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