Assessment

Diagnosis

PlanningImplementation

Evaluation

HEALTHCARE PROCESS

It is the FIRST STEP of the Health Care Process. The following are its key components: Health Interview Physical Examination Laboratory or Diagnostic Examination Records Review

A systematic way of collecting objective data from a client using the four examination techniques in order to assess or identify current health status. Different Approaches: Cephalocaudal Proximodistal Mediolateral Outer to Inner /External to Internal

Obtain physical data about the client’s functional abilities Supplement, confirm, or refute data obtained in the client’s health history Obtain data that will help the nurse establish diagnoses and plan the client’s care. Evaluate the physiologic outcomes of health care and thus the progress of a patient’s health problem To identify areas for health promotion and disease prevention

METHODS OF EXAMINATION

I.P.P.A. Technique

Assess moisture, color and texture of the body surfaces, as well as shape, position, size, color, and symmetry of the body.

Visual examination of the patient done in a methodical, deliberate, purposeful, and systematic manner.

INSPECTION

Assess temperature; turgor; texture; moisture; vibrations; position, size, shape, consistency and mobility of organ or masses; distention; pulsation; and the presence of pain upon pressure(tenderness)

The use of hand to touch and feel the patient’s skin, organs, mass, and other delineated structures in the body

PALPATIONExamination of the body using the sense of touch.

Palmar surfaces of the examiner's fingertips and finger pads are used for discriminatory sensation, such as texture, vibration, presence of fluid, or size and consistency of a mass

The dorsum, or back of the hand, is used to assess surface temperature.

Light palpation, light pressure is applied by placing the fingers together and depressing the skin and underlying structures about 1/2 inch (1 cm).

Use to check muscle tone and to assess for tenderness

LIGHT PALPATION

Place the hand with fingers together parallel to the skin surface or area being palpated, while moving the hand in circle.

Deep palpation is used with caution because pressure can damage internal organs. The skin and underlying structures are depressed about 1 inch (2 cm).

To identify abdominal organs and abdominal masses.

Two – handed deep palpation

place the fingers of one hand

on top of those of the other.

The top hand applies pressure

while the lower hand remains

relaxed to perceive the tactile

sensation.

Deep Palpation using lower hand to support the body while the upper hand palpates the organ

Deep Palpation is done with two hands

(bimanually) or one hand.

Usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed

PERCUSSION

Striking of the body surface with short, sharp strokes in order to elicit palpable vibrations and characteristic sound.

It is used to determine the location, size, shape, It is used to determine the location, size, shape, and density of underlying structures; to detect and density of underlying structures; to detect the presence of air or fluid in a body space; and the presence of air or fluid in a body space; and to elicit tenderness.to elicit tenderness.

DIRECT PERCUSSION - Using one hand to strike the surface of the body

Jing Salaria, RN,MD

TYPES OF PERCUSSION

INDIRECT PERCUSSIONUsing the finger of the one hand to tap the finger of the other hand.

Jing Salaria, RN,MD

plexor strikes the finger of the examiner’s other hand, which is in contact with the body surface being percussed (pleximeter- the middle finger of the nondominant hand).

TYPES OF PERCUSSION

Percussion is used to access the location, shape, size, and density of tissues. (Left) The non-dominant hand is placed directly on the area to be percussed, and the middle finger is placed firmly on the body surface. (Right) The tip of the middle finger of the dominant hand strikes the joint of the middle finger of the opposite hand

AAUSCULTATIONUSCULTATION

Listening to sounds produced within the body.

Stethoscope bell and diaphragm. Use the diaphragm of the stethoscope to detect high-pitched sounds. The diaphragm should be at least 1.5 inches wide for adults and smaller for children. Hold the diaphragm firmly against the body part being auscultated. Use the bell of the stethoscope to detect low-pitched sounds. The bell should be at least 1 inch wide. Hold the bell lightly against the body part being auscultated.

Introduce self to the client. Verify his identity. Explain the purpose why such procedure is necessary and how he could cooperate (i.e. positioning). Help him put on a clean gown and offer a bedpan or a urinal to empty his bladder. Ensure privacy by closing the doors or pulling the curtains around him. Invite a relative or a significant other to stay with the client, as necessary.

Provide adequate lighting. Gather the equipment:

height chart, weighing scale, Snellen’s chart, penlight, card board, sterile gloves, tongue depressor, 4x4 Gauze, tuning fork, stethoscope, wrist watch, tape measure, marker/pencil, record sheet & waste receptacle.

Ensure the examination table is at a comfortable working height. Perform hand hygiene.

Materials Needed

Position and drape the client

appropriately

STANDING = assessment of posture, gait & balance

DORSAL RECUMBENT= used in patient having difficulty maintaining supine position

SITTING = used to take vital signs

SUPINE

SIM’s = assessment of rectum and vagina

PRONE = assessment of hip and posterior thorax

LITHOTOMY = assessment of female rectum and vagina.(for a brief period only)

KNEE-CHEST= assessment of rectal area (for briefperiod only)

SALIENT POINTS:

Subjective data should be documented in patient’s own words.

Objective data should be specific. No generalizations and judgmental phrases

Data gathered in the nursing health history may be confirmed or refuted by the nurse during the interview or the physical assessment

PROCEDUREI. Obtain vital signs & anthropometric measurement

(height/weight).

PROCEDUREI. Obtain vital signs & anthropometric measurement

(height/weight).

NOTE: Given: IBW= A-B where, A= ht. in cm -100

B= (A) x 0.10 C= (IBW) x 0.10

N Range = IBW-C (Lower Limit) = IBW+C (Upper Limit)

BMI= wt. in kg/ ht. in (m)2

BMI Interpretation

<18 = Underweight18-24 = Normal

>25 = Obese

Example computation

A = 134.62 -100 = 34.62

B = 34.62 x 0.10 = 3.46

IBW = 34.62 – 3.46 = 31.16

Example computation

To get the normal range: C = 31.16 x0.10 = 3.12

Upper limit = 31.16 + 3.12 = 34.28Lower limit = 31.16 – 3.12 = 28.04

Example computation

BMI = 55 / (1.346)2 = 29.7 30

II. Assess the General Appearance:A. Body build, height and weight in relation to age, lifestyle and healthB. Posture and GaitC. Over-all hygiene and groomingD. Body and breath odorE. Signs of distressF. Mood / AffectG. Quantity, Quality & Organization of SpeechH. Relevance & Organization of Thoughts

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ASSESSMENT OF THE INTEGUMENTARY SYSTEM

• Skin• Nails • Hair• Scalp

Part 1. Anatomical Parts of the Skin

1. SKIN COLOR

Normal• Varies from light

to deep brown, from ruddy pink to light pink

Deviations from Normal• Pallor• Cyanosis• Jaundice• Erythema

2. Skin Color UniformityNormal• Generally uniform

except in areas exposed to sun; areas of lighter pigmentation in dark skinned

2. Skin Color Uniformity

Deviations • Hyperpigmentation

Birthmarks – abnormal distribution of the melanin

2. Skin Color Uniformity

Deviations • Hypopigmentation

Vitiligo due to destruction of melanocytes in the area

Albinism – complete or partial lack of melanin

3. Assess for Edema• Excessive accumulation of fluid in body tissues • Note the degree to which the skin remains

indented or pitted when pressed by a finger Edema scale

1+ = barely detectable2+ = indentation of less than 5 mm3+ = indentation of 5 to 10 mm4+ = indentation of more than 10 mm

ANASARCA

4. Inspect, palpate, and describe skin lesions

• According to type/structure, color, number, distribution, locationTYPES:Primary skin lesions – abscess, ulcer, tumor,

and open woundSecondary skin lesion crusts, kelloids,

scars, etc.

Primary and Secondary Primary and Secondary LesionsLesions

PRIMARY SKIN LESIONS

PRIMARY SKIN LESIONSPRIMARY SKIN LESIONS

PRIMARY SKIN LESIONSPRIMARY SKIN LESIONS

Cyst

5. Observe and palpate skin moisture

• Done by touching or palpating the skin of the extremities

NormalNormal MoistMoist

DeviationsDeviations Excessively dryExcessively dry

6. Palpate skin temperature

Normal• Uniform; within

normal range

Deviations• Generalized or localized;

hyperthermic or hypothermic

7. Palpate Skin Turgor• Refers to fullness or elasticity• Indicative of status of hydration of the body.• Assessed by pinching the skin on an extremity.

