A comprehensive health assessment

encompasses the physical, psychological,

social, and spiritual dimensions of living. Ruth
Craven EDD, RN

 Health

History

the nurse gathers

subjective data by
talking to the client.
Subjective data is what the
client tells you
Subjective data are clients
perceptions about their
health problems

Physical Exam

the nurse gathers

objective data
through the physical
exam
Objective data are
observations or
measurements made by
the nurse

Establish the client-nurse relationship

Obtain information about all aspects of the
clients health
Identify client strengths
Identify actual and potential health
problems
To establish a data base from which the
subsequent phases of the nursing process
evolve

Assessment a collection of data about an

individuals health state
Data includes:
Subjective data
Objective data: (data gained through physical exam
and from the clients record, including lab and
diagnostic tests)
These elements form the data base. The nurse
makes a judgment or diagnosis about the clients
health state. Thus, the purpose of the assessment is
to make a nursing diagnosis.

What is spoken of as a clinical picture is

not just a photograph of a sick man in bed;
it is an impressionistic painting of the
patient surrounded by his home, his work,
his relations, his friends, his joys, sorrows,
hopes, fears. Francis Peabody Weld, 1881 - 1927

See Potter & Perry Chapter 16, pp. 214-216 *

Biographical data
Chief complaint (reason for visit)
PQRST
HPI (history of present illness)
Past history also called health history
Environmental history
Family history of illness
Life-style
Psychosocial Data
Spiritual Health
ROS (review of systems)
Patterns of health care

Does the patient have an advanced

directive?

On admission, the nurse asks the client What

caused you to come to the hospital? The client
responds we were on a cruise and I caught a
cold and was not feeling well. My husband told
me to go to the hospital when I began to cough
and have chest pain. Which of the following
would be considered the chief complaint?

A.
B.
C.
D.

I caught a cold
I was not feeling well
My husband told me to go to the hospital
I began to cough and have chest pain

Goals: To obtain baseline data about the

clients health, functional ability
To identify variations from normal,
And to gain objective data to support
information given during the interview.
Data gained will help the nurse formulate
nursing diagnoses and establish a plan of
care.

The nurse must look calm, confident, and

organized
Utilize principles of infection control
Gather all necessary equipment
Avoid expressions of alarm or disgust
Be sensitive to the clients needs
Have a quiet, well-lit room without
interruptions

Eyes, ears, nose,

hands/fingers
Gloves
Cotton balls
Penlight
Stethoscope
Blood pressure cuf
Thermometer
Tongue blade

See p. 489 for complete list

Explain the procedure and assist the client in

appropriate positioning (see chart, p. 490)
Use a head-to-toe approach
Move from external to internal
Examine normal or unafected side first
Observe for symmetry, comparing one side to
the other
Perform the physical exam while
standing on the clients right side. (this
helps to better identify anatomic landmarks).

Inspection
Palpation
Percussion
Auscultation

Concentrated watching,
a thorough and unhurried
visualization, and note
any odors.
Adequate lighting is
essential
Position and expose body
parts so that all surfaces
can be viewed
Inspect for size, shape,
color, symmetry,
position, and
abnormalities
Compare to opposite side
of body

Tapping the skin surface

to create vibrations of
underlying structures
that produce sound.
Used to determine the
size and shape of
internal organs
-direct percussion
-indirect percussion
- fist percussion

Flatness
Dullness
Resonance**
Hyperresonance
Tympany

Soft intensity such as sound

heard over muscle or bone
Medium thudlike over liver/heart
Loud intensity, low in pitch,
hollow sounding normal lung
Very loud intensity heard over
hyperinflated lung tissue
(emphysema)
Loud, hollow sounding heard over
air-filled organ such as empty
stomach or large distended colon
from gas

Feeling/touching
Touch is used to determine the extent of
tenderness, tremor, spasm, to elicit crepitus
(of bones), and to determine variations of
the skin
Also use to determine size, shape,
consistency, and mobility of structures, and
to evaluate abnormal fluid collections

Have warm hands, well-trimmed nails, and

wear gloves when necessary
Feel for temperature, turgor, texture,
moisture, vibration, and shape
Light palpation involves slight pressure, do
before deep palpation
Deep palpation done to assess size and
contour of organs
Use dorsum of hand to assess
temperature of skin
Always palpate painful area LAST!

Listening for sounds produced by the body

Usually use stethoscope to block out

environmental sounds and increase
Transmission to ears
Bell of stethoscope low frequency
sounds such as vascular sounds
Diaphragm higher pitched sound such
as lung sounds and peristalsis
Listen for: pitch, loudness, quality, duration, location,
and timing

A. Observation

B. Palpation

C. Percussion

D. Auscultation

In order to elicit information about the

patients chief complaint, the nurse uses
the PQRST format as a guide for further
questioning. Which of the following
questions will elicit information regarding
the P of the PQRST?

A.
B.
C.
D.

Can you point to where it hurts?

Is the pain constant?
Can you describe the pain?
What did you do to relieve the pain?

Health assessment begins with a general

survey that involves observation of the
clients general appearance and mental
status (p. 495)
Measurement of vital signs, height, and
weight are also included

The best way to proceed is in a head-totoe manner

You will become faster, more efficient, and

more thorough and competent with
PRACTICE!

At the end of this semester, you will be a

beginning expert in putting it all
together!

