Health Assessment

Health assessment is an important part of the nursing process. The client should be prepared for the assessment to assure calm and cooperation. The room used for the assessment should be clean, warm, and free of distraction. Any necessary equipment should be available and in good repair. The nurse should position and drape the client for comfort and privacy and place the client in the proper position for the examination (sitting, supine, dorsal recumbent, Sims, prone, kneechest, and lithotomy). A complete health assessment includes a health history and a physical assessment and is fully documented. Physical assessment proceeds with a systematic examination of the client from headto-toe, an examination of a body system, or an examination of a specific body part. The general survey includes a review of the clients primary health concerns; physical appearance, mood, and behavior; signs and symptoms; vital signs; and height and weight. The nurse should observe initially for any signs of distress, general body presentation, psychological status, and problem areas. Height and weight are important in picking up any developmental lags or signs of illness. Height is expressed in inches, feet, centimeters, or meters. Weight is expressed in ounces, pounds, grams, or kilograms. Clients who are weighed daily should be weighed at the same time of day on the same scale, with the client wearing the same type of clothing. Weights are often important in drug dosage calculations and to evaluate the effectiveness of drug, fluid, and nutritional therapy. Weights below normal may indicate that the client has cachexia, a weight loss marked by weakness and emaciation that usually occurs with a chronic illness. Heights and weights are compared to evaluate the growth of infants and children. Vital signs include the measurement of body temperature (T), pulse (P), respiratory rate (R), and blood pressure (BP). TPRs and BPs are usually recorded on graphic forms. Thermoregulation is the bodys physiological function of heat regulation to maintain a constant internal body temperature. Temperature is measured in degrees. The normal internal temperature of humans is 98.6oF or 37oC. Body heat is produced through food metabolism in the bodys cells. One form of this energy is thermal energy, measured in terms of heat. A kilocalorie is an energy value or heat measure of a given food. One kilocalorie equals 10,000 calories, the amount of heat required to raise the temperature of one kilogram of water to 1oC. The basal metabolic rate (BMR) is the rate of energy use in the body needed to maintain essential activities. Heat is produced in the deep tissue organs (brain, liver, and heart) and the skeletal muscles. When body temperature rises, the hypothalamus reduces body heat by stimulating vasodilatation, the widening of blood vessels, and inhibiting of heat production. When the body is cold, the vessels vasoconstrict, muscles shiver, and the hairs stand on end. People typically adjust their environments to establish a comfortable temperature.

There are two types of respiration, external respiration, the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood system, and internal respiration, the interchange of oxygen and carbon dioxide between the circulating blood and cells throughout the body. Inspiration (inhalation) is the intake of air into the lungs. Expiration (exhalation) is the movement of gases from the lungs to the atmosphere. Vital capacity is the amount of air exhaled from the lungs after a minimal full inspiration. Five physiological pulmonary functions provide oxygen to the tissues and remove carbon dioxide. These functions are (1) ventilation, the inspiration and expiration of air between the atmosphere and the alveoli; (2) circulation, the flow of blood through the lungs; (3) diffusion, the exchange of oxygen and carbon dioxide between the atmosphere and the lung alveoli; (4) transport, the carrying of oxygen and carbon dioxide in the blood and body fluids to and from the cells; and (5) regulation, the neurogenic system that adjusts alveolar ventilation. Hemodynamic regulation is the physiological function of circulating blood to maintain nutrition, remove waste, and carry hormones from one part of the body to another. The heart rate accelerates or decelerates according to the control of cardiac centers of the brains medulla. Blood flows to the tissues during the systolic phase of the heart beat and from the tissues back to the heart during the diastolic phase of the heart beat. Stroke volume is the amount of blood that enters the aorta with each ventricular contraction. Cardiac output (CO) is the volume of blood pumped by the heart in one minute. CO is measured by multiplying the stroke volume by the heart rate (pulse). Pulse pressure is the ratio of stroke volume to compliance (distensibility) of the arteries. Blood pressure is controlled by the volume of circulating blood, the amount of cardiac output, peripheral vascular resistance, and the viscosity of the blood. A major factor affecting vital signs is age. The thermoregulatory and respiratory centers of newborns are immature. Likewise, thermoregulation and respiratory function are typically compromised in the older adult. Other factors influencing vital signs are gender, heredity, race, lifestyle, environment, medications, pain, exercise, metabolism, anxiety, postural changes, diurnal variations, and hormones. Body temperature is measured on either the centigrade scale or the Fahrenheit scale. The sites usually used to measure body temperature are the oral (OT), rectal (RT), and axillary (AT) temperature sites. The ear canal temperature (ET) and the pulmonary artery temperature (PAT) can also be measured. However, the latter is impractical for routine care. Oral and rectal temperatures are higher than axillary temperatures because they are taken in contact with mucous membranes. The rectal temperature is higher than the oral temperature because the anal sphincter closes off the area from environmental air. ATs and RTs are used for clients who are comatose, cannot cooperate, or have a nasogastric or feeding tube in place. Pyrexia is the elevation of the core body temperature above normal, at 37.4oC (101oF) or 38oC (100.4oF) rectally. Pulse assessment is the measurement of pressure created when the heart contracts, ejecting blood. The following pulses can be taken: Temporal, carotid, apical, brachial, radial, ulnar, femoral,

