Health Assessment

A. Health Assessment in General
1. Purposes of Health Assessment

• Data collection 
• Supplement, confirm or refute historical data 
• Identify changes in client’s status 
• Evaluate the outcomes of care 

2. Components of Health Assessment: history and physical exam
History:
I. Chief complaint

• Location 
• Quality 
• Quantity 
• Precipitating or aggravating factors 
• Duration 
• Associated findings 

II. General health status
III. Medical history
IV. Family history
V. Social history
VI. Occupation
VII. Activity level
VIII. Sleep
IX. Nutrition
X. Medications; including substance use/abuse
XI. Psychosocial factors

Physical Exam: Skills
I. Inspection

• Process of observing the differences between normal physical signs and deviations 
• Requires knowledge of normal physical signs throughout the lifespan 

Principles of inspection

• In good lighting and with whole body partly visible 
• Observe each area for size, shape, color and position 
• Compare body parts bilaterally for symmetry 

II. Palpation

• Use touch to assess resistance, resilience, roughness, texture and mobility 
• Palpation may be either light or deep in pressure:

1. Use light palpation to determine tenderness 
2. Deep palpation usually depresses the area by 1 to 2 inches; use it to examine specific organs 

•  Use palmar surface of fingers to determine position, texture, size, consistency and pulsation; also presence and shape of mass 
• Use back of hand to test temperature 
• Use palm of hand to sense vibration 

III. Percussion

• Tap the body with fingertips: to detect fluid or to assess location, size, density and borders of organs 
• Tapping the body produces vibration and sound waves which you hear as percussion tones 

Methods

• Direct: striking the body surface with two fingers 
• Indirect: striking the middle finger of the non-dominant hand on the back surface with the fingers of the dominant hand rather than the body surface, while keeping the palm and remaining fingers of the body 
• Character of percussion sounds depends on the density of the tissue being percussed 

Percussion Sounds:

• Tympany: drum like, loud, high pitch, moderate duration; usually found over space containing air such as the stomach 
• Resonance: hollow sound of moderate to loud intensity; low pitch, long duration; usually heard over the lungs 
• Hyperresonance: booming sound of very loud intensity; very low pitch, long duration; usually heard in the presence of trapped air (such as emphysematous lung) 
• Flatness: flat sound of soft intensity; high pitch, short duration; usually heard over muscles 
• Dullness: thud-like sound of soft intensity; high-pitch, moderate duration; usually heard over solid organs (such as heart, liver) 

IV. Auscultation

• Listening (with unassisted ear or stethoscope) to sounds made by the body 

Assess presence of sound and their character 

• Frequency (high or low pitch) 
• Loudness (loud or soft) 
• Quality (blowing, gurgling, booming, thud-like, hollow or flat) 
• Duration (short, moderate or long) 

V. Olfaction

• Use of sense of smell to differentiate common body odors from abnormal ones 

Common odors include:

• Urine: ammonia 
• Skin: body odor 
• Body wastes: feces, vomitus 
• Mouth: halitosis 

VI. Physical exam 

1. Equipment 

2. Client positions 

3. Reporting general appearance and behaviors 

• Gender and race 
• Age 
• Obvious signs of distress 
• Body type 
• Posture 
• Gait 
• Body movements 
• Hygiene 
• Dress 
• Affect and mood 
• Speech 

4. Vital signs 

5. Height and weight

6. Body temperature 

• Range: 36 to 38 degrees Celsius (98.6 to 100.4 degrees Fahrenheit) 
• Measure core temperature: rectum, tympanic membrane, esophagus or urinary bladder 
• Measure surface temperature: skin, axilla or mouth 

Body temperature normally varies with:

• Age 
• Exercise 
• Hormone level 
• Circadian rhythm (time of day) 
• Stress 
• Environment 

