Health

Assessment
(Objectives)

NAME:
YEAR & SECTION:
VITAL SIGNS Assessing Body Temperature
QUESTIONS FINDINGS
Preparation
1. Assess for signs of fever or
hypothermia.
2. Sites most appropriate for
measurements of body temperature.
3. Factors that may alter core body
temperature.
4. Complete the equipment and supplies
needed.
Procedure
5. Explain to the client what you are
going to do, why it is necessary, and
how she can cooperate.
6. Wash your hand and observe other
appropriate infection control
procedures.
7. Provide client privacy
8. Position the client appropriate for the
procedure.
9. Place the thermometer.
10. Wait for the appropriate time before
removing the thermometer.
11. Remove the thermometer and
discard the cover or wipe with a cotton
ball with alcohol.
12. Read the temperature. If the
temperature is obviously too high or too
low, or inconsistent with the client's
condition, RECHECK it with a
thermometer known to be functioning
properly.
13. Document the temperature in the
client record.

VITAL SIGNS Assessing the Peripheral Pulse

QUESTIONS FINDINGS
Preparation
1. Assess for signs or cardiovascular
alterations, other than pulse rate, rhythm,
or volume.
2. Assess for the factors that may alter
pulse rate.
3. Site most appropriated for the
assessment of peripheral pulse.
4. Complete equipment and the supplies
needed.
Procedure
5. Explain to the client what you are going
to do, why it is necessary, and how she
can cooperate
6. Wash your hands and observe other
appropriate infection control procedures.
7. Provide client privacy.
8. Assist/Position the client appropriate
for the procedure.
9. Select the pulse point.
10. Palpate and count the pulse, Place two
or three middle fingertips lightly and
squarely over the pulse point.
Assess the pulse rhythm and volume.
11. Document the pulse rate, rhythm and
volume and your actions in the client
record.

VITAL SIGNS Assessing the Respirations

QUESTIONS FINDINGS
Preparation
1. Assess the skin and mucous
membrane coloe, position assumed for
breathing, signs of anoxia, chest
movement, activity tolerance, chest
pain, dyspnea, and medications
affecting respiratory.
2. Assess for the factors that may alter
pulse rate
3. Complete the equipment and
supplies needed.
Procedure

4. Explain to the client what your are

going to do, why it is necessary, and
how she can cooperate.
5. Wash hands and observe other
appropriate infection control procedure.
6. Provide client privacy
7. Assist/Position the client appropriate
for the procedure.
8. Observe and palpate. Count the
respiratory rate.
9. Observe the depth, rhythm, and
character of respirations.
10. Document the respiratory rate,
depth, rhythm, and character in the
clients record.

VITAL SIGNS Assessing the Blood Pressure

QUESTIONS FINDINGS
Preparations
1. Assess the signs and symptoms of
hypertension, hypotension and factors
affecting blood pressure.
2. Complete the equipment and
supplies needed.
Procedure
3. Explain to the client what you are
going to do, why it is necessary, and
how she can cooperate.
4. Wash hands and observe other
appropriate infection control procedure.
5. Provide client privacy.
6. Assist/ Position the client
appropriately.
Adult client should be sitting unless
otherwise specified. Both feet should be
flat on the floor.
Elbow should be slightly flexed with the
palm of the hand facing up the forearm
supported at heart level.
Exposed the upper arm.
7. Wrap the deflated cuff evenly around
the upper arm. Locate the brachial
artery. Apply the center of the bladder
directly over the artery
For an adult, place the lower border of
the cuff appropriately 2.5 cm (1 inch)
above the antecubital space.
8. To assess the preliminary palpatory
determination of systolic pressure.
Palpate the brachial artery with
fingertips
Close the valve on the pump by turning
the knob clockwise.
Pump up the cuff until you no longer
feel the brachial pulse.
Release the pressure completely in the
cuff, and wait one to two minutes
before making further measurements.
9. Position the stethoscope properly.
Ensure that the stethoscope hangs
freely from the ears to the diaphragm
Place the bell side of the amplifier of the
stethoscope over the brachial pulse.

10. Auscultate the client's blood

pressure.
Pump up the cuff until the
sphygmomanometer reads 30mmHg
above the point where the brachial
pulse disappeared.
Release the valve on the cuff so that the
pressure decreases at the rate of 2-3
mmHg per second.
As the pressure falls, identify the
manometer reading at each of the fives
phases.
Deflate the cuff rapidly and completely.
Wait one to two minutes before making
further determination
 ASSESSING SKIN, HAIR AND NAILS

Questions: Findings
1. Gather equipment (gloves, exam light,
penlight, magnifying glass, centimeter
ruler. Wood lamp if available
2. Explain procedure to client
3. Ask client to gown
Skin
1. Note any distinctive odor
2. Inspect for generalized color variations
(browness, yellow, redness, pallor,
cyanosis, jaundice, erythema, vitiligo).
3. Inspect for skin breakdown
4. Inspect for primary, secondary, or
vascular lesions. (Note size, shape,
location, distribution and configuration).
5. Palpate lesions.
6. Palpate texture (rough, smooth) of skin,
using palmar surface of three middle
fingers.
7. Palpate temperature and moisture of
skin using dorsal side of the hand.
8. Palpate thickness of skin with
fingerpads.
9. Palpate mobility and turgor by pinching
up skin over sternum.
10. Palpate for edema, pressing thumbs
over feet or ankles.
Scalp and Hair
1. Inspect color
2. Inspect amount and distribution
3. Inspect and palpate for thickness,
texture, oiliness, lesions, and parasites.
Nails
1. Inspect for grooming and cleanliness.
2. Inspect for color and markings.
3. Inspect shape.
4. Palpate texture and consistency.
5. Test for capillary refill.
Analysis of Data
1. Formulate nursing diagnoses.
2. Formulate collaborative problems.
3. Make necessary referrals.
 ASSESSING NUTRITIONAL STATUS

QUESTIONS FINDINGS
Current symptoms
1. Gather equipments (balance beam scale
with height attachment, metric measuring
tape, marking pencil, and skinfod
calipers).
2. Measure height.
3. Measure weight (1 kg = 2.205 lb).
4. Determine BODY MASS INDEX
(BMI=weight in kilograms/height in
meters squared or use the NIH website:
http//[Link]/bmi/[Link]
). Compare results to BMI in Table 13-3,
on page [Link] the e textbook.
5. Measure waist circumference and
compare findings to Table 13-5on page
230 in the textbook.
6. Measure MID-ARM CIRCUMFERENCE
(MAC) and compare findings to Table 13-6
on page 231 in the texbook.
7. Measure TRICEPS SKINFOLD
THICKNESS (TSF) and compare to Table
13-7 in page 232 in the textbook.
8. Calculate MID-ARM MUSCLE
CIRCUMFERENCE (MAMC), MAMC (cm) -
(0.314 x TSF). Refer toTable 13-8 on page
233 in the textbook for interpretation.
Analysis of data
1. Formulate nursing diagnoses (wellness,
risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.
 ASSESSING HEAD AND NECK

QUESTIONS FINDINGS
Head and Face
[Link] head for size, shape, and
configuration.
2. Palpate head for consistency while
wearing gloves.
3. Inspect face for symmetry,
features, movement, expression, and
skin condition.
4. Palpate temporal artery for
tenderness and elasticity.
5. Palpate temporomandibular joint
for range of motion, swelling,
tenderness, or crepitation by placing
index finger over the front of each
and asking client to open mouth. Ask
if client has history of frequent
headaches.
Neck
1. Inspect neck while it is in a slightly
extended position and using a light)
for position, symmetry, and presence
of lumps and masses.
2. Inspect movement of thyroid and
cricoid cartilage and hyoid gland by
having client swallow a small sip of
water.
3. Inspect cervical vertebrae by
having client flex neck.
4. Inspect neck range of motion by
having client turn chin to right and
left shoulder, touch each ear to the
shoulder, touch chin to chest, and lift
chin to ceiling
5. Palpate trachea by placing your
finger in the sternal notch, feeling to
each side, and palpating the tracheal
rings.
6. Palpate the thyroid gland
[Link] thyroid gland for bruits
if the gland is enlarged (use bell of
stethoscope).
B. Palpate lymph nodes for
size/shape, delimitation, mobility,
consistency, and tenderness
a. Preauricular nodes (front of ears)
b. Postauricular nodes (behind the
ears)
C. Occipital nodes (posterior base of
skull)
d. Tonsillar nodes (angle of the
mandible, on the anterior edge of the
sternocleidomastoid muscle)
e. Submandibular nodes (medial
border of the mandible); do not
confuse with the lobulated
submandibular gland
f. Submental nodes (a few
centimeters behind the tip of the
mandible); use one hand
g. Superficial cervical nodes
(superficial to the sternomastoid
muscle)
h. Posterior cervical nodes (posterior
to the sternocleidomastoid and
anterior to the trapezius in the
posterior triangle)
i. Deep cervical chain nodes (deep
within and around the sternomastoid
muscle. [Link] nodes
(hook fingers over clavicles and feel
deeply between the clavicles and the
sternomastoid muscles)
Analysis of Data
1. Formulate nursing diagnoses
(wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals
 ASSESING EYES

Procedure Findings
Perform Vision Test
1. Test distant visual acuity (with
Snellen chart, normal acuity is 20/20
with or without corrective lenses)
2. Near visual acuity (with handheld
vision chart, normal acuity is 14/14
with or without corrective lenses)
3. Visual fields
Perform Extraocular Muscle
Function Test
1. Corneal light reflex (using a
penlight to observe parallel alignment
of light reflection on cornea)
2. Cover test (using opaque card to
cover an eye to observe for eye
movement)
3. Position test (observing for eye
movement)
External Eye Structure
1. Inspect eyelids and eyelashes (width
and position of palpebral fissures,
ability to close eyelids, direction of
eyelids in comparison with eyeballs,
color, swelling, lesions, or discharge}
2. Inspect position of eyeballs
(alignment in sockets, protruding or
sunken)
3. Inspect bulbar conjunctiva and
sclera (clarity, color, and texture)
4. Inspect palpebral conjunctiva
(eversion of upper eyelid is usually
performed only with complaints of eye
pain or sensation of something in eye)
5. Inspect the lacrimal apparatus over
the lacrimal glands (lateral aspect of
upper eyelid) and the puncta (medial
aspect of lower eyelid) observe for
swelling, redness, or drainage
6. Palpate the lacrimal apparatus,
noting drainage from the puncta when
palpating the nasolacrimal duct
7. Inspect the cornea and lens by
shining a light to determine
transparency
8. Inspect the iris and pupil for the
shape and color of the iris and size
and shape of the pupil
9. Test Accommodation of Pupils by
shifting gaze from far to near
(normally pupils constrict)
 ASSESSING EARS

Physical Assessment Guide to Collect Objective Client Data

Question Findings
External Ear Structures
[Link] the auricle, tragus, and
lobule for size and shape, position,
lesion/Discoloration, and Discharge
2. Palpate the auricle and mastoid
process for tenderness.
Otoscopic Examination
[Link] the external auditory canal
with the otoscope for discharge, color
and consistency of cerumen, color
and consistency of canal walls, and
nodules.
[Link] the tympanic membrane ,
using the otoscope, for color and
shape, consistency and landmarks.
3. Have the client perform the
valsalva maneuver, and observe the
center of the tympanic membrane for
a flutter. (Do not do this procedure
on an older client, as it may interfere
with equilibrium and cause
dizziness).
Hearing and Equilibrium Test
1. Perform the whisper test by having
the client place a finger on the tragus
of one ear. Whisper a two- syllable
word 30.4-60.9 cm (1-2 ft) behind the
client. Repeat on the other ear.
2. Perform the weber test by having
the client place a finger on the center
of the head or forehead and asking
whether the clients hear the sounds
better in one ear or the same in both
ears.
3. Perform the rinne test by using a
tuning fork and placing the base on
the client’s mastoid process. When
the client no longer hear the sound,
note the time interval, and move it in
front of the external ear. When the
client no longer hears a sound, note
the time interval.
4. Perform the Romberg test to
evaluate equilibrium. With feet
together and arms at the side, close
eyes for 20 seconds. Observe for
swaying. (Refer to textbook, Chapters
16 and 26).
Analysis of Data
1. Formulate nursing diagnoses
(wellness, sick, actual).
2. Formulate collaborative problems
3. Make necessary referrals.
 ASSESSING MOUTH, THROAT, NOSE AND SINUSES

Physical Assessment Guide to Collect Objective Client Data

Question Findings
Mouth
1. Note any distinctive odor
2. Inspect and palpate lips, buccal
mucosa, gums, and tongue for color
variations (pallor, redness, white
patches, and bluish hue), moisture,
tissue consistency, or lesions
(induration, roughness, vesicles,
crust, plaques, nodules, ulcers,
cracking, patches, bleeding, Koplik
spots, cancer sores). Stensen and
Wharton ducts.
3. Inspect gums for hyperplasia,
blue-black line.
4. Inspect teeth for number and
shape, color, (white, brown, yellow,
chalky white areas), occlusion.
5. Inspect and palpate tongue for
color, texture, and consistency
(black, hairy, white patches, smooth,
reddish, shiny without papillae),
moisture, and size (enlarge or very
small).
Throat
1. Inspect the throat for color,
consistency, torus palatinus, and
uvula (singular).
2. Inspect the tonsils for color and
consistency, grading scale
(1+2+3+4+).
Nose
1. Inspect and palpate the external
nose for color, shape, consistency,
tenderness and patency of airflow.
2. Inspect the internal nose for color,
swelling, exudate, bleeding, ulcers,
perforated septum, or polyps.
Sinuses
1. Palpate the sinuses for tenderness
2. Percuss and transilluminate the
sinuses for air versus fluid or pus.
Analysis of Data
1. Formulate nursing diagnoses
(wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.
 ASSESSING THORAX AND LUNGS

Physical Assessment Guide to Collect Objective Client data

Question Findings
Current Symptoms
1. Gather equipment (gown, and
drape, gloves, stethoscope, exam
light, mask, skin marker, metric
ruler).
2. Explain the procedure to client
3. Ask the client to put on a gown.
Posterior Thorax
1. Inspect for shape and
configuration of the chest wall and
position of scapulae.
2. Inspect for use of accessory
muscles.
3. Inspect the client’s positioning
noting posture and ability to support
weight while breathing.
4. Palpate for tenderness and
sensation with gloved fingers.
5. Palpate for surface characteristics
such as lesions or masses with gloved
fingers.
6. Palpate for fremitus, using the ball
or ulnar edge of one hand while the
client says ninety-nine. Assess for
symmetry and intensity of vibration.
7. Palpate for chest expansion. Place
hands on the posterior chest wall
with your thumbs at the level of T9 or
T10, and observe the movement of
your thumbs as the client takes a
deep breath.
8. Percuss for tone, starting at the
apices above the scapulae and across
the tops of both shoulders,
9. Percuss intercostal spaces across
and down, comparing sides.
10. Percuss to the lateral aspects at
the bases of the lungs, and compare
sides.
11. Percuss for diaphragmatic
excursion, using the procedure in
Chapter 18 of the textbook.
12. Auscultate for breath sounds
(normal: bronchial, bronchovesicular,
and vesicular), noting location.
13. Auscultate for adventitious
sounds (crackles, fine or coarse,
pleural friction rub, wheeze, sibilant,
or sonorous).
14. Auscultate for voice sounds over
the chest wall: Bronchophony –ask
the client to repeat the phrase ninety-
nine egophony – ask the client to
repeat the letter E whispered
pectoriloquy- ask the client to
whisper the phrase one-two-three.

Anterior Thorax
1. Inspect for shape and
configuration to determine the ratio
of anteroposterior diameter diameter
to transverse diameter (normally 1.2).
2. Inspect for position of sternum
from anterior and lateral viewpoints
3. Inspect for slope of the ribs from
anterior and lateral viewpoints.
4. Inspect for quality and pattern of
respiration, noting breathing
characteristics, rate, rhythm, and
depth.
5. Inspect intercostal spaces while
client breathes normally.
6. Inspect for use of accessory
muscles.
7. Palpate for tenderness and
sensation, using fingers.
8. Palpate surface characteristic such
as lesions or masses, using fingers of
gloved hand.
9. Palpate for fremitus while the
client says ninety-nine
10. Palpate for chest expansion by
placing hands on anterolateral wall
with the thumbs along the costal
margins and pointing toward the
xiphoid process. Observe the
movement of the thumbs as the client
takes a deep breath.
11. Percuss for tone above the
clavicles and then the intercostal
spaces across and down, comparing
sides.
12. Auscultate for breath sounds,
adventitious sounds, and voice
sounds.
Analysis of Data
1. Formulate nursing diagnoses
(wellness, risk, actual).
2. Formulate collaborative problems
3. Make necessary referrals.
 ASSESSING ABDOMEN

Physical Assessment Guide to Collect Objective Client Data

Question Findings
Current Symptoms
1. Gather equipment (pillow/ towel,
centimeter, rules, stethoscope,
marking pen).
2. Explain the procedure to client
3. Ask the client to put on a gown
Abdomen
1. Inspect the skin, noting color,
vascularity, striae, scars, and lesions
(wear gloves or inspect lesions).
2. Inspect the umbilicus, noting
color, location and contour
3. Inspect the contour of the
abdomen
4. Inspect the symmetry of the
abdomen
5. Inspect abdominal movement,
noting respiratory movement, aortic
pulsations, and / or peristaltic
waves.
6. Auscultate for bowel sounds,
noting intensity, pitch, and
frequency.
7. Auscultate for vascular sounds
and friction rubs.
8. Percuss the abdomen for tone
9. Percuss the liver
10. Percuss the spleen
11. Perform blunt percussion on the
liver and the kidneys
12. Perform light palpation, noting
tenderness or guarding in all
quadrants.
13. Perform deep palpation, noting
tenderness or masses in all
quadrants.
14. Palpate the umbilicus
15. Palpate the aorta
16. Palpate the liver, noting
consistency and tenderness.
17. Palpate the spleen, noting.
consistency and tenderness
18. Palpate the kidney
19. Palpate the urinary bladder
[Link] the test for shifting
dullness
21. Perform the fluid wave test
22. Perform the ballottement test.
23. Perform the test for appendicitis
Rebound tenderness
Rovsing sign
Referred rebound tenderness
Obturator sign
Hypersensitivity test
24 Perform the test for cholecytitis
(Murphy sign)
Analysis of Data
1. Formulate nursing diagnoses
(wellness, risk, actual)
2. Formulate collaboration problems
3. Make necessary referrals