Health Assessment and Physical
Examination
Purpose of Health assessment and physical exam - Answers -Triage for emergency
care
Routine screening to promote health and wellness
To determine eligibility, i.e. for insurance
To admit a patient to a hospital or long-term care facility
Gather baseline data
Support or refute subjective data obtained from the patient
Identify and confirm nursing diagnoses
Make clinical decisions about a patient's changing health status and management
Evaluate the outcomes of care
Formal definition of Health Assessment - Answers -an organized systematic process of
collecting objective and subjective data based upon a health history and head-to-toe
systems examination.
In regards to cultural sensitivity, what should we consider and/or avoid doing? -
Answers --Consider health beliefs, use of alternative therapies, nutritional habits,
relationships with family, and personal comfort zone.
-Avoid stereotyping.
-Avoid gender bias.
-Avoid bias period.
Obtaining Health history using PQRST - Answers -P-Provication (What caused it, what
it makes it better/worse?
Q- Quality (sharp, dull, shooting, pressure, pain?)
R- Radiates (location? Movement?
S- Severity ( scale of 1-10)
T- Time (duration; how long has it been going on for? Constant, intermittent?)
Name the two types of data collection - Answers -subjective data and objective data
subjective data - Answers -Cannot observe directly and is obtained from patient
objective data - Answers -what you observe directly and your findings
Preparation for examination includes: - Answers -Safety, infection control, environment,
equipment, physical preparation of patient (positioning, gown/drapes), psychological
preparation of patient, and assessment of age group.
, Techniques of Physical Assessment - Answers -Inspection, palpation, percussion, and
auscultation
Inspection - Answers -general observation of the patient as a whole, progressing to
specific body areas. Inspect each area for size, shape, color, symmetry, position, and
abnormality. Validate findings with patient (is this typical?)
-sight, smell, listen
Auscultation - Answers -Listening with a stethoscope. Learn normal sounds first before
identifying abnormal sounds or variations. Requires concentration and practice.
Palpation - Answers -to examine by touch; light and deep palpation, emotional
component. Parts of hand to detect different characteristics
percussion - Answers -tapping on a surface to determine the difference in the density of
the underlying structure. Sound determines location, size, and density of structures.
Percussion Tones - Answers -Flatness- muscle
Dullness- liver/spleen
Resonance- Lungs
Tympany- stomach
Systematic Physical Assessment includes which systems? - Answers --Neuro
-Respiratory
-Cardiovascular
-Abdomen: GI/GU
-Musculoskeletal
-Integument (drains, Ivs)
In a NEURO check, what are you assessing for? - Answers -- Level of consciousness
(How awake, alert, aware, and responsive are they of their actial surroundings.
-Orientation (Speech, behavior consistent with reality of their environment. Alterations
can be subtle)
- Pupils/ PERRLA (Pupils equal, round, reactive to light, and accommodation. When
looking for accommodation, the muscles of the eye, under normal circumstances,
contract or relax in a response to an item coming closer to or moving father away.
-Muscles strength in extremities(grips, push, pull, paddle)
In a Level of Consciousness (LOC) what are you assessing for? - Answers -Awareness
and understanding of surroundings
-arousal(Alert to comatose)
-Orientation (Time, place, person, and as appropriate the event)
*'Normal" LOC would be alert, orientated to time, person, place, event
A&O X4 - Answers -alert and oriented to person, place, time, and event
Examination
Purpose of Health assessment and physical exam - Answers -Triage for emergency
care
Routine screening to promote health and wellness
To determine eligibility, i.e. for insurance
To admit a patient to a hospital or long-term care facility
Gather baseline data
Support or refute subjective data obtained from the patient
Identify and confirm nursing diagnoses
Make clinical decisions about a patient's changing health status and management
Evaluate the outcomes of care
Formal definition of Health Assessment - Answers -an organized systematic process of
collecting objective and subjective data based upon a health history and head-to-toe
systems examination.
In regards to cultural sensitivity, what should we consider and/or avoid doing? -
Answers --Consider health beliefs, use of alternative therapies, nutritional habits,
relationships with family, and personal comfort zone.
-Avoid stereotyping.
-Avoid gender bias.
-Avoid bias period.
Obtaining Health history using PQRST - Answers -P-Provication (What caused it, what
it makes it better/worse?
Q- Quality (sharp, dull, shooting, pressure, pain?)
R- Radiates (location? Movement?
S- Severity ( scale of 1-10)
T- Time (duration; how long has it been going on for? Constant, intermittent?)
Name the two types of data collection - Answers -subjective data and objective data
subjective data - Answers -Cannot observe directly and is obtained from patient
objective data - Answers -what you observe directly and your findings
Preparation for examination includes: - Answers -Safety, infection control, environment,
equipment, physical preparation of patient (positioning, gown/drapes), psychological
preparation of patient, and assessment of age group.
, Techniques of Physical Assessment - Answers -Inspection, palpation, percussion, and
auscultation
Inspection - Answers -general observation of the patient as a whole, progressing to
specific body areas. Inspect each area for size, shape, color, symmetry, position, and
abnormality. Validate findings with patient (is this typical?)
-sight, smell, listen
Auscultation - Answers -Listening with a stethoscope. Learn normal sounds first before
identifying abnormal sounds or variations. Requires concentration and practice.
Palpation - Answers -to examine by touch; light and deep palpation, emotional
component. Parts of hand to detect different characteristics
percussion - Answers -tapping on a surface to determine the difference in the density of
the underlying structure. Sound determines location, size, and density of structures.
Percussion Tones - Answers -Flatness- muscle
Dullness- liver/spleen
Resonance- Lungs
Tympany- stomach
Systematic Physical Assessment includes which systems? - Answers --Neuro
-Respiratory
-Cardiovascular
-Abdomen: GI/GU
-Musculoskeletal
-Integument (drains, Ivs)
In a NEURO check, what are you assessing for? - Answers -- Level of consciousness
(How awake, alert, aware, and responsive are they of their actial surroundings.
-Orientation (Speech, behavior consistent with reality of their environment. Alterations
can be subtle)
- Pupils/ PERRLA (Pupils equal, round, reactive to light, and accommodation. When
looking for accommodation, the muscles of the eye, under normal circumstances,
contract or relax in a response to an item coming closer to or moving father away.
-Muscles strength in extremities(grips, push, pull, paddle)
In a Level of Consciousness (LOC) what are you assessing for? - Answers -Awareness
and understanding of surroundings
-arousal(Alert to comatose)
-Orientation (Time, place, person, and as appropriate the event)
*'Normal" LOC would be alert, orientated to time, person, place, event
A&O X4 - Answers -alert and oriented to person, place, time, and event
