Document Sample
umentation Powered By Docstoc
					Health Assessment

     CHD 1 – VN 230

     Presented by:
     Cynthia Bartlau, RN, PHN, MSN
Components of a Health
   Chief Complaint
   Present Illness
   Past History
   Health Maintenance (immunizations)
   Family History
   Personal and Social History
   Review of Systems
LVN Role in Health

   ACUTE CARE - Assessment q shift
   LONG TERM CARE – Assessment q
    weekly, monthly, prn
Purpose for Physical
   Compare patient status
   Determine effects of interventions
   Early detection of changes
Set the Setting
   Know your patient
   Know the Diagnosis/ Chief Complaint
   Lighting
   Gather equipment
At the Beginning
   Introduction
   Explain what you are doing
   Ask permission to continue
   Provide privacy
   Ask before you touch
   Continue to explain what you are going to do
Continue throughout
   Ensure
     Patient Comfort
     Privacy
     Special needs

   Ask open ended questions
   YET, stay on focus
   Consider biases
   Be respectful and courteous
   Prevent discriminating care
   Explain your findings
Body Parts and Areas
   Location and position
     Anatomical    position
        Standing  upright
        Facing forward

        Arms at sides with palms forward

        Feet slightly apart
   Body cavities & membranes
     Dorsal   cavity
        Cranial cavity (skull & contains brain)
        Spinal cavity (formed by the spine & spinal
        Meninges (line these cavities & cover the
         organs of the CNS central nervous system
   Ventral cavity
     Thoracic     cavity (heart and lungs)
        pleural membranes line the chest wall (parietal
         pleura) and the lungs (visceral pleura)
        pericardial membranes line the heart
 Abdominal     cavity
    (liver,stomach, kidneys, intestines, pancreas,
     gallbladder, spleen)
    Peritoneum is the membrane that lines the
     abdominal wall
    Mesentery is the membrane that folds around
     and covers the outer surfaces of the
     abdominal organs
 Pelvic   cavity
    (urinary bladder & reproductive organs,
     uterus, prostate)
   A plane is an imaginary flat surface that
    separates two sections of the body or organ
   Frontal plane
     Divides    the body into 2 sections
        Front(ventral/anterior)
        Back (dorsal/posterior)
   Transverse
       Divides the body into 2 sections
          Upper (superior)
          Lower (inferior)

   Sagittal plane
       Divides the body into 2 unequal sections from top
        (superior) to bottom (inferior)
            Midsagittal plane divides the body into 2 equal right and
             left halves
   Cross-section – a plane perpendicular to the long
    axis of an organ
   Longitudinal – a plane along the long axis of an
Areas of the Abdomen
   Four (4) quadrants
     RUQ  – Right Upper Quadrant
     LUQ – Left Upper Quadrant
     RLQ – Right Lower Quadrant
     LLQ – Left Lower Quadrant

   Quadrants are more frequently used for
   Nine area divisions
     *Epigastric
     *Umbilical
     *Suprapubic (hypogastric)
     Right hypochondriac
     Left hypochondriac
     Right lumbar
     Left lumbar
     Right iliac
     Left iliac
*Most frequently used for more specific location
Physical Assessment
   Inspect – to see
     Use appropriate lighting
     Provide privacyfor client
     Expose body areas adequately
     Use instruments when appropriate, i.e. otoscope,
      ophthalmoscope, penlight
                                 Palpate – to feel

   Light                                    Light and Deep
      Depress area to 1 cm or less,         Warm hands
       slowly and gently                     Place client in a comfortable
      Keep hand relaxed                      relaxed position
      Use for palpating skin and            Progress systematically
       superficial areas                     Use bilateral and symmetrical
   Deep                                      pattern (right to left)
      Depress area to 4 cm or more          Compare corresponding areas
      Slowly, gently, and deliberately       of each side of body
      Rested hand during inspiration        Select a starting point and
      Increased depth of probe with
                                              moved in a clockwise
       expiration                             direction, i.e., abdomen,
                                              breasts, etc...
      Instructed patient to breath
       deeply                                Palpate potentially tender areas
   Size of masses - tips of fingers
   Temperature changes - dorsa of hands and fingers
   Vibrations - lateral surface or ulnar aspect of hand
   Rebound tenderness - distal portion of fingers placed
    opposite suspected area, slowly and deeply palpated and
    rapidly released
   Bimanual palpation
     Using the palmar surfaces of both hands
     One hand on top of the other
     With one hand elevating the organ and the other palpating it
Percuss – to tap
   Percussion Sounds - elicits 4 percussion notes on
    selected body surfaces
     Flatness (thigh muscle) elicit and describe sound
     Dullness (liver) elicit and describe sound
     Resonance (normal lung) elicit and describe
     Tympani (gastric air bubble) elicit and describe
   Indirect
   Place distal portion of pleximeter finger firmly
    on skin, remaining fingers on hand not touching
    body surface
   Use top of plexor (finger) immediately
   Hold forearm stationary and used wrist
    movement in striking motion
   Strike a quick, sharp blow with plexor (finger)
   Rebound plexor (finger) immediately
   Use lightest blow that would produce sound
   Deliver strikes with equal force
   Limit strikes to three or less in each area,
    returned to an area when necessary for further
Auscultate – to listen
   Appropriate positioning of stethoscope on self
   Use diaphragm of stethoscope for high-pitched
    sounds - breath, bowel, and normal heart sounds
   Use bell of stethoscope for low-pitched sounds -
    extra heart sounds or murmurs
Assessment Fundamentals
    General survey…
    Complete vs Focus Assessment
30 second Assessment
   LOC                     Dress/grooming/person
   Sign of distress         al hygiene
   Skin color/obvious      Odors of body/breath
    lesions                 Facial Expressions
   Sexual development
   Weight
   Posture/gait/motor
Sequencing an
   Assess what is showing
   Always compare sides
   Assess least personal body parts 1st
     Gain   rapport
   Explain before exposing, keep exposure
   Ask questions for subjective data as you are
Assessment            Normal Findings           Deviations
General Appearance:                             from Normal

