HEALTH ASSESSMENT

INTRODUCTION:
Nurses work in many settings seeking information about clients health status the nurse
conductor held assessment it health fairs clinics in physician’s office, a client home or in
hospitals health screening focus on a specific physical problem.
If a screening determines that a client has a risk for a disease the client is referred for a more
complete physical examination A complete health assessment involves a health history
involves a long lonely client interviews together subjective data about the clients condition of
physical examination is a head to a review of each body system date offers objective
information about the client In contrast a health screening helps to determine whether a
person has high probability of having a characteristic for a disease (Larson 1986)
An example it is a blood pressure screening the nurses used physical assessment skill during
on examination to make clinical judgement the clients conditions and response a fake to the
extent of the examinations the accuracy of the nurses assessment influences the choice of
therapy continuity of Health care improves when the nurses makes on going objective and
Comprehensive assessment paragraph change physical examination or physical assessment is
an integral part of the nursing assessment it is performed following the health history for
complete health assessment is generally conducted from the head to toy however the
procedure can very in many ways according to the age of the client individual civility of the
illness the preferences of the nurses in the agencies priority and procedures regardless of what
process is used the patient energy and time need to be considered. the health assessment is
there for conducted is systematic and efficient manner that requires the to waste position
change of the patient and evaluation of the health status of an individual by performing a
physical examination obtaining a health history.
Health assessment is a plan of cure that identify the scientific needs of a person and how
these needs will be addressed by the healthcare system or is killed facility the health
assessment is the evaluation of the health status by performing a physical exam after taking a
health history it is done to detect disease in people.
DEFINITION
Health - The condition of being sound in body mind or spirit speciality freedom from
physical disease or pain.
According to who health is a state of complete physical mental and social will be and not
Marely the absence of disease or infirmity.
Assessment - All data and information relevant to the care of patient their problems and
needs"(Taber's)
Health assessment is the first step to determine health status it is gathering of information to
have all the necessary puzzle pieces to make a clear picture of the person health status

1
NURSING ASSESSMENT-
Assessment the most critical step Answer the questions what is happening actual problem or
What could happens (potential problems) Involving collecting organising and analysing
information data about the patient.
Health assessment is the evaluation of health status of an individual along the health contain
Health assessment has been separated by author from physical assessment to include the
focus on health occurring on a container is a fundamental teaching in the Health care industry
it is understood health occurs on a country name so the term used is assessment but maybe
preference by the specialty focus such as nursing physical therapy etc in healthcare the
assessment focus many very by the type of Health care practitioner.
For example -in Emergency room the focus in chief complaint and how to help that person
related to the pursued problem if the problem is a heart attack then the intensity of focus is on
the biological physical problem initially
A health assessment is a plan of care that identifies the specific needs of a person in how
those needs will be addressed by the healthcare system or skilled nursing facility health
assessment is the evaluation of the health status by performing a physician exam after taking
a health history
Health assessment -a health assessment is a plan of care that is identifies the specific needs of
a person in how those needs will be addressed by the health care system of skilled nursing
facility.
Health assessment is the evaluation of the health status by performing a physical exam after
taking a health history.
Nursing assessment -physical assessment requires and organised and systematic approach
using the techniques of inspection palpation percussion and auscultation It also requires a
trusting relationship and report between the nurse the patient to decrease the stress the patient
may have from being physical exposed and vulnerable.
NEEDS OF HEALTH ASSESSMENT IN NURSING
• The patient will be much more legs and cooperative if you expect what will be done
and the reason for doing it.
• While the findings of a nursing assessment do something contribute to the
identification of a medical diagnosis the unique focus of a nursing assessment is on
the patients responses to actual or potential problem.
• It is major component of nursing care.
• it is a process which include both physical and psychological condition aspect to
evaluate clients condition.
BASIC CONCEPTS
Health (WHO) –A state of complete physical mental and social welding north mainly the
options of disease.
Wellness- level of well-being a person pursue of being healthy.