popliteal, posterior tibial, and dorsalis pedis. The apical pulse, auscultated with a stethoscope, is considered the most accurate. A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate. Tachycardia is an excess of 100 beats per minute in an adult. Bradycardia is a heart rate less than 60 beats per minute in an adult. Pulse rhythm is the regulation of the heartbeat. Arrhythmia is an alteration in the pulse rhythm. Pulse volume is a measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction. Pulse volume is described as normal, weak, strong, or bounding. The pulse can be traced using an electrocardiogram. Respiratory assessment includes the rate, depth, and rhythm of ventilatory movement. The normal respiratory rate is 12 to 20 breaths per minute. Dyspnea is difficulty in breathing. Bradypnea is a respiratory rate of 10 or less breaths per minute. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hypoventilation is the use of slow, shallow respirations. Hyperventilation is the use of deep, rapid respirations. Cyanosis is the bluish discoloration of the skin resulting from reduced oxygen levels in the arterial blood. A pulse oximeter is a noninvasive procedure for measuring oxygenation saturation. Blood pressure measurements are usually taken in the arm, over the brachial artery. Sites on the forearm or leg are used when the brachial arteries are not available. Blood pressure is measured with a sphygmomanometer and stethoscope. The cuff of the sphygmomanometer should be of adequate size for the extremity. Hypotension is a systolic blood pressure less than 90 mm Hg or 2030 mm Hg below the clients normal systolic pressure. It is caused by decreased blood volume, cardiac output, or peripheral vascular resistence. Orthostatic hypotension (postural hypotension) is the sudden drop of 25 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when moving from a lying to a sitting position or from a sitting to a standing position. Hypertension is a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. There are four techniques used in physical examination: Inspection (observing), palpation (feeling), percussion (tapping), and auscultation (listening). During physical examination, the nurse scrutinizes the integumentary system (skin, hair, scalp, and nails), observing for lesions, discolorations, moisture, temperature, texture, edema (swelling), mobility, and turgor. Assessment of the head and neck includes inspection and palpation of the skull; inspection of the face; assessment of visual acuity; inspection of the fundus of the eye with an ophthalmoscope; inspection and palpation of the ear; test of auditory acuity; inspection of the mouth and pharynx; and inspection, palpation, and auscultation of the neck. Respiratory assessment includes inspection, palpation, percussion, and auscultation. Lung sounds reflect the passage of air into and out of the lungs. The nurse may hear crackles on inspiration (popping sounds), rhonchi (continuous, low-pitched musical sounds) on expiration over the trachea and bronchi, wheezes on expiration (low-pitched snoring or high-pitched musical sounds), pleural

friction rubs (creaking, grating sounds) over the anterior lateral lungs, and inspiratory stridor (continuous crowing sounds). Cardiovascular assessment entails inspection, palpation, and practiced auscultation of heart sounds, in addition to an assessment of heart rate and rhythm. Assessment of the breasts involves inspection and palpation, observing for inequality in size of breasts and obvious tumors. Abdominal assessment includes inspection, auscultation, percussion, and palpitation. When assessing the genitalia, the nurse should ensure the clients privacy. During breast and genitalia assessments, the nurse should also look for opportunities to teach breast self-examination; testicular selfexamination; the importance of mammograms; and the importance of cervical, colon, rectal, and prostate cancer screening. Musculoskeletal assessment includes inspection and palpation of the muscles and joints, range of motion (ROM), and muscle testing. Neurologic examination involves an assessment of mental status, sensation, cranial nerves, motor functioning, cerebellar function, and reflexes.