Observe body          Varies with lifestyle     Excessively thin
build, height, &                                or obese

Observe client’s      Relaxed, erect posture;   Tense, slouched,
posture & gait        coordinated movement      bent posture;

Observe client’s      Clean, neat               Dirty, unkempt
overall hygiene &
Assessment             Normal Findings   Deviations from
General Appearance:                      Normal
Note body &       No body odor or        Foul body odor;
breath odor in    minor body odor        ammonia odor;
                  relative to work or
relation to activity                     acetone breath
level             exercise; no breath    odor; foul breath
Observe for signs No signs of distress   Bending over
of distress in                           because of
posture or facial                        “abdominal pain” or
expression                               wincing or labored
Note obvious       Healthy appearance Pallor; weakness;
signs of health or                    obvious illness
Assessment             Normal Findings       Deviations from
Behavior:                                    Normal
Client’s attitude      Cooperative           Negative, hostile,
Client’s               Appropriate to        Inappropriate to
affect/mood;           situation; oriented   situation; disoriented
appropriateness of     x4                    to place & situation;
response & level of                          oriented to name
orientation                                  only; flat affect
Quality, quantity, &   Understandable,       Rapid or slow pace
organization of        moderate pace         Uses generalizations;
speech                 Exhibits thought      lacks association
Relevance &            Logical sequence      Illogical sequence
organization of        Makes sense; has      Flight of ideas;
thoughts               sense of reality      confusion
Head to Toe
   General survey          Head (eyes, ears, nose
   Orientation              etc)
   Signs of distress       Upper strength
   Skin                    Chest (back then front)
   Build (ht & wt)         Abdomen
   Sexual development      Lower strength
   Odors                   Peripheral pulses
   Vital Signs
Physical Assessment
   Head-to-toe assessment (focused or general)
     Neurosensory
     Cardiovascular
     Respiratory
     Gastrointestinal
     Integumentary
     Musculoskeletal
   General information
     Height  & weight
     Vital signs
Neurological Assessment

   A/A/Ox4
     Orientation:person, place, time, & situation
     Response to verbal command
     Hand grips & leg pushes
     PERRLA
     Glasgow Coma scale
        Eye opening
        Verbal response

        Motor response
Glasgow Coma Scale
                                 Eye Opening
Spontaneous               4
To verbal stimulus        3
To painful stimulus       2
No response               1
                              Verbal Response
Spontaneous               5
Confused conversation     4
Inappropriate words       3
Incomprehensible sounds   2
No response               1
                              Motor Response
Obeys commands            6
Localizes pain            5
Withdraws from pain       4
Abnormal flexion          3
Abnormal extension        2
No response               1
   Blood pressure
   Pulses (bilateral, characteristics: rate,
    rhythm, quality)
   Capillary refill (<3sec.)
   Skin color/temperature
   Edema (location, degree)
   Heart sounds (clear/distant)
       Classification of BP
   Category                SBP         DBP
                           mmHg        mmHg
   Normal                  <120 and    <80

   Prehypertension         120-   or   80-89
   Hypertension, Stage 1   140-   or   90-99
   Hypertension, Stage 2   160   or   100

US DHHS - May 2003
   Respirations (rate, characteristics, depth,
   Use of accessory muscles
   Lung sounds
     Wheezes
     Rales/crackles
     Rhonchi

   Cough/secretions (characteristics)
   Use of oxygen (amount) or room air + O2 sat
   Abdomen (general contour)
   Circumference (if disease related)
   Bowel sounds (location, frequency, intensity)
   Appetite (gastric distress, N/V)
   Bowel movement (frequency,
   Urine elimination (pattern, changes)
   Urine (amount, characteristics)
Integumentary (Skin)
   Mucous membrane (color, moistness)
   Skin turgor (good, poor, tenting)
   Skin color/temperature
   Skin integrity (describe lesions)
   Range of motion
   Gait/stability/strength
   Contractures
   Using appropriate equipment & positioning,
    complete an organized head to toe
    assessment on one classmate or more
   Complete documentation on LBCC “Care
    Plan Worksheet” assessment section

Shared By: