • The heat of the body is measured in units called degrees. • The core internal temperature of 98. 6 degrees Fahrenheit (F) does not vary more than 1. 4 degrees F. • Core internal temperature is higher than the skin and external temperature. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 18

Thermoregulation § Heat Production • • Basal Metabolic Rate (BMR) Vasodilation Vasoconstriction Piloerection Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 19

Thermoregulation § Heat Loss • • Radiation Conduction Convection Evaporation § Insensible Heat Loss Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 20

Thermoregulation § Behavioral Control of Body Temperature • The person makes appropriate environmental adjustments in response to the body’s signaling conditions of either being overheated or too cold. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 21

Respiration § Respiration is the act of breathing. § Terms related to respiratory function are: • • • External respiration Inspiration Expiration Vital capacity Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 22

Respiration § Major physiological pulmonary functions are: • • • Ventilation Circulation Diffusion Transport Regulation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 23

Hemodynamic Regulation § The circulatory system transports nutrients to the tissues, removes waste products, and carries hormones from one part of the body to another. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 24

Hemodynamic Regulation § Systemic Circulation • • • Arteries Arterioles Capillaries Veins Venules Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 25

Hemodynamic Regulation § Cardiac Cycle • Systole • Diastole § Stroke Volume § Cardiac Output § Compensatory Mechanisms Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 26

Hemodynamic Regulation § Pulse • The pulse is caused by the stroke volume ejection and distension of the walls of the aorta. • The bounding of blood flow in an artery is palpable at various points in the body (pulse points). Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 27

Hemodynamic Regulation § Blood Pressure • Measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 28

Blood Pressure § Systolic Pressure • Maximum pressure exerted against arterial walls during systole § Diastolic Pressure • Pressure remaining in the arterial system during diastole Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 29

Hemodynamic Regulation § Hemodynamic regulators for blood pressure control are: • • Blood volume Cardiac output Peripheral vascular resistance Viscosity Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 30

Factors Influencing Vital Signs § § § Age Gender Heredity Race Lifestyle Environment Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 31

Factors Influencing Vital Signs § § § Medications Pain Exercise Anxiety and Stress Postural Changes Diurnal (daily) Variations Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 32

Assessing Body Temperature § Temperature Scales • Centigrade or Fahrenheit scales are used to measure temperature. • Glass or electronic thermometers are used. § Temperature Sites • Oral • Rectal • Axillary Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 33

Assessing Body Temperature § Alterations in Body Temperature • • • Pyrexia Hyperthermia Heat Exhaustion Heat Stroke Hypothermia Frostbite Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 34

Assessing Pulse § Sites • The most accessible peripheral sites are the radial and carotid sites. • The carotid site should always be used to assess the pulse in a cardiac emergency. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 35

Assessing Pulse § A peripheral pulse is palpated by placing the first two fingers on the pulse point with moderate pressure. § A Doppler ultrasound stethoscope is used on superficial pulse points. § A stethoscope is used to auscultate the heart’s rate and rhythm. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 36

Assessing Pulse Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 37

Assessing Pulse § A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate. § Pulse Characteristics • • Pulse quality Pulse rate (bradycardia, tachycardia) Pulse rhythm (dysrhythmias) Pulse volume Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 38

Assessing Pulse § Nursing Considerations • An irregular pulse rate, if not previously documented, should be reported immediately. • Clients on certain cardiac medications may need to monitor their pulse rate. • Routine exercise lowers resting and activity pulses. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 39

Assessing Respirations § Sites • Observation of chest wall expansion and bilateral symmetrical movement of the thorax • Placement of back of hand next to client’s nose and mouth to feel expired air Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 40

Assessing Respirations § Rate is counted by number of breaths taken per minute. § Observation of thoracic and abdominal movements includes: • Depth, rhythm, and symmetry • Costal (thoracic) breathing • Diaphragmatic breathing Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 41

Assessing Respirations § A stethoscope is used to auscultate breath sounds throughout the respiratory system. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 42

Assessing Respirations § § Dyspnea, Bradypnea, tachypnea, apnea Hypoventilation Hyperventilation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 43

Assessing Respiratory Function § Cyanosis • Bluish appearance in the nail beds, lips, and skin • Reduced oxygen levels in the arterial blood Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 44

Assessing Respiratory Function § Clients with respiratory alterations require additional nursing assessment. • Pulse oximetry • Apnea monitor Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 45

Assessing Respiratory Function Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 46

Assessing Blood Pressure § The direct method of measuring blood pressure requires an invasive procedure. § The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 47

Assessing Blood Pressure § The most common site for indirect measurement is the client’s arm over the brachial artery. § Accurate measurement requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 48

Assessing Blood Pressure § Korotkoff sounds are five distinct phases of sound heard with a stethoscope during auscultation. § The forearm or leg sites can be palpated to obtain a systolic reading when the brachial artery is inaccessible. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 49

Assessing Blood Pressure § Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure. § Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 50