2
Disease -Alteration of structure and functional of body disease and discomfort
Illness - It is response to a disease and sickness it is the individual perception

PURPOSE OF HEALTH ASSESSMENT

➢ To evaluate the clients current physical condition.
➢ To identify early sign of developing health problems.
➢ To established a best friend for future comparisons.
➢ To evaluate the clients responses to medical and nursing interventions.

COMPONENT OF A HEALTH ASSESSMENT

Health history - focus on interviewing skill
Physical examination - head toy sequence or system sequence

TYPES OF HEALTH ASSESSMENT

• There are four type of health assessment-
• Initial assessment
• Focus assessment
• Emergency assessment
• Time lapsed assessment or on-going assessment
INITIAL ASSESSMENT - Initial assessment also called admission assessment it performed
when the client inter a Health care from a Health care agency the purpose of evaluate the
climate health status to identify functional health pattern in depth comprehensive database
which is critical for evaluation
PROBLEM FOCUS ASSESSMENT - A problem focus assessment collected data about a
problem that his already been identified this type of assessment is a narrow scope and a sorter
time frame then the initial assessment in focus assessment nurse determine whether the
problem still exist and weather the status of problem has changed that is improved words
need dissolved this assist in include arisal of any new overlooked or nursing diagnosed
problem in intensive care limit may perform focus assessment every few minute.
EMERGENCY ASSESSMENT - Emergency assessment take place in live straightening
situation in which the preservation of life is the top priority times of the enhance rapid
identification of and intervention for the client health problems of often the client difficulties
involve airway breathing in circulatory problems the abrupt changes in self-concept or rules
of relationship social conflict leading to violence act can also initial and emergency
emergency assessment focuses on few initial health pattern and is not comprehensive.
TIME LEFT ASSESSMENT OR ON-GOING ASSESSMENT - it is another type of
assessment take place after the initial assessment to evaluate changes in the client functional
health nurses perform time lips re assessment when substantial periods of time have lapsed
the between assessment.

3
Example - periodic output patient clinic visits home health visits health and development
screenings.
NURSING HISTORY
• Systematic collection of subjective data and objective data used to determine a client
functional health pattern status.
• The nurse collector physiological socio cultural development and spiritual client data
this data is the nurse in identifying nursing diagnosis and collaborative problems
GUIDELINES FOR TAKING THE NURSING HEALTH HISTORY-
• Establish privacy comfortable and quite environment.
• Allow the client to state problems and expectations for the interview.
• Provide the client with an orientation to the structure purposes and expectations of the
health.
• Communicate and negotiate priorities with the client.
• Listen more than you talk.
• Observer nonverbal communication example body language.
• If the client encountered past health history with any health members review
information before starting interview.
• Make a judgement about the balance between allowing a client to talk in and
unstructured manner and the need to structure requested information.
• Clarify the client definitions of all key terms and description.
• Keep notes adequate enough for future recording.
• Record the nursing health history as soon as possible after the interview.
TYPES OF NURSING HEALTH HISTORY
A complete health history- This is taken on initial visits to health care facilities.
An interview health history-Used to collect information in visits following the one in which
the data base collect.
A problem-focused health history- used to collect data about a specific problem, systems or
region.
• Client must be able to provide information however, it is usually not possible the
entire health history during the interview.
• Record as much of the health history during interview as possible and the reminder
soon after the interview.
• The nurse should take notes during the data collection. the nurse must probe clarify
and quality in structured ways.