Equipment needed for physical exam

• Client gown 
• Drapes 
• Stethoscope 
• Gloves 
• Percussion hammer 
• Sphygmomanometer (blood pressure gauge and cuff) 
• Thermometer 
• Tape measure 
• Cotton swabs 
• Flashlight 
• Tongue depressor 
• Scale 
• Lubricant 
• Eye chart 
• Miscellaneous: safety pin, ruler, paper towels

Health and Health Promotion

HEALTH
A. Definitions of health vary

• Traditional definition: freedom from disease 
• 1958 World Health Organization definition: “state of complete physical, mental and social well-being and not merely the absence of disease and infirmity” 

B. Health belief model

• Psychological and behavioural theory 
• Attempts to explain individual health behaviours 
• Health behaviours

1. The individuals perception of susceptibility of illness 
2. The individuals perception of seriousness of the illness 
3. The likelihood that the person will take preventive action 

• Modifying Factors

1. Cultural beliefs 
2. Economics 
3. Political factors 
4. Social factors 
5. Personal beliefs 

Health Promotion
A. Definitions

1. Health Promotion Behaviour is a behaviour in which the client views health as a goal and engages in behaviours designed to achieve or maintain that goal 
2. Health Care includes prevention, early detection, treatment and rehabilitation for clients with potential for or existing illness or disability 
3. Healthy Lifestyle can increase or maintain client’s level of wellness and functional ability 
4. Health Screening (for risk factors or illness) can prevent or minimize illness and disability 
5. Disease Prevention Behaviors are behaviours designed to decrease the likelihood/risk of illness 

• Primary prevention 

1. Health promotion and disease prevention 
2. Applied to clients considered physically and emotionally healthy
3. Example: exercise programs, healthy diet 

• Secondary prevention 

1. Early detection of illness 
2. Focuses on individuals who are experiencing health problems and illness and who are at risk for problems and illnesses and who are at risk for complications 
3. Activities are directed at diagnosis and prompt treatment 
4. Example: breast self examination, cholesterol screening 

• Tertiary prevention 

1. Prevention of further deterioration in disease or disability 
2. Occurs when a defect or disability is permanent and irreversible
3. Activities are directed at rehabilitation 
4. Example: alcoholics anonymous 

B. Primary Health Care

• Accessible, community-based or work-based health care services based on principle of universal access, which ensures health care for all individuals regardless of employment or insurance status
• Health Security Act of 1993 offered universal access to basic hospital, preventive, physician and long-term services. It included these seven services:

1. Physical examinations
2. Screening tests 
3. Diagnosis and treatment of common acute illness 
4. Management of chronic illnesses 
5. Liaison with community resources 
6. Provision of prenatal care 
7. Identification of need for specialty referrals 

• Providers include physicians and advanced practice nurses such as: nurse midwives and nurse practitioners
• Services provided through a managed care model
• Specialty services provided and reimbursed only after referral from the primary care provider
• Primary care settings include:

1. Health maintenance organizations (HMOs) 
2. Public health departments 
3. Occupational health clinics 
4. Schools 
5. Nurse managed clinics 
6. Collaborative practice settings 

C. Health Promotion Model

• Developed by Nola Pender 
• Health promotion depends on seven factors of cognition-perception

1. Importance of health to the person 
2. Perceived control of health 
3. Perceived self-efficacy 
4. Definition of health 
5. Perceived health status 
6. Perceived health benefits from the health-promoting behaviour 
7. Perceived barriers to the health-promoting behaviour 

D. Risk Factors – probability of acquiring a particular health problem

• Varies with age, race, ethnicity, gender 
• Risk increases with certain lifestyle choices, such as smoking, occupation, diet, environment 
• Modifiable risk factors include occupation and diet 
• Non-modifiable risk factors include race and age 
• Examples: Risk factors are important in

• Coronary artery disease 
• Cancer 
• Colon cancer 

1. Over 50 years of age 
2. Family history of colon polyps or cancer 
3. Urban living 
4. Diet high in fats and low in fiber