Assessment of the skin uses the skills of

inspection and palpation
Begin by inspecting the hands and nails
Inspection note color, vascularity or
bruising, evidence of perspiration, edema
(swelling), hygiene, injury, or lesions
Palpation note temperature, turgor,
texture, thickness, moisture, and edema

Cyanosis Bluish discoloration due to low oxygen

levels
Jaundiced yellow-orange color due to increased
amounts of bilirubin in the skin
Erythema redness of the skin due to increased
vascularity
Tan-brown due to increased amounts of melanin
Pallor -decrease in color

A. Notify the physician of the findings

B. Take the patients blood pressure
C. Hold all medications until further notice
D. Don a gown and gloves
E. Apply lotion to the lesions
F. Move the patient to a private room
G. Assess the patient for pain from the
lesions

A = Asymmetric lesion
B = Border irregularity
C = Color of lesion varies with shades of
tan, brown, or black, and possibly red, blue,
or white
D = Diameter greater than 6 mm
E = Elevated or enlarging lesion

Decreased elasticity
Wrinkling
Color changes
Increased translucence
Dryness
Decreased turgor
Hair: thins, grays, texture changes

The home care nurse is visiting a new client. Her

hospital records stated that she has petechiae
on her arms and legs. How would the nurse
expect the clients extremities to appear upon
assessment?

A. Purplish-blue lesions with areas fading to

green-yellow
B. Flat, round 1-3mm lesions that are reddish
purple
C. Spiderlike lesions of varying size that are
bluish in color
D. Purple blotches varying from 0.5-1cm in size

Inspection note angle, shape, contour,

ridges, symmetry, cleanliness, color
Nail changes may result from illness/disease

Palpation palpate for texture,

consistency, thickness, adherence to nail
bed
Blanch test for capillary refill *
See p. 507 client teaching R/T nail
care

Inspection note symmetry and shape of

eyes, eyebrows, nasolabial folds, and
mouth, note any abnormal movements,
edema, pallor, sweating, lack of expression,
lesions, or pigment changes.

Palpation palpate the skull for size,

shape, tenderness, depressions, or swelling

Look for redness, edema, inflammation, or

lesions on the lids
The irises should be the same size, color,
and shape
The conjunctiva should be clear and shiny.
Note excessive redness or exudate. The
sclerae should be white or buf

 Note

the
patients pupils
as they respond
to light

Direct response the illuminated pupil

constricts in response to light directed into
that eye
Consensual response the opposite pupil
constricts in response to the light
A direct and consensual response is a
normal finding

PERRLA (A = accommodation, need to

assess this, otherwise chart only
PERRL)

Assessing visual fields

this is a check of
peripheral vision

Assessing EOMs
(extra-ocular
movements)
this is a check of eye
movements in the six
cardinal fields of gaze

(p. 510)
http://www.youtube.com/wat
ch?v=PAor9WG7XF4&feature=r
elated
(208 on video)

A. Pupillary dilation when looking at a far

object
B. Pupillary constriction when looking at a
near object
C. Involuntary blinking in the presence of
bright light
D. Changes in peripheral vision in response
to light

Peripheral vision diminishes

Visual acuity decreases as the lens becomes
opaque and loses elasticity (presbyopia)
The ability to accommodate to darkness
and dim light decreases
Near vision decreases
Color vision declines; older people are less
able to perceive purple color and
discriminate pastel colors

A. The eye focuses the image in the center

of the pupil
B. The eyes converge to focus on the light
C. Constriction of both pupils occurs in
response to bright light
D. Light is reflected at the same spot in
both eyes

Observe for position &

symmetry
The ears should line up with
the outer corner of the eye
Note any lesions, nodules,
drainage, or redness
Note any discharge, redness,
or odor at the opening of the
ear canal
Pull the helix back and note
any tenderness (may indicate
otitis externa)
Patients wearing oxygen
inspect the top crease of the
ear for skin breakdown

Skin of the ear becomes dry and less resilient

Increase hair along the ear and in the ear
Pinna increases in both width and length and
ear lobes enlongates
Earwax is drier
Sensorineural hearing loss occurs
Generalized hearing loss on all frequencies
occurs (presbycusis). The first symptom is
loss of high frequency sounds: the f, s,
sh and ph sounds.

A 31-year-old client tells you that he has

noticed pain in his left ear when people
speak loudly to him. What would be an
appropriate response?

A. I would just cover my ear to prevent the

pain.
B. This is normal for people of your age.
C. Have you noticed any change in your
ability to hear?
D. I will check your ear for a middle ear
infection.

Penlight, gloves, tongue

blade
Inspection lips for
color, moisture, texture,
lesions. Teeth for tartar,
decay, and gums for
gingivitis. Note any
lesions, masses,
discolorations, size and
discharge of tonsils
Palpation palpate any
lesions, nodules, or
masses for size,
tenderness, consistency

Candida of the tongue

Aphthous lesion

Take 3 minutes to discuss the following

brain twister with your partner

When assessing the pupils of a patient

who is blind in their right eye, what will
the nurse assess?

What if the patient has a prosthetic eye?

(aka fake eye or glass eye?)

Refer to Potter & Perry for these selfexams

BSE on starting on page 537
Male genital exam starting on page 547

The nurse has a pivotal role in health

promotion and these 2 self exams are
important in the promotion of health.