COMPONENT OF HEALTH HISTORY

Biographic data-the information gathered health history.
• Client full name

4
 • Address and telephone no.
• Sex and race.
• Religion.
• Marital status.
• Occupation (usual and current)
• Source of referral.
• Usual source of health care
• Data of interview
Client complains- The chief complain statement is a short subject statement in the client own
words indicates the client’s purpose for requesting health care at this time.
Example-
• Chest pain for 3 days
• Swollen ankles for 2 weeks
• Fever and health care for 24 hours
HISTORY OF PRESENT ILLNESS
• Gathering information relevant to the chief complain
• Onset of clients problem
• Self-medical treatment
COMPONENT OF PRESENT ILLNES
1. Introduction, client’s summary and usual health.
2. Investigation of symptoms onset data, gradual or sudden, duration, precipitating factors
frequency, location, quality and alleviating or aggravating factors.
3. Negative or positive finding related to chief complain.
4. Relevant family information.
5. Disability system affected the client’s total life.
PAST HEALTH HISTORY
• The purpose of the past history is to identify all major past the health problems-
• Childhood illness example history of rheumatic fever history of accident and
disabling
• history of hospitalisation history of operation how and why is done
• history of immunization and allergies
• physical examinations and diagnostic studies
• supportive devices cane catheter Walker
FAMILY HISTORY
• Family history of communicable disease
• Hereditary factor
• Strong family history of certain problems
• Cause of death of family member

5
CURRENT HEALTH INFORMATION
• Allergy environment indigestion drug other habits alcohol tobacco drug caffein
• medication taken regularly by doctor or self-prescription
• Exercise pattern
• Sleep pattern
• The patient of sedentary and active activities in the clients usual routine.
PSYCHOSOGICAL HISTORY
How client and his family or stress the nurse can a seas if there is psychosociological or
social problem and if it affect the general Health of the client.

PHYSICAL EXAMINATION
An examination should be designed for the client’s needs if a client is actually ill the nurse is
only the involved body system a more comprehensive examination is conducted when the
client feels more it is end the nurse then learn about the clients total health status.
A complete physical examination is performed for routine securing to promote wellness
behaviours and preventive healthcare measures to determine eligibility for health assurance
military service or new job and to admit a client to a hospital setting or long term care
facility.
The nurse use physical examination to -
Gather a data base-the nurse initially gathered through detailed information about the client
status from the clients health history one assessment finding usually cannot conclusively will
the nature of an abnormality a complete assessment is needed for definitive diagnosis.
APPLICATION OF HEALTH ASSESSMENT DATA IN NURSING DIAGNOSIS

ASSESSMENT FINDINGS PATTERNS NURSING

METHOD DIAGNOSIS
Inspection of skin • Skin along sacral Pressure area around
area intact coccyx
• 3cm area of skin
redness
• No skin lesion
observes.
Palpitation of skin • Tenderness Skin moisture High risk for
around sacral area promotes impaired skin
on palpation maceration. integrity
• Skin moist from
diaphoresis
• Good skin turgor
Hysterical data • Clint suffered Continued pressure
fractured left leg exerted over sacrum

6
 • Immobilized due
to left leg traction
• Diet history
reveals normal
caloric and
nutrient intact

2) Developing nursing diagnosis and a care plan-

The accuracy of the database allows the nurse to develop individualised nursing diagnosis
physical examination findings help determine diagnosis so the nurse can select the correct
type of interventions.
3) Managing client problems
When caring for clients the nuts makes many observations in performs many therapies at the
nurses success in giving care depends on the ability to recognise change in the status.
4) Evaluating Nursing care
Nurses become a countable by evaluating the result of nursing interventions physical
assessment skill enhance evaluation of nursing measures through monitoring psychological
and behavioural outcomes.
SKILLS OF PHYSICAL ASSESSMENT
• Inspection
• Palpation
• Percussion
• Auscultation
• Olfaction
1. INSPECTION - Inspection is the use of vision hearing and smell to detect normal
characteristic or significant physical sign of the body parts and function it help to
know normal physical characteristics before trying to distinguish abnormal
finding.
PRINCIPLES OF INSPECTION
• Good lightning and exposure r essential
• to inspect each area for size same colour symmetry and position and compare with the
opposite side of the body look for presence of abnormalities
• Use additional light example a pen light to inspector board activities
• Inspection is considered a visual skill but should include all fiction since the sense of
smell can sometimes direct abnormalities that may not be seen
• To confirm the assessment if you are unsure about an order

2. PALPATION -Further assessment of body part is made through pulp and which
use the hands to touch body parts in order to make sensitive measurement of
specific physical sign.