• Tuberculosis 

1. History of exposure to person with TB 
2. History of travel or living outside United States 
3. History of prison time 
4. HIV infection 
5. Cancer chemotherapy 
6. Malnutrition 
7. Homelessness 
8. History of IV drug use 
9. Medical workers

• Diabetes: candidates for screening 

1. Strong family history of diabetes mellitus 
2. Markedly obese 
3. Obstetrical history of babies weighing over nine pounds at birth 
4. Obstetrical history of miscarriage or fetal death 
5. Pregnant women between 24-48 weeks gestation 
6. History of gestational diabetes

E. Screening recommendations for the average American

• Cholesterol – once every five (5) years if normal age 45 and older 
• In women: mammography 
• In women: the first Papanicolau smear at the onset of sexual activity and/or over age 19, annually
• In men: prostate-specific antigen – annually 50 years of age or at age 40 for those at risk
• For colon cancer:

1. Digital rectal exam every year after the age of 40
2. Guiac test for occult blood every year after the age of 50
3. Proctoscopy every three (3) to five (5) years after the age 50 after two negative annual exams
4. Colonoscopy

• Tuberculosis skin tests: intradermal injection of antigen
• Diabetes: fasting plasma glucose, ideally eight (8) to twelve (12) hours fast
• Vision: after age 39, medical eye exam every three (3) to five (5) years
• Hearing: candidates for screening include:

1. Family history of childhood hearing impairment
2. Perinatal infection (rubella, herpes, cytomegalovirus)
3. Low birth weight infants
4. Chronic ear infection
5. Down syndrome

HEALTH PROMOTION PROGRAMS AND HEALTH SCREENING

I. Blood Pressure Screening

• Screening should be done annually beginning at age 21 for both males and females
• Screening for children and adolescents is also recommended but optimal interval has yet to be determined
• Auscultatory method with a properly calibrated and fitting cuff should be used
• Person should be seated quietly in a chair for at least five minutes with feet on the floor and arms supported at heart level
• At least two measurements should be done, two minutes apart
• Pre-hypertensive individuals (SBP 120-139 and DBP 80-89) should be counseled on lifestyle modifications such as weight reduction, exercise, diet and smoking cessation
• SBP >140 and/or DBP >90 should be referred to a health care provider for antihypertensive drug therapy

II. Breast Self-Examinations

• Should be started by age twenty
• Done at the same time of the month - preferably seven days after onset of the menstruation cycle; if no menstruation cycles, do at the same time of each month
• Technique should be reviewed by a health care provider to ensure effectiveness
• Limited effectiveness, but when done regularly helps a woman understand how her breast normally feel
• Most changes are benign, but unusual or spontaneous changes should be checked by a health care provider without delay. These include:

1. lump or thickening (breast or underarm)
2. red or hot skin
3. orange peel skin
4. dimpling or puckering
5. itch or rash, especially in nipple area
6. retracted nipple
7. change in direction of nipple
8. bloody or spontaneous discharge
9. unusual pain
10. a sore on the breast that does not heal

III. Risky Behaviors - assist in assessment of behaviors that impact the health of individuals in the following developmental stages

• Adolescents (age 13-19)
• Eating disorders
1. Anorexia Nervosa - restrictive eating
2. Bulimia Nervosa - binge eating followed by purging
• Injury prevention
1. wearing of seat belts
2. wearing of helmets
3. sports injuries
4. homicide and suicide
• Substance abuse
1. tobacco
2. underage drinking
3. illicit drug use
• Sexual  behavior
1. number of sex partners
2. use of contraception
3. unintended pregnancy
4. exposure to sexually transmitted diseases
• Young Adult (age 20-35)
• Eating disorders - onset of obesity
• Injury prevention
1. Motor vehicle accidents
2. Occupational hazards
3. Homicide and suicide
• Substance abuse
1. tobacco
2. alcohol use
3. illicit drug use
• Sexual behavior
1. sexually transmitted disease - use of condoms
2. unintended pregnancy
• Stress
1. depression
2. Changing roles
• marriage
• beginning a new family
• starting a new job
• Middle Adult (age 35-65)
• Obesity
• Lack of exercise
• Substance abuse
1. tobacco
2. alcoholism
3. illicit drug use
• lack of preventative health care
• stress
1. job
2. family/divorce
3. acceptance of aging
• Older Adult (age 65 and older)
• Obesity
• Lack of exercise
• Substance abuse
1. tobacco
2. alcoholism
3. illicit drug use
• Injury prevention
1. falls
2. seatbelts
3. suicide
4. multiple medications

