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    Rationale For Health Assessment

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    This document outlines the rationale for various components of a physical assessment of a client. It describes examining the client's appearance, body structure, mobility, behavior, and vital signs. The assessment helps identify any abnormalities, ensure the client's comfort and privacy, and allows the nurse to properly evaluate the client's health status and develop an effective nursing care plan.

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    Rationale For Health Assessment

    Uploaded by

    Reg
    435 views8 pages
    This document outlines the rationale for various components of a physical assessment of a client. It describes examining the client's appearance, body structure, mobility, behavior, and vital signs. The assessment helps identify any abnormalities, ensure the client's comfort and privacy, and allows the nurse to properly evaluate the client's health status and develop an effective nursing care plan.

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    Rationale for Health Assessment

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    This document outlines the rationale for various components of a physical assessment of a client. It describes examining the client's appearance, body structure, mobility, behavior, and vital signs. The assessment helps identify any abnormalities, ensure the client's comfort and privacy, and allows the nurse to properly evaluate the client's health status and develop an effective nursing care plan.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    435 views8 pages

    Rationale For Health Assessment

    Uploaded by

    Reg
    This document outlines the rationale for various components of a physical assessment of a client. It describes examining the client's appearance, body structure, mobility, behavior, and vital signs. The assessment helps identify any abnormalities, ensure the client's comfort and privacy, and allows the nurse to properly evaluate the client's health status and develop an effective nursing care plan.

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    A.

    Preliminaries Rationale

    1. Explain to the client what are you going to do, To perform the right procedure to the client with

    why it is necessary, and how he can cooperate client at ease and comfortable and with client’s

    consent.
    2. Assemble necessary equipment and supplies For easy access when performing needed
    physical examination to the client.

    3. Wash hands and observe appropriate infection to prevent spread of microorganisms.

    control and procedure


    4. Provide for client privacy. for client’s comfort and security.

    B. Physical Appearance Rationale

    1. The person appears his or her stated age This helps to assess possible nursing diagnosis

    with regards to client’s chronological age or may

    not appear, and ensure effective communication

    and preventive measures.


    2. Sexual development is appropriate for Identifying client sexual development whether it
    sex and age. is appropriate for sex and age helps in providing
    adequate assessment. Client may have delayed
    puberty, male client with female characteristics
    and female client with male characteristics.

    3. Level of consciousness Observing if Client is responding appropriately to


    question and attentive at the time of physical
    assessment and may determine patterns of post
    convulsive states and cerebrovascular disorder.

    4. Skin color Observing Client skin color is even without

    obvious lesions: light to dark beige-pink in light

    skinned client. Presence of Extreme Pallor,

    flushed skin, or yellow skin in light skinned client,

    loss of red tones and ashen gray cyanosis in dark-


    skinned client may suggest skin disorder and can

    help for further assessment.

    5. Facial features This also help to identify the nature of the pain.
    No sign of distress, Wincing and frowning on face
    may be visible if pain is evident.

    C, Body Structure Rationale

    1. Stature- Observing client’s stature if Proportional to age, if


    not Dwarfism, Gigantism may determine the
    disorder.

    2. Nutrition- Types of nutrient intake of client may be evident


    based on Client proportion to height and weight.
    Client may exhibit malnourished or obesity, this
    will help to assess possible diagnosis.

    3. Symmetry Identifying the client’s body type falls on normal


    range, proportion to age, height and weight,
    equal distance of body from proportion head to
    foot. Abnormalities such as Arm span is greater
    than height. Marfan syndrome be visible. Body
    range is not proportional to age and height may
    suggest imbalance hormonal development.

    4. Posture The keen observation of Client’s posture if erect

    and comfortable for age and upright. Tense,

    slouched, bent posture, uncoordinated

    movement, scoliosis, lordosis or kyphosis may be

    observed so proper assessment will be

    supported.

    5. Position- Understanding the course of frequent changes of

    position by the client determine how much the

    pain or uncomfortability is.


    6. Body Build, Contour This helps to assess the possible deformities
    evident. Observing whether client body structure
    is Proportionate to height and varies with lifestyle
    or may excessively thin or obese.

    D. Mobility Rationale

    1. Gait Accompanying patterns and symptoms


    introduced disorder if beyond deviations from
    normal. Identify if client’s Gait is rhythmic and
    coordinated, with arms swinging at side. Client is
    waddling or steppage gait, slumped shoulders is
    visible suggest disorder.

    2. Range of motion To assess whether client can abduct, adduct, flex,


    extend and execute circumduction without
    feeling of distress. Or Client feels distress when
    executing a range of motion suggest presence of
    neurological disorder.

    E. Behavior Rationale
    1. Facial Expression Appropriate facial expression, no sign of distress.
    Client smiles and maintains eye contact and
    interact is associated with stable neurological
    function and cognitive. Inappropriate facial
    expression, sign of distress, discomfort is evident.

    2. Mood and Affect This help to provide structured assessment of

    patient’s behavioral and cognitive function. Client

    shows mood and affect appropriate to situation,

    cooperative, able to follow instructions. Or

    disorder such as when client is negative, hostile,

    withdrawn, anxious, inappropriate to situation,

    sudden mood change, paranoia.

    3. Speech/Speech patterns This will help identify any altered speech and

    motor activity resulting from depression or


    organic disease or neurological disorders.
    4. Clothing/Personal hygiene Client is neat and clean and dress appropriately

    to the setting or weather. Clothes in good

    condition this may assess the neurological

    thinking of the client.

    F. Measurement Rationale

    1. Weight This is also to help identify health range of the

    client. Proportionate to age and height.

    Underweight or over weight.

    2. Height This is also to help identify client’s height

    proportion to age or dwarfism or gigantism is

    evident.

    3. Body Mass Index This is to assess client’s is Healthy, within the

    normal range or Client falls within underweight

    range or obese range.

    4. Waist Circumference This is to assess if Client falls within appropriate

    waist circumference depending on gender or

    Inappropriate waist circumference for the

    gender.

    G. Vital Signs Rationale

    1. Heart rate, pulse rate, Blood pressure, This are taken to the client to assess the general
    temperature physical health and provides clues for possible

    diseases and shows progress toward recovery.

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