NormalNormal When pinched, skin When pinched, skin

springs back to springs back to previous state in less previous state in less than than 3 seconds3 seconds

DeviationsDeviations Skins stays pinched or Skins stays pinched or

indented or moves back indented or moves back slowly.slowly.

Note that this is not as valid in elderly people as in Note that this is not as valid in elderly people as in younger people because skin elasticity decreases younger people because skin elasticity decreases with age; thus, other parameters should be used, with age; thus, other parameters should be used, such as: I&O, daily weightsuch as: I&O, daily weight

Let’s have a break…

1. Inspect fingernail plate shape, curvature & angle

Normal– Colorless and a

convex curve.

– Angle between nail and nail bed: usually 160o

Deviations from Normal• Concave

• Clubbed fingernails (>180O) due to chronic tissue hypoxia

Examples of Nail Abnormalities

2. Inspect and palpate finger & toenail bed color

Normal• Highly vascular and

pink in light skinned; dark skinned may be brown or black

Deviations from N• Bluish or purplish

tinges; • Pale

3. Inspect tissues surrounding nails

Normal• Intact epidermis

Deviations from N• Hangnails (paronychia =

ingrown nail)• Inflammation of

surrounding tissues

4. Perform Blanch Test/Capillary refill test

Normal• Prompt return or pink

or usual color, less than 2-4 seconds

Deviations • Delayed return of pink

or usual color, usually >4 seconds

(Skull and Face)

Part 3. Structures of the Skull

1. Inspect skull size, shape, proportion & symmetry

Normal• Round and is of normal

size or head circumference Normocephalic • In proportion w/ gross

body structure • Frontal, parietal and

occipital prominences;• Smooth skull contour

Deviations from Normal• Disproportionate• Asymmetric prominences• Increased head circumference

• Square-head• Bulging / depressed bone

2. Palpate skull nodules or masses & depression

Normal• Smooth, uniform

consistency; absence of nodules/masses or depression

Deviations from Normal• Sebaceous cysts; local

deformities from trauma; masses; nodules

3. Inspect facial featuresNormal• Symmetric facial

features;• Eye brow hair equally

distributed • palpebral fissures equal

in size; • symmetric nasolabial

folds

Deviations from N• Asymmetric features• Increased facial hair; thinning

of eyebrows; exopthalmos; moon face;

4. Inspect eyes for edema and hollowness

Normal• No edema, eyes not

sunken

4. Inspect eyes for edema and hollowness

Sunken eyes, cheeks and temples (indicative of dehydration, starvation, and illness)

Deviations• Periorbital edema

5. Inspect symmetry of facial movements

Normal• Symmetric facial

movements

Deviations• Asymmetric facial

movements, drooping of lower eyelid and mouth; involuntary facial movement

Raise or lower both Raise or lower both eyebrowseyebrows

Blink both eyesBlink both eyesClose both eyes tightlyClose both eyes tightlySmile and show the Smile and show the

teethteethFrownFrownPuff the cheeksPuff the cheeks

Assessing the Hair

1. Evenness of growth of hair over scalp

Normal• Evenly distributed

Deviations from Normal• Patches of hair loss, i.e.

alopecia

2. Hair thickness or thinnessNormal• Thick Hair

Deviations from Normal• Very thin hair (hypothyroidism)

3. Hair Texture and Oiliness3. Hair Texture and Oiliness

NormalNormal Silky, resilient hairSilky, resilient hair

Deviations from NormalDeviations from Normal Brittle hair (poor nutrition)Brittle hair (poor nutrition) excessively oily or dry hairexcessively oily or dry hair

Normal• No infection/

infestation

Deviations from Normal• Flaking, sores, lice, nits

4. Note presence of 4. Note presence of infection / infestationinfection / infestation