IV. Scoliosis Screening

• Recommendations vary but generally accepted to perform screening at onset of adolescence
• Significantly more prevalent in girls than boys
• Early intervention important because untreated scoliosis can lead to disfigurement, impaired mobility, and cardiopulmonary complications
• Technique - clothing should be removed from upper body

1. While standing, check adolescent for asymmetry of shoulders, scapula, hips or waist
2. Assess for misalignment of spinous processes - lateral curvature and convexity of thoracic spine indicate scoliosis
3. With feet together and legs straight, have adolescent bend forward until back is parallel to floor; check for prominence of ribs on one side only and hip and leg asymmmetry - chest wall on side of convexity is prominent and scapula on side of convexity is elevated

• Abnormalities are to be followed up by a health care provider and referral to orthopedist may be necessary for severe curvatures

V. Testicular Self-Examinations

• Monthly self-examination should begin in adolescence, since this is the highest risk group
• Best time to perform exam is during or after a bath or shower when the scrotum is relaxed
• Limited research to determine if regular examinations reduce death rate but they are strongly encouraged for men with risk factors such as

1. family history of testicular cancer
2. cryptochidism
3. previous germ cell tumor in one testicle

• Findings that should be reported to a health care provider include

1. hard lumps or nodules
2. change in size, shape or consistency of the testes

F. Compliance

• Definition: adherence to primary or secondary prevention recommendations
• Factors influencing compliance

1.  Personal meaning and perceptions: knowledge, values, beliefs, outcome expectations
2. Social factors: environmental context, social relationships, social support, societal norms, economic resources
3. Deficiencies in the health care system: access, costs, wait time, monolingual services

 G. Noncompliance

•  An individual’s informed decision not to adhere to a therapeutic recommendation
• Individual unable or unwilling to alter habitual behaviours or adopt new behaviours necessary to a prescribed therapeutic regimen 

TIMING OF MAMMOGRAMS 

• The National Cancer Institute (NCI) and the American Cancer Society differ in their recommendations for scheduling of mammograms 
• NCI recommends (2002): 

1. Women in their 40s should be screened every one (1) to two (2) years with mammography 
2. Women aged 50 and older should be screened every one (1) to two (2) years 
3. Women who are at higher than average risk of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and the frequency of screening 

• The ACS guidelines for the detection of breast cancer in asymptomatic women (2002): 

1. Women 40 years of age and older should have a mammogram every year 
2. Women 40 years and older should have a physical examination of the breast every year, performed by a health care professional, such as a physician, physician assistant, nurse or nurse practitioner. This examination should take place near and preferable before, the annual mammogram 
3. Women 20-39 should have a physical examination of the breast every three (3) years, performed by a health care professional such as physician, physician assistant, nurse or nurse practitioner 

• BSE is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away 

POINTS TO REMEMBER:

• Measure vital signs when the client is at rest
• Compare both sides of the body for symmetry
• Assess the systems related to the client's major complaint first
• Offer rest periods if client becomes tired
• Culture and religious beliefs may play a role in observed differences
• Warm hands and equipment such as stethoscope before touching client 
• Tell client what you are going to do before touching client
• Normal variations exist among clients and there is a range of normalcy for all physical findings
• Maintain the client's privacy throughout the examination
• Control for environmental factors which may distort findings
• Check equipment prior to exam for functioning
• Consider growth and developmental needs when assessing specific age groups
• Integrate client teaching throughout the exam