11.01 Introduction to Health Assessment

Overview

• While it is impossible to list every possible disorder of the various body systems, this course will attempt to provide the outline for a basic physical assessment to allow the nurse the ability to determine if the patient has any outlying abnormalities. This is not intended to be a complete guide to pathophysiology but to provide a framework for completing a thorough head to toe assessment.

• • • • Checklist for General Assessment
        Body Structure/Mobility
        Behavior
        Health History

        Vital Signs
        Height Weight
        Pulse Rate
        Respirations
        Temperature
        Blood Pressure
        Pain

        Integumentary
        Inspect: color, moisture, hair, rashes, lesions, pallor, edema
        Palpate: temperature, turgor, lesions, edema, texture

        Scalp
        Inspect: shape, symmetry
        Palpate: tenderness, deformity

        Nails
        
        Inspect: shape, color
        Palpate: capillary refill

        Head
        
        Inspect: symmetry, shape, size, uniformity

        Neck
        
        Inspect: symmetry, lesions, scars
        Palpate: tenderness, lymph nodes, thyroid gland, TMJ

        Eyes
        
        Inspect: interior and exterior, visual fields, acuity, reflexes

        Ears
        
        Inspect: color, shape, symmetry, interior inspection
        Palpate: tenderness, deformity

        Nose
        
        Inspect: shape, symmetry, interior inspection
        Palpate: frontal sinus, maxillary sinuses

        Mouth and Throat
        Inspect: exterior and interior

        Thorax and Lungs (anterior and posterior)
        Inspection: respiration quality, symmetry, deformity, tracheal location
        Palpation: tenderness, fremitus, chest expansion
        Percussion: percussive tones, diaphragmatic excursion
        Auscultation: breath sounds and quality

        Heart and Great Vessels
        Inspection: jugular venous pulse
        Palpate: pulses, PMI
        Auscultate: heart sounds (bell and diaphragm)

        Peripheral Vascular System
        Inspect: color, edema
        Palpate: temperature, edema

        Abdomen
        Inspect: discomfort, uniformity, color, symmetry, scars, hernia, peristalsis, pulsations
        Auscultate: bowel sounds, bruits
        Percussion: four quadrants, liver, spleen, renal tenderness
        Palpation: light to deep, liver, spleen, aorta, rebound tenderness, fluid wave

        Musculoskeletal
        Inspection: asymmetry, deformity, atrophy
        Palpation: major joints, tenderness, deformity, range of motion

        Neurological
        Inspect: mental status (health history), cranial nerves, coordination, movement, senses
        Palpate: motor strength, muscle tone, reflexes, senses

        Genitourinary
        Inspect: general appearance, lesions, scars
        Palpate: breast exam, testicular exam, prostate exam, vaginal exam, Pap smear

        Lymphatic
        Palpate: assess lymph node locations