7
 3. PERCUSSION- It is speaking the body surface with a finger to produce a
vibration that travels through body tissues the character of sound determines the
location size and density of underlying structure to verify abnormality.

TYPES OF PERCUSSION
• Direct percussion - In this type the nurses streaks the areas to be percussed directly
with the pets of two three or four fingers or with the pets of the middle finger the
strike are rapid in the moment is from the wrist technique is not generally used to
purchase the thorax but is useful in purchasing in adult sinuses.

• Indirect percussion - It is the streaking of an object example hold against the body
area to be examine this takening is generally use to purchase the thorax.

4. AUSCULTATION - It is the process of listening the sound produced within the body.
TYPES OF ASCULTATION
• Director Auscultation-It is done by the use of the unaided ear. example to listen to a
respiration wheeze or a moving joint.
• Indirect auscultation-It is done by the use of stethoscope which amplifies the sound
converse than to the nurse of is used primarily to listen to sound from within the body
Example - Heart beats and bowel sound.
5.OLFACTION -Action is the sense of smell certain alteration in the body function create
characteristic body the sense of smell can detect abnormities date go and recognised by any
other means.
Example of Odor

ODOR SITE OR SOURCE POTENTIAL SOURCE

Ammonia Urine UTI
Halitosis Oral cavity Poor dental hygiene
Alcohol Oral cavity Injection of alcohol
Sweet fruity Oral cavity Diabetic acidosis

PREPARATIONS FOR EXAMINATION

A disorganized approach when preparing for a physical examination can cause error and
incomplete findings proper preparation for the environment equipment and client insure a
smooth examination with few interruptions
PREPARING THE ENVIRONMENT
To promote the patient comfort and ensure and efficient examination .The examination room
should have be following features

8
 • Physical examination require privacy
• A well occupied examination room is preferable
• Adequate lightening is needed to illumination body parts
• The eliminate source of noise takes precaution to prevent interruption from her.
• Curtain or dividers to enclose the patients bed. proper examination for the patient of
warm comfortable temperature.
PREPARING EQUIPMENT
Hand washing is done before equipment preparation and the examination. There may be
needed for specific instrument

EQUIPMENT FUNCTION
In continent Seat protect the bed linen from getting soiled
Drapes NCR privacy for the
Forms Document pertinent information
Gloves Prevent cross infection
Gown For easy assist of different body parts
Paper towel dry hand and arms
Percussion hammer test various reflex of the body
Height/weight scale measure body weight and height of the client
Specimen container collect sample
Sphygmomanometer measure blood pressure
Stethoscope assaulted different body sound
Measuring tape measure head circumference just circumference
Tongue depressor facilities visualising pharynx
Wrist watch record time of examination
Eye chart test visual acuity
Ophthalmoscope examine fundus of the eye
Tuning fork Test hearing acuity
Vaginal speculum for vaginal examination

PREPAIRING THE PATIENT

1.Physical preparation:- the clients physical comfort is vital for successful examination
before starting the nurse ask if the client need to use the toilet and empty bladder and bowel
examination of the abdominal genital and rectum. Physical preparation involves bring sure
the client draped and dressed properly the client in the hospital will likely be wearing a
simple gown.

9
POSITION PICTURE AREA ASSESSED
Sitting Head and neck big
posterior thorax and lungs
interior thorax breast axilla
hot vital sign and upper
extremities.

Supine Head and neck interior

thorax and lungs breast
axilla heart abdomen e
pulses

Dorsal recumbent Head and neck interior

thorax and lungs breast
axilla heart abdomen e
pulses

Lithotomy Lithotomy- female

genitalia and genital tract

Sims Rectum and vagina

Prone Back musculoskeletal

Lateral Heart

10
Knee chest Rectum

2. Vital Sign -Most nurses prefer measuring vital sign before physical examination because
positioning or moving the client interfere with obtaining accurate values.
3. Height and Weight- A person general level of health can be reflected by his or her height
and weight is routine measures during health screening and visit to physicians officers or
clinics.
4. Integument- The intimate consists of the skin nail hair and scalp provides the body
external protection.
5. Skin :- The skin is a window for the nurse to detect a variety of conditions affecting the
client changes in oxidation circulation nutrition local tissue damage.
A simple ABCD rule (Americal Concer society1993)
A. Is for asymmetry
B. Is for border irregularity, edges are ragged.
C. Is for colour.
D. Diameter.

6. Moisture:- Moisture the hydration of skin and mucus membrane helps to reveal. Body
fluid imbalance, changes in the environment, a regulation body temperature. Moisture
refers to wetness and oiliness skin force such as axilla is normally moist.
7. Temperature:-The temperature of the skin depend on the amount of blood circulation
through the determine increased or decreased skin temperature. It is good to remember
that if an examination room is called the clients skin temperature and colour can be
affected.
8. Texture- The character of skin surface and the feel of deeper portions are its texture, the
nurses determines if the clients skin is smooth or rough thin or thick tight or supply by
stroking it lightly with the fingertips.
9. Turgor- Is the skin elasticity which can be diminished by edema or dehydration normally
the skin loses the elasticity with age.
10. Vascularity- Vascularity circulation of the skin affects colour in localized areas and the
appearance of superficial blood vessels with aging capillaries become fragile petechial
may indicate serious blood clotting disorders drug, reaction or liver disease.
11. Edema- Area of the skin becomes swollen or oedematous from fluid build-up in the
tissues direct trauma and impairment of Venus return or two common causes for edema.
The nurse inspects the oedematous area for location, colour and shape. The formation of
edema separates the skin surface from the pigmented and vascular layer.
12. Lesions- the skin is normally free of lesion except common frical or age related changes
such as scheme turgor or senile keratosis.
11
HAIR AND SCALP- Following types of hair cover in body terminal hair values hair, nurses
assess the distribution, thickness texture and lubrication of hair.
NAIL
• Health History- before assessing nail nurses ask the client has had any recent trauma.
• Abnormalities of nail bed- Approximately 160 degree angle between nail plate and
nail
• Clubbing- change in angle between nail and nail base
• Beau’s lines- transverse depression in nails indicating temporary disturbance in nail
growth.
• Chronic lack of oxygen- heart or pulmonary disease.

HEAD AND NECK

Health History- The history allow the nurse to determine a client risk of intracranial
injury the nurse ask client that you have any recent trauma to head or if neurological
examination symptoms such as headache dizziness, seizure.

EYE
Visual acuity
Assessment of visible acuity the ability to see small detail test Central vision the nurse
should assist to ask the client to read printed material under a adequate lightning seat
or stand client up to 20 feet away from chart. If client enable to read nurse uses e-
chart for one picture of family object in street of reading later line tell the nurse which
direction of each E is pointing or the name of object.
Visual field
A person look straight ahead all object in the peripheries in normally be seen to assess
the clients stand or seed to feet 7 cm away facing the nurse at high level. The client
gently close or on one eye and neck it the nurse eye directly opposite the nurse close
the opposite I so that the field of vision is super imposed on that of client.
The client gently close or one eye and neck at the nurse eye directly opposite the
nurse close the opposite eyes so that the field of vision is super imposed on that of
client.
Extra ocular moment
six small muscles guide the moment of each eye both I move parallel to each other in
each direction of gauge the client 2 feet away facing the nurse the nurse hold a finger
it a comfortable distance 6 to 12 in inch or 5 to 30 cm in front of client eye.

EYE BROWS
The nurse inspect eyebrows for size intention hair texture the Bros suit race and lower
symmetrically in ability to move eyebrows may indicate facial nervous paralysis. The test
accommodation the client is ask her to gas it or distance object then it taste object held by the

12
nurse approximately 10 cm 4 inches from the bridge of client nose if assessment of pupillary
reaction in normal in all test the nurse record the abbreviation P E R R L A (Pupil equal
round reactive to light and accommodation)
Eyelids The nurse inspects eyelids for position colour condition of surface condition and
direction of laces and ability to close and blink and abnormal draping of lead over the pupil is
called ptosis.
Lacrimal apparatus: This condition, common in unconscious patient or these with facial
nerve paralysis the nurse look evidence of assess tearing or oedema in the inner canthus.
Conjunctive and sclera: It covered the expose surface of eyebrows and full up to the outer
age of the cornea if foreign body appear to be emended in the eye the nurse must isn't attend
to remove it.
Cornea: the cornea is the time transparent colourless portion of the eye covering the pupil
and iris it look like the crystal of wrist watch and irregularly in the surface may indicate and
pupil and iris: The nurse observe the cube pills for size save equality accommodation and
reaction to light the people may be normal break ground regular and equal in size (3-7 mm in
diameter).The test accommodation the client is ask her to gas it or distance object then it taste
object held by the nurse approximately 10 cm 4 inches from the bridge of client nose if
assessment of pupillary reaction in normal in all test the nurse record the abbreviation P E R
R L A (Pupil equal round reactive to light and accommodation)
EAR
Health history- it include review of risk for hearing problem history of year surgery trauma
and the client current impose to high level
Auricles-when the nurse assess client to sitting the nurse inspect auricles position, colour
shape size and symmetry the nurse palpate auricle for texture tenderness swelling in nodules.
Ear canal & ear drum- the deep structure of internal and middle year can be observed only
with the use of an otoscope
Hearing acuity -the nurse often tell if client has hearing loss from response to conversation.
NOSE AND SINUSES
Health history- In assessment for a history of nose bleed epistaxis the nurse also ask if the
client has been he or she nots or has difficulty breathing.
Nose-When inspection the external knows the nurse observe for shape size skin colour and
presence of deformity or inflammation the septum is inspected for alignment perforation or
bleeding normally the septum is close to midline thicker interiorly then posteriorly.
Sinuses - the examination of the sinuses is limited to pulp patient in case of allergies or
inspection the interior of the sinus become inflamed and swollen.

13
MOUTH AND PHARYNX
The nurse assist the mouth and fearing to detect sign of overall health determine oral hygiene
needs and developed nursing therapy for client with dehydration restricted intake oral trauma
or oral airway obstruction.
History of mouth- The nurse determine of the client wears dangers or written and if they
comfortable feet the nuts also assist to the history of pain or reason of the mouth and pen with
saving it can be helpful to know if the client is a history of tonsillectomy.
Lips- The lips are inspected for colour texture hydration counter and lesson is the client open
the mouth the nurse views the leaves from end to end normally the lips are pink moist
cementrical and smooth with the surface free from reasons.
Mucosa-to view the inner oral the nurse is the client open the mouth slightly and gently fell
the lower lips away from the teeth the nurse pulpits for any buccal by placing the index finger
within the buckle cavity and the thumb on the outer surface of the cheek.
Gums and teeth-The equally of the climb dental hygiene is easily determined by inspecting
the teeth to examine posterior surface for the tooth the nurse his say the client open the mouth
with lips related.
Tongue and flow of mouth-the tongue is carefully inspected all site in the floor of the mouth
is checked the upper surface of tongue and flow of the mouth is highly vascular
Pharynx-examination of the pharyngeal structure is performed to rule out infection,
inflammation or lesion when a penlight the nurse first inspect the uvula and soft palate a
client with typical sour throat has redness and oedematous uvula and tonsillar pillars with
possible yellow exudate.

