HEALTH ASSESSMENT – ADOLESCENTS AND

ADULTS

F O R : Y R 1 M AY 2 0 2 4 I N TA K E
B Y: V I N C E N T C H I O N A M U N T H A L I
INTRODUCTION
WHAT INFERENCES CAN YOU
MAKE FROM THE PICTURE?
 BROAD OBJECTIVE

• By the end of the

presentation, all students
should be able to acquire
adequate knowledge, proper
attitude and adequate skills
 LEARNING OBJECTIVES

At the end of the lesson

students,
should be able to:
• Define health assessment
• Explain the importance of
health assessment
• State the components of
health assessment
• Describe the steps in
conducting health
assessment
DEFINITION OF HEALTH ASSESSMENT

• It is the comprehensive history

taking, physical examination and
other investigations in order to
identify patient’s problems and
needs and intervene accordingly
 IMPORTANCE OF HEALTH ASSESSMENT

• Provides information about client’s physical

health
• It gives details of the event of the present
problem
• It comprises of facts about social and family
history that are essential for providing
comprehensive care.
 CONT

• It helps to obtain information

regarding all the variables that may
affect client’s status.
• The data is used to develop nursing
diagnosis and plan for
comprehensive care for the client.
 COMPONENTS OF HEALTH ASSESSMENT

• History taking (subjective data)

• Physical examination (objective data)
• Diagnostic testing: Laboratory and/or
x ray
 1. HISTORY TAKING (SUBJECTIVE DATA)

• A health assessment history taking

(interview) is a verbal interaction
between the nurse and client or
patient based.
It occurs in a form of interview to
collect data on which nursing
diagnoses are made
• Interviewing is one way of learning
the patient as an individual and
his/her experience with the illness
• Taking history is the first and most
important part of your interaction with
the patients and helps to establish a
trusting relationship
• The items in a history vary with the age
of the patient, gender, illness, available
time, and the goals of the visit
 SETTING FOR INTERVIEWS

• Consider the environment – ensure

environment is quite and free of
interruption for privacy
• Make sure the patient is comfortable.
• Use open- ended questions
• Review the patient’s file to identify
personal data and have information
about past diagnosis and treatment
• Write down short phrases, words and
dates to aid your memory later.
SUBJECTIVE DATA
Date and time
• Write date and time - always important
Personal data
• Includes name, age, gender, marital
status, religion, education, occupation,
address and address/phone number of
next kin for identity
Chief complaints
• What brings the patient to a health
facility; if possible in the patient’s own
words.
• Sometimes you may have clients just for
regular check ups or seeking preventive
services e.g. family planning
History of Present Illness
• This section gives clear and
chronologic account of the problem
for which the patient is seeking care.
• The data come from the patient, but
organization is done by the nurse.
a) The seven attributes of a
symptom
• Location - where is it?
• Onset- is it sudden or gradual?
When did the symptoms erupt?
• Quantity or severity - how bad is it?
• Frequency - how often does it
come?
• Predisposing factors
• Aggravating factors – things that
precipitate the problem
 CONT

• Relieving factors – actions taken to

relieve the problem
• Associated symptoms
b) Current medications- including dose,
route and duration; home remedies and
birth control.
c) Allergies - including the specific
reaction
 PAST HISTORY

• Medical history - Ask patient for

history of major diseases such as
diabetes, hypertension, hepatitis,
asthma, TB, HIV, cancer, anaemia
and information about
hospitalizations
• Surgical History - include dates,
indication, and outcome. Also
include accidents and injuries and
transfusions.
 CONT

• Obstetric/gynecologic- includes
obstetric and menstrual history, birth
control, number of children and risk
practices,
• Psychiatric history- includes dates,
diagnoses, hospitalizations,
treatments.
 CONT
Family history

• Note occurrence within the family of any

of the following conditions: diabetes,
heart disease, hypertension, stroke,
kidney disease, TB, cancer, arthritis,
anaemia, allergies, asthma, headaches,
epilepsy, mental illness, alcoholism and
drug addiction
• Note age and health or cause of
death, each of immediate family
member i.e. parents, siblings, spouse,
and children
 CONT

Personal and social history

• Captures important and relevant
information about the patient as a
person, lifestyles that create risk or
promote health, and health
maintenance measures.
• occupation and education
• home situation and significant
others,
• Smoking and drinking.
• leisure activities/hobbies
Nutritional history
• Usual dietary patterns (type of food
and how often), knowledge of food
groups, food preparations and
hygiene
OBJECTIVE DATA
PURPOSE OF PHYSICAL EXAMINATION:

• To obtain baseline data about the

client’s functional abilities.
• To supplement, confirm, or
disprove data obtained in the
nursing history.
• To obtain data that will help
establish nursing diagnoses and
plans of care.
• To evaluate the progress of a
client’s health problem.
• To make clinical judgments about
a client’s health status.
• To identify areas for health
promotion and disease
prevention
 REVIEW OF SYSTEMS

• Ask about common symptoms in

each major body system to identify
problems that the patient has not
mentioned.
• The main purpose is to make sure that
you have not missed any important
systems, particularly in areas that you
have not already explored while
discussing with the patient.
• Review of systems therefore is basically
under history taking or subjective history
• These detailed questions depend on
age, complaints on general state of
health, and the purpose for the visit
General
• Ask about usual weight change,
weakness, fatigue and fever
• Skin: rashes, lumps, sores, itching, dryness,
colour change, change in hair or nails
• Head: Headache, head injury, dizziness,
• Ears: Hearing, tinnitus, earaches, infection,
discharge. If hearing is decreased, use or nonuse
of hearing aids.
• Nose and sinuses: Frequent colds, nasal
stuffiness, discharge, or itching, hay fever,
nosebleeds, sinus trouble.
 CONT

• Mouth and throat: Condition of teeth, gums,

bleeding gums, dentures, if any, frequent sore
throats and hoarseness of voice.
• Neck: Lumps, swollen glands, goiter, pain, or
stiffness in the neck.
• Breasts: Lumps, pain or discomfort, nipple
discharge, self-examination practice.
 CONT

Respiratory system.
• Cough, sputum (color, quantity),
hemoptysis, dyspnea, wheezing,
asthma, bronchitis, emphysema,
pneumonia, TB, pleurisy, last chest x-
ray.
Gastrointestinal system
• Trouble swallowing, heartburn,
appetite, nausea, vomiting,
regurgitation, vomiting blood,
indigestion. Frequency of bowel
movements, color and size of stools,
change in bowel habits,
 CONT

rectal bleeding or bloody stools,

hemorrhoids, constipation, diarrhea.
Abdominal pain, food intolerance,
excessive belching or passing of gas.
Jaundice, liver or gallbladder trouble,
hepatitis.
• Urinary system: Frequency of
urination, polyuria, nocturia, burning
or pain on urination, hesitancy,
dribbling, incontinence, urinary
infections, stones.
 CONT

Reproductive system
• Males: Hernias, penile discharge or
sores, testicular pain or masses, history of
STIs and their treatments.
• Sexual interest, function, satisfaction,
condom use, and problems. Exposure to
HIV infection.
 CONT

Females: Age at menarche, regularity,

frequency and duration of periods,
amount of bleeding, bleeding between
periods or after intercourse and pain
during intercourse
• LMP, dysmenorrheal, age of menopause
and menopausal symptoms
 CONT

• Discharge, itching, sores, lumps,

STIs and treatments.
• Number of pregnancies, number and
types of deliveries, number of
abortions (spontaneous and induced),
complications of pregnancy, birth
control methods.
• Sexual interest, function, satisfaction,
any problems, including dyspareunia.
Exposure to HIV infection.
 CONT

• Peripherical vascular: leg cramps,

varicose veins, past clots in the veins.
• Musculoskeletal: Muscle or joint pains,
stiffness, arthritis, gout, backache.
• If present, describe location and
symptoms (e.g. swelling, redness,
tenderness, stiffness, weakness, limitation
of motion or activity.)
 CONT

• Neurologic: Fainting, blackouts,

seizures, weakness, paralysis, numbness
or loss of sensation, tingling sensations,
tremors or other involuntary movements.
• Hematologic: Anaemia, easy bruising or
bleeding, past transfusions, and any
reactions to them.
• Endocrine: Thyroid trouble, heat or
cold or intolerance, excessive
sweating, diabetes, excessive thirst or
hunger, polyuria.
2. PHYSICAL EXAMINATION (OBJECTIVE DATA)

Physical examination is a systematic

and comprehensive assessment or
examination of the body from head to
toe.
• It starts with general survey. Observe
the patient’s general state of health
i.e. appearance, motor activity, gait,
posture, grooming, personal hygiene,
body colors, weight and height
including reactions to persons or
things in the environment
 CONT

Purposes of physical examination

• To obtain baseline data about the
client’s functional abilities
• To supplement, confirm or refute data
obtained in the nursing history
• To obtain data that will help establish
nursing diagnosis and plan of care,
• To evaluate the physiological
outcomes of health care and thus the
progress of a client’s health.
 MODALITIES/TECHNIQUES OF PE

1. Inspection
• Use of vision, hearing in examination
• Observation of general appearance
thus;-
• body size
• changes in shape
• posture, gait and height
• skin colour
• sound e.g. breathing sounds
 CONT

2. Palpation
• Palpation is examination of the body
using the sense of touch. The pads of
the fingers are used.
• It is done by pressing gently while
moving the hand in a circle
 CONT

It is used to determine texture (hair) temperature

of skin, position, size, consistency and mobility
of organs or masses, distension (urinary bladder
or abdomen), and presence of pain upon
applying pressure.
a) Light palpation
• To detect characteristics of the skin
and superficial tissues e.g.
temperature or skin turgor etc.
 b) Deep palpation
• This is done with two hands
(bimanually) or one hand. Deep
palpation is done with extreme
caution because pressure can damage
internal organs.
• It is done to detect deeper masses in
the body but it is usually not
indicated in clients who have acute
abdominal pain or pain that is not yet
diagnosed.
 CONT

General guidelines
• The nurse’s hands should be clean and
warm and the fingernails short.
• Areas of tenderness should be palpated
last.
• Deep palpation should be done after
superficial or light palpation.
 CONT

3. Percussion
• This is the act of striking the body surface to
elicit sounds that can be heard or vibrations
that can be felt.
• In direct percussion, the nurse strikes the area
to be percussed directly with the pads of two,
three fingers or with the pad of the middle
finger.
 CONT

• Indirect percussion is the striking of

an object held against the body area
to be percussed Using the finger of
one hand to tap the finger of the other
hand.
• Sounds produced may be;
• Flatness – dense tissues
• Dullness – dense tissues e.g. liver and
spleen
• Resonance – hollow sound e.g. lungs
• Tympany – musical or drum like (air
filled organ)
 CONT

4. Auscultation
• Process of listening to sounds
produced within the body. This can
be done by ear or using a stethoscope
e.g. heart sounds, chest sounds or
bowel sounds.
 EQUIPMENTS REQUIRED DURING
PHYSICAL EXAMINATION

• Weighing scale
• Sphygmomanometer
• Stethoscope
• Tongue depressor
• Tuning folk
• Otoscope
• Snelly’s chart
• Reflex hammer
• Speculum
• Gloves
• Lubricant
• Thermometer
• Kidney dish
• Dry swabs and antiseptic solution
• Exam coach
• Hand washing soap
• Towel
• Water
• Trolley
• Tray
 HEAD TO TOE EXAMINATION

• Remember always to provide privacy

. Patients physical comfort is vital
for successful examination.
• After the general survey, vital signs
are checked which include body
temperature, pulse rate, respirations
and blood pressure
HEAD
• Hair - check for distribution, texture,
amount, nits, ringworm, alopecia,
scalp lesions, palpate for swellings
tenderness, superficial nodes
Face
Eye - eyebrows for hair quality,
alignment and movement, eyelids,
blinking, redness, excessive tearing
yellowish discharge, deformity,
inflammation of the eye, inspect the
conjunctiva and sclera.
 CONT

Nose - polyps, masses, sense of smell and

bleeding
Ears – wax, sense of hearing and discharge
Mouth , pharynx & lips – colour, moisture,
ulcers and cacking end, cleft lip in children
dentures gingivitis, white patches, teeth, dental
caries, tongue for colour, movement, and
mouth odor.
 CONT

Neck
symmetry, any masses, scars, visible
lymph nodes and distended jugular
veins
 CONT

UPPER EXTREMITIES
• Skin for scars and rash; and nails
especially capillary refill,
• Muscle strength and tone
• Oedema, symmetry
 BREAST EXAMINATION
Inspection
• Check for skin changes
• Check for symmetry, contours and
retractions in four views:
• Arms at sides
• over heads
• pressed against hips
• and leaning forward
 PALPATION

Palpate the breast for masses and if

present, assess according to the
following characteristics location,
size, shape, consistency, discreteness
and mobility
• Discharges
Procedure
• The palpation portion of the breast
begins with the palpation for axillary,
subclavicular and supraclavicular
lymph nodes
• This is most effectively performed
with client in a sitting position.
• Then client should be in supine
position with hand on forehead but
keeping shoulders pressed against the
bed to flatten the lateral breast tissue
• Palpate the breast in circular motion
starting at 12 o’clock and moving in
concentric rings inward to areola and
nipple then squeeze the nipple.
Chest
• Inspection check the skin, shape and
size, lesions, chest indrawings,
oedema.
• Percussion strike the body surface to
elicit sounds that can be heard or
vibrations that can be felt
• Palpation feel for any swellings on
the front and back of the chest
• Auscultation using the stethoscope
lung sounds are detected posterorly:
 CONT

• Crackles
• Wheezes –sounds produced by rapid
passage of air through a bronchus that is
narrowed
• Also auscultate for heart sounds on the
anterior chest
• Palpate the axilla for enlarged nodes.
 CONT

Abdomen
Inspection
• - Skin integrity
• - Symmetry
• Ask the client to take deep breath and hold it
(makes an enlarged liver or spleen more
obvious)
• Distension
 CONT

• The abdomen is divided into four quadrants;

• Right upper quadrant
• Left upper quadrant
• Right lower quadrant
• Left lower quadrant
Auscultation- listen to bowel sounds in the
abdomen
 CONT

Percussion- several areas of the

abdomen in each of the four
quadrants to determine presence of
tympany (gas in the stomach and
intestines) and dullness.
Palpation
• Palpate sensitive areas last
• Start with light palpation
• For deep palpation depress the
abdominal wall about 4 to 5cm
 CONT

• Note masses and structure, size, location

• Palpate the liver to the right and spleen to
the left side of the abdomen
• Deeply palpate both kidneys
• Palpate the bladder
• Check for rebound tenderness
 CONT

LOWER EXTREMITIES
• Inspect the skin and toe nails, lesions
• Check symmentry
• Palpate for oedema
• Check for varicose veins
Genital area
• Inspect for any sores, hair
distribution, discharge.
• Palpate- the inguinal area for any
enlarged lymph nodes
 DOCUMENTATION

• Compile the observations and

findings and document using
SOAPIE format and come up with
nursing problems and nursing
diagnosis to write a nursing care plan
 3. INVESTIGATIONS

• These are x ray and laboratory

investigations that are carried out in
order to confirm the diagnosis.
• This ensures the provision of
comprehensive nursing care
POSITIONS ASSUMED DURING PHYSICAL
EXAMINATION

• Several positions are used during the

examination of the patient depending
on what the examiner is aiming at
examining
• Includes: sitting, supine, dorsal
recumbent, Sims, prone and
lithotomy
 CONCLUSION

• Assessing a client’s health status is a major

component of nursing care. This assessment task
can only be accomplished by collecting nursing
health history and conducting physical
examination
 REFERENCE

• Kozier & Erbs (2016).

Fundamentals of Nursing-
Concepts, Process and
Practice (10th ED.) Tokyo:
Pearson