Assessing Blood Pressure § Orthostatic Hypotension (postural hypotension) • Sudden drop in systolic pressure when client moves from a lying to a sitting to a standing position Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 51

Assessing Blood Pressure § False Readings • Clients who have recently eaten, ambulated, or experienced an emotional upset • Improper cuff width • Improper technique in deflating cuff • Improper positioning of extremity • Failure to recognize an auscultatory gap Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 52

The Physical Examination § Techniques • • Inspection Palpation Percussion Auscultation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 53

Integumentary System § Skin § Hair and Scalp § Nails Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 54

Skin Assessment § Skin assessment provides a noninvasive window to observe the body’s physiological functions. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 55

Skin Assessment § § § § Color Lesions Moisture Temperature Texture Mobility and Turgor Edema Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 56

Integumentary System § Hair • The amount and texture of hair vary with age, sex, race and body part. • Vellus • Terminal hair § The scalp should be smooth, clean, intact, and free of lumps or tender areas. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 57

Integumentary System § Nails • • Clubbing Koilonychia (spoon nail) Beau’s line Paronchia Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 58

Physical Examination § Head • Skull and face assessment involves inspection and palpation. • The client’s face has its own unique characteristics related to race, state of health, emotions, environment. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 59

Physical Assessment § Eyes • Conjunctive and sclera are assessed for color, redness, swelling, exudate, foreign bodies • Visual acuity • Fundoscopy Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 60

Physical Assessment § Ears • • Auditory screening Inspection and palpation of external ear Placement, symmetry Otoscopic assessment § Nose and Sinuses • Inspection and palpation • Use of a penlight Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 61

Physical Examination § Mouth and Pharynx • • Breath Lips Tongue Buccal mucosa Gums and teeth Hard and soft palate Pharynx Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 62

Physical Examination § Neck • • Neck muscles Lymph nodes of head and neck Thyroid gland Trachea Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 63

Physical Examination § Thorax and Lungs • Landmarks for inspection, auscultation, and percussion • Anterior and posterior examination • Shape and symmetry • Thoracic expansion • Tactile fremitus Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 64

Thorax and Lungs § Auscultation of Normal Breath Sounds • Vesicular sounds • Bronchovesicular sounds • Bronchial sounds Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 65

Thorax and Lungs. § Auscultation of Adventitious Breath Sounds • • • Crackles Rhonchi Wheezes Pleural friction rub Stridor Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 66

Heart and Vascular System § Heart • Landmarks for inspection, palpation, auscultation • Heart sounds • Palpation for thrills and heaves • Abnormal auscultatory findings - Murmurs - Bruits Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 67

Heart and Vascular System § Vascular System • Blood perfusion of peripheral vessels - Peripheral pulses compared bilaterally - Skin temperature, color Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 68

Physical Examination § Lymphatic System • Lymphatic drainage • Lymph nodes Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 69

Breasts and Axillae § Palpation of four quadrants of breasts § Palpation of supraclavicular, infraclavicular, and axillary nodes § Education and encouragement of questions about breast self-examination (BSE) § Breast cancer can also occur in males. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 70

Breasts and Axillae § Drainage patterns of the left breast. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 71

Abdomen § Inspection • • • Contour Symmetry Umbilicus Surface motion Scars Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 72

Abdomen § Auscultation • All four quadrants in a systematic fashion • Beginning with the RLQ - Tympany Dullness Bruits Hyperactive or hypoactive bowel sounds Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 73

Abdominal Quadrants Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 74

Abdomen § Light palpation in all four quadrants beginning with the RLQ • • Resistance Tenderness Rebound tenderness Organ enlargement Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 75

Female Genitalia and Anus § Cultural Considerations § Inspection and Palpation • • • Mons pubis and vulva Labia majora, labia minora Clitoris Urethral meatus and vaginal introitus Perineum and anus Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 76

Male Genitalia, Anus, and Rectum § Testes and male gonads § Seminal vesicles and bulbourethral glands § Epididymis, vas deferens, ejaculatory ducts § Scrotum, penis, spermatic cord § Anorectral exam including the prostate § Monthly testicular self-examination (TSE) Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 77

Musculoskeletal System § § Inspection Palpation Range of Motion (ROM) Bilateral Comparison Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 78

Musculoskeletal System § Muscle • • Hypertrophy Atrophy Hypertonicity Hypotonicity Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 79

Musculoskeletal System § Joints • Arthritis • Osteoarthritis • Crepitus Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 80

Neurologic System § Mental Status • Physical appearance and behavior • Communication • Level of consciousness Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 81

Mental Status § Cognitive Abilities and Mentation • • Attention Memory Judgment, insight Spatial perception Calculation Abstraction Thought process and content Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 82

Neurological Assessment § Sensory Assessment • • Exteroceptive sensations Proprioceptive sensations Cortical sensations Dermatome map Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 83

Neurological Assessment § § Cranial Nerves Assessment Motor Assessment Cerebellar Assessment Reflex Assessment Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 84