Health assessment and head to toe examination for 1st year Bsc nursing students.

1. HEALTH ASSESSMENT
Presented By,
Amrutha Nayaka,
3rd Year BSc nursing,
Kidwai College of Nursing,
Bangalore.

2. HEALTH:
According to WHO,
Health is “a state of complete physical, mental,
social, spiritual well- being, and not merely absence of disease
or infirmity”.
ASSESSMENT = MEASUREMENT
(Health assessment is the collection of data about
client’s health status.)

3. Introduction:
Assessment is a key component of nursing
practice, required for planning and provision of
patient and family- centered care.

4. Purpose of Assessment:
 To collect data about physical, mental and social well
being of client.
 To get clear picture of the client’s health status and
health related problems.
 To determine the cause and extent of disease.
 To determine the nature of treatment required for
client.
 To collect data systematically.
 To get holistic (complete) view of the client.
 To formulate appropriate nursing care plan.

5. Process of Assessment:
Health
History
Physical
Examination
Health Assessment

6. Health history is the collection of
data regarding client’s health in a
chronological order.

7. COMPONENTS OF HEALTH HISTORY:
1. Biographical Information/ Base line data
2. Chief complaints
3. Present health history
4. Past health history
5. Family history
6. Personal history
7. Environmental history
8. Socio economic history
9. Psychological history

8. 1. Biographical Information/ Base line
data
This includes information regarding
• client’s name/patient name
• Age
• Gender/sex
• Address
• Hospital number
• Marital status
• Education
• Occupation
• Date of Admission
• Diagnosis

9. 2. Chief complaints
• Condition that brought client to
healthcare facility;
• Reason for visit,
• Any recent changes.

10. 3. Present health history
Present health history is the expansion of chief complaints. It should
include
Onset of the problem, clinical manifestations, including severity of
symptoms, pain, etc..
E.g.: Client is admitted to the hospital with the complains of cough with
mucus secretion since 2 weeks,
cough increases during night and decreases with rest,
on and off fever since yesterday and
headache at forehead since today .

11. 4. Past health history
It is the information about client’s previous experience
with any disease or surgery.
This health history includes the detail of
• Childhood illness
• Adult illness
• Psychiatric illness
• Injuries, burns, fractures etc.
• Hospitalization
• Surgical & diagnostic procedures
• Current medication
• Allergies

12. 5. Family history
This is the information is about,
• type of the family,
• number of members in the family, and
• their health status.
FAMILY TREE
• This is the diagrammatic representation of family members.
• Three generation has to be denotes in the family tree,
• Family tree is also known as genogram.

16. 6. Personal
history
It includes client’s personal details such as
• Dietary pattern
• Sleep pattern
• Elimination pattern
• Habits
• Bathing pattern
• Etc.

17. 7. Environmental history
It includes client’s environmental details such as,
• Type of the house
• Number of rooms
• Ventilation
• Water supply
• Power supply
• House drainage system

18. 8. Socio economic history
It includes collecting data regarding client’s
• Life style
• Which class they belong
• What is the monthly or annual income of
the family

19. 9. Psychological
history
Here, We have to see whether client is
co-operative with her/his
• Family
• Relatives
• Neighbors
• Friends

21. Introduction
A comprehensive head-to-toe assessment is
done on patient admission. The head-to-toe
assessment includes all the body systems, and the
findings will inform the health care professional on
the patient’s overall condition.

22. DEFINITION:
It is the systematic collection of
objective information that is directly
observed or is elicited through
examination techniques.

23. PURPOSES
• To understand the physical and mental well
being of the patient.
• To detect diseases in early stages
• To determine the cause of disease
• To understand any changes in the condition
of diseases, any improvement or
deterioration.

24. METHODS:
1)Inspection
2)Palpation
3)Percussion
4)Auscultation

25. 1.INSPECTION
 Visual examination of the body is called inspection.
 It is the observation with the naked eyes to determine the
structure and functions of the body.
 Observe the client while facing him or her in the bed or chair.
 Observe the client’s skin color and texture.
 Look at overall body structure.
 Note all parts of the body as the examination proceeds.
 Inspection also evaluates verbal and behavioral responses and
mental status.

26. 2. PALPATION
 It is the feeling of the body with the hands, to note the size and
positions of the organs.
 In palpation, the finger pads and not the finger tips are used.
 Obtain information by using the hands and fingers to palpate.
 A light or deep palpation depends on the area being palpate.
 The palmar surface of fingers and finger pads are used to determine position
of the organs, size and consistency, fluid accumulation, pain and masses.
 The ulnar surface of the hand is used to distinguish vibration and
temperature.
 The moisture and warmth of the skin can also be determined during
palpation.

28. 3. Percussion
 It is the examination, by tapping with the fingers
on the body to determine the condition of the
internal organs, by the sounds that are produced.
 It is done by placing a finger of the left hand firmly
against a part to be examined and tapping with the
finger tips of the right hand.
 Produces sound waves by using the fingers as a
hammer.

30. 4. Auscultation
 It is the listening to sound within the body with aid of a
stethoscope, fetoscope or directly with the ear placed
on the body.
 Place the stethoscope on the client’s bare skin to
listen for the presence and characteristics of sound
waves.
 The bell of the stethoscope is used to detect low pitch
sounds, The diaphragm detects high pitched sounds.

32. HEAD-TO-EXAMINATION
The examination is carried out in an orderly
manner focusing upon one area of the body at
a time.
The observation of the patient starts as the
patient walks into the examination room.

33. EQUIPMENT REQURIED WHILE HEAD-TO-TOE EXAMINATION

34. Sphygmomanometer

35. Stethoscope

36. Fetoscope

37. TPR Tray

38. Tongue depressor

39. Laryngoscope

40. Tape measure

41. Weighing machine

42. Ophthalmoscope

43. Otoscope

44. Tuning fork

45. Nasal speculum

46. Percussion hammer

47. Cotton wool

48. Vaginal speculum

49. Protoscope

50. Gloves

51. Snellen alphabet chart

52. General Appearance:
• Nourishment: well-nourished / undernourished
• Body build: thin / obese
• Health: healthy / unhealthy
• Activity: Active / dull(tired)
Vital Signs
• Temperature
• Pulse
• Respiration
• Blood pressure
 Height
 Weight

53. Skin Conditions
• Color: Pallor/jaundice/cyanosis/flushing. etc.
• Texture: dryness/wrinkling/excessive moisture
• Temperature: Warm/cold/clammy
• Lesions: papules/wounds, etc.
Head and Face
• Shape of the skull and fontanel
• Skull circumference
• Scalp : Cleanliness/ condition of the hair /dandruff/ infections
like ringworm
• Face: Pale/ fatigue/ pain /fear / anxiety / enlargement of
parotid glands, etc.

54. Eyes
• Eye brows: normal / absent
• Eye lashes: infection / sty
• Eye lids: Oedema / lesions
• Eye balls: Sunken / protruded
• Sclera: Jaundiced
• Pupils: Dilated/ constricted reaction to light
• Lens: Opaque / transparent
• Eye muscles: Strabismus[squint]
• Vision: Normal / myopia /hypermetropia.

56. Ears
• External ear: discharge
• Tympanic membrane: Perforations / lesions / bulging
• Hearing : Hearing acuity
Nose
• External nares: Crusts / discharges
• Nostrils : Inflammation of the mucus membrane / septal
deviations

57. Mouth and Pharynx
• Lips: Redness / swelling / cyanosis
• Odor of the mouth: foul smelling
• Teeth: Discoloration and dental caries
• Mucus membrane & gums: Ulceration & bleeding /
swelling / pus formation
• Tongue: pale / dry / lesions / tongue tie / sords
• Throat and pharynx : Enlarged tonsils / redness / pus

58. Neck
• Lymph nodes: enlarged / palpable
• Thyroid gland: enlarged
• Range of motion: Flexion / extension / rotation
Chest
• Thorax: shape / symmetry of expansion / posture
• Breathe sounds: sigh / swish / rustle / wheezing / rales /
pleural rub, etc.
• Heart : Size and location / cardiac murmurs

59. Abdomen
• Observation(Inspection): Skin rashes / scars /
pregnancy, etc.
• Palpation: Liver margin / palpable spleen /
tenderness at the urea of appendix
• Percussion: Presence of gas / fluid / masses
• Auscultation: bowel sounds / fetal heart sounds

60. Genital and Rectum
Male
• Descent of the testes
• Presence of sexually transmitted diseases
• Hemorrhoids
• Enlargement of the prostate gland
Female
• Vaginal discharges
• Presence of STD’s
• Hemorrhoids
• Pelvic masses

61. Extremities
• Movement of joints / tremors / clumbing of fingers /
Ankle edema / reflexes, etc.