NECK
It includes assessing make muscles lymph nodes of the head carotid arteries jugular veins
thyroid glands and trachea and abnormality of superficial link not may reveals the presence of
infection.
History-The nurse determine death if the client has not a recent cold or infection or field
week or fatigue.
Neck muscles-With the client setting and facing the nerve and inspection of grass snake
structure is made.
Lymph nodes- An extensive system of lymph not collect the limb for from the head ears
nose, cheeks and lips.
Thyroid gland- It lies in the interior lower neck in front of end to both side of the trachea the
gland is fixed to the trachea with the isthmus over laying the trachea and connecting the
hundred irregular cane shaped lobes.

14
TRACHEA
It is the part of upper airway that can be direct pulpited it is normally located in the midline
above the Supra external nose the position of trachea is determined by palping at the Supra
external notch.
THORAX & LUNGS
Physical assessment of thorax and lungs in chest and in the look at ventilating and respiratory
function of the lungs before assisting throat and lungs the nose must be familiar with chest
landmarks.
Posterior thorax-The examination begin with observing for any sign or symptoms in other
body system that may indicate pulmonary problems during speech the sound created by vocal
cords is transmitted through the lungs to the chest wall this vibration are called tactile or
vocal permits.
Lateral thorax-the client seat during the lateral chest examination usually the nurse extend
the assessment of posterior thorax to the lateral side of the chest.
Anterior thorax- It is the inspected from same features is posterior thorax the seat or lies
down with head elevated.
HEART
Assessment of heart functioning is closely compared with findings from the vascular
examination the nurse forms a mental image of heart exact location. In adult the heart is
located in the centre of chest precordium behind and to the left of sternum.
An infant heart is positional more horizontally. The apex of heart is at the 3rd or 4th intercostal
space just to the left of midclaviculors.
Vascular system-examination of the vascular system includes measuring the blood pressure
and assessing the integrity of peripheral vascular system.
Carotid arteries-When left ventricle pumps blood goes in to the aorta blood goes into the
aorta pressure waves are transmitted throughout the arterial system. The carotid artery supply
oxygenated blood to the head and neck and it protect by the overlying steno cleidomastoideus
muscle.
Jugular vein-The most accessible veins are the internal and external jugular vein in the neck
both vein drain bilaterally from the head and neck in to the superior vena cava.
Peripheral arteries-It involve palpation over arteries that are close to the body surface and
lies over bone the nurse examine each peripheral arteries using the distal pad of the second
and third fingers.
The strength of pulse in measure by force is which blood is injected against the arterial wall.

0 Absent not palpable

1+ Pulse is diminished, barely palpable.
2+ Easily palpable, normal pulse

15
 3+ Full increased pulse
4+ Bounding can't be obliterated.

Sympathetic system: The legs are drained by superficial and deep lymph nodes but only two
groups of facial nodes are palpable.
Breast: It is important the breast of female and male client. a small amount of glandular
tissue a potential site for the growth of cancer cells.
Female breast: breast cancer is the second leading cause of death among women.
approximately one of every time women develop breast cancer by age 85%.
Champion (1989) found that knowledge and individualized teaching with return
demonstration correlated significantly with a women's intent to practice breast self-
examination and with proficiency in examinations.
Male breast: examination of all male breast is relatively easy. The nipple and areola are
inspected for nodule's oedema and ulceration. The breast enlargement in young male may be
indicative of steroid use.
Abdomen: The abdomen examination can be complex because of the organ located within
and near the abdominal cavity.
The examination includes assessment of structure of lower gastrointestinal GI tract in
addition to the liver stomach, kidney and bladder.
Female genitalia: The perineal are must be well eliminated the nurse gloves both hands .the
perineum is extremely sensitive and tender.
The nurse inspect the urethra orifice carefully for colour and position.
The nurse may also inspect the pus at this time looking for lessons.
Internal genitalia: An examination of internal genitalia requires much skill and practices
usually.it is performed only by advance nurse practitioners.
Male genitalia: An examination of male genitalia assess the integrity of the external genitalia
,the inguinal ring and canal because the incidence of several transmitted high an assessment
of the genitalia should be a routine part of any health maintenance examination for this age
group.
Penis: To inspect penis surface thoroughly the nurse must manipulate the genitalia or have
the client assist, the nurse inspect the corona, prepuce and gland assess.
Scrotum: the nurse specially caution which inspecting and palpating the scrotum because the
structure that lies within the scrotum sac area very sensitive.
Inguinal ring and canal: During the inspection the client is asked to strain or bear down. the
manoeuvre will help to make a hernia more visible.
Rectum and anus: A good time to perform the rectal examinations is after the genital
examination. the procedure can be uncomfortable, so the nurse help the client to relax by
explaining all steps.

16
Musculoskeletal system: It can be done as separate examination or integrated with other part
of the total physical exanimated with other part of the total physical examination.
RANGE OF JOINT MOVEMENT
S.N Terms Range of motion Example
1. Flexion Movement decrease < Elbow, fingers, knee.
between 2 adjoining bones
2. Extension Movement increase < Elbow, knee, fingers
between 2 adjoin bone.
3. Hyper extensive Movement of body part Hand
beyond its normal resting
position
4. Promotion Movement body part so that Hand, forearm
front or ventral surface
faced double ward
5. Supination Movement of body part that Leg, arms, fingers
front or ventral surface
faced upward.
6. Abduction Movement of extremity Leg, arms, finger
away from midline of body
7. Internal rotation and Rotation of joint inward Knee, hip
external internal rotation of joint
outward external
8. Eversion & exversion Turning body part away Foot
midline of body
9. Dorsiflexion Flexion of toes and foot Foot
upward.
10. Planter flexion Bending of toes and foot Foot
down wards

NEUROLOGICAL SYSTEM
MENTAL AND EMOTIONAL STATUS
Level of consciousness: It exist along a continuum from full awareness alertness and
cooperation to unresponsiveness to any form of external stimuli
The GCS allow the nurse to evaluate a client neurological status.
Behaviour and appearance: Behaviours, moods, hygiene, grooming and choice of dress,
reveal pertinent, information about mental status.
Language: Normal cerebral function allows a person to understand spoken or written words
and to express the self through writing word or gesture.
Intellectual function: It includes memory knowledge, abstract thinking, association and
judgement each aspect of function is tested with specific technique.

17
Cranial nerve function: Nerve may assess all 12 cranial nerve or test a single nerve or
selected group of nerves.
Sensory function: The sensory pathway of the central nervous system conduct the sensation
of pain, temperature, position, vibration and rude and finally localized touch.
Motor function: It includes measurement made during the muscular skeletal examinations.
The cerebellum coordinates muscular activity, maintains balance and equilibrium and help to
control posture.
Reflexes: It testing assess the integrity of sensory and motor pathway of the reflex are and
specific spinal card segment.
When a muscle and tendon are stretched nurse impulses travel along afferent nerve pathway
to dorsal horn of spinal cord.
AFTER EXAMINATION
The nurse may record findings from physical assessment during the examination or act the
end special form are available to record date. physical examinations findings are integrated in
to the care plan.
The client often needs a member of other examinations such as x-ray or laboratory test after a
physical examination. The test after a physical examination. The test provide additional
screening.

SUMMARY
Through physical assessment the nurse make insight clinical decisions about the best
approaches to client care before examinations begins. The nurse prepares the client and
sitting measures are takes to ensure privacy and psychological and physical comfort.
The examination must be organized, each system overview entails memorise observation
basic principles for a thorough examination include comparing both side of the body for the
symmetry.

18
 BIBLIOGRAPHY

1. Basavanthapa B T.,(2002). fundamental of nursing.1st Ed. Jitender Publication; New

Delhi. 2000-2015.

2. Kaur l., Kaur M.,(2021). A Text Book Of Nursing fundamental. 1st Ed. S Vikas And
company; Jalandhar city. 288-323.

3. Nancy SR.,(2006). Principles and Practice of Nursing. 6th Ed. N.R. Brothers; Indore
166-184

4. Perry P.,(2007). Basic Nursing Essential for Practice. 6th Ed. Elsevier; New Delhi.
274-331.

