CHAPTER 22 Assessing Health Status

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CHAPTER 22 Assessing Health Status
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AssessmentA Primary Nursing Function

• Performed on an almost continuous basis
• Initial detailed assessment on admission
• Includes health history, demographic data,
  psychosocial data, and physical examination
• Knowledge of current health problems
• Includes a cultural assessment
• Focused assessment on every successive shift
• (Contd)

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Assessment

• (Contd)
• The initial or admission assessment should
  include
• an interview to determine
• Social data
• Marital status, occupation, visual or hearing
  deficits
• Dentures, prostheses
• ALLERGIESfood, drug or other
• Medications being taken (including OTC and herbal
  supplements)
• (Contd)

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Assessment

• (Contd)
• Diet
• Any limitation or special foods
• Smoking
• Use of alcohol
• Activities of daily living
• Previous surgeries
• Health problems, current and past
• Reason for admission
• (Contd)

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Assessment

• (Contd)
• Physical data
• Head and neck
• Chest
• Abdomen
• Genitourinary system
• Extremities and musculoskeletal system
• Endocrine system

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Techniques of Physical Assessment

• Inspection and observation
• Visual observation of
• General appearance
• Contours of the body
• Skin tone and color, rashes, scars, lesions
• Deformities or extremity weakness
• (Contd)

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Techniques of Physical Assessment

• (Contd)
• Palpation
• Performed using the hands and finger tips to
  touch and feel various parts of the body
• Used to ascertain
• Size, shape, and position of body parts
• Texture, temperature, and moisture of skin
• Presence of muscle spasm or rigidity
• (Contd)

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Techniques of Physical Assessment

• (Contd)
• Palpation
• Pain, tenderness, or swelling
• Presence of a growth
• Restriction in body part movement
• Skin temperature and turgor
• Presence of edema
• (Contd)

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Techniques of Physical Assessment

• (Contd)
• Percussion
• Another method of obtaining information about
  body structures
• Light, quick tapping on the body surface to
  produce sounds
• Variations in the sounds reflect characteristics
  of organs or structures below the surface.
• (Contd)

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Techniques of Physical Assessment

• (Contd)
• Percussion helps in determining
• Size of organs
• Location of organs
• Density of organs
• Presence of air or fluids in tissue or in a body
  cavity
• (Contd)

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Techniques of Physical Assessment

• (Contd)
• Auscultation
• Listening to presence or absence of body sounds
  using a stethoscope
• Particularly useful for
• Lung sounds
• Heart sounds
• Abdomen (bowel sounds)
• (Contd)

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Techniques of Physical Assessment

• (Contd)
• Lung sounds
• Use the diaphragm of the stethoscope
• Auscultate all lung lobes
• Heart sounds
• Use the diaphragm for normal S1-S2 and to count
  heart rate
• Use the bell for some abnormal heart sounds
• The bell should be rested lightly on the chest
  and should not stretch the skin.
• (Contd)

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Techniques of Physical Assessment

• (Contd)
• Olfaction
• Using the nose to identify odors characteristic
  of certain problems such as
• Breath odor for sweetness, acetone or alcohol
• Wound odors
• Odors from discharges such as vaginal infections
• (Contd)

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Techniques of Physical Assessment

• (Contd)
• Olfaction
• Using the nose to identify odors characteristic
  of certain problems, such as
• Breath odor for sweetness, acetone, or alcohol
  
• Wound odors
• Odors from discharges such as vaginal infections

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Basic Physical Examination

• Height and weight (without shoes)
• Infant without diaper (never leave unattended)
• Vital sign measurement
• Review of body systems
• Head and neck chest, heart, and lungs
• Skin and extremities
• Abdomen
• Genitalia, anus, and rectum

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Review of Body Systems

• Head and neck
• General appearance
• Appearance of the eyes
• Condition of the hair
• Difficulty in hearing or seeing
• Pupils equal in size and accommodated to light
• Corneas clear (or is there opacity)
• (Contd)

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Review of Body Systems

• (Contd)
• Chest, heart, and lungs
• Is the chest symmetrical?
• Are shoulders at equal height?
• Is there any lordosis, kyphosis, or scoliosis?
• Any signs of dyspnea?
• Is there a noticeable PMI?
• Heart sounds, normal? (S1-S2)
• Apical pulse rate normal?
• (Contd)

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Review of Body Systems

• (Contd)
• Lung sounds
• Using the diaphragm of the stethoscope, listen
• Over the trachea
• Over the upper area of the chest
• Over the central chest and back
• Sounds
• Vesicular
• Bronchovesicular
• Adventitious
• (Contd)

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Review of Body Systems

• (Contd)
• Skin and extremities
• Inspect skin for
• Rashes or lesions
• Flaking or dryness
• Signs of dehydration or edema (shoe or ring
  tightness)
• Turgor
• Capillary refill (less than 3 seconds)
• Assess peripheral pulses
• (Contd)

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Review of Body Systems

• (Contd)
• Abdomen
• Bowel sounds should be assessed in all four
  quadrants on admission
• Normal (5 to 30 sounds/min)
• Hypoactive
• Hyperactive
• Silent
• Distention or tenderness

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Assessment of the Areas of Basic Needs

• RNS Hope
• Rest and activity
• Nutrition, fluids, and electrolytes
• Safety and security
• Hygiene
• Oxygenation
• Psychosocial and learning
• Elimination

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Patient and Family Teaching

• Need for regular physical examinations
• Recommended periodic diagnostic tests
• Need for immunizations
• Warning signs of cancer
• Ways to perform breast self-examinations
• Method of performing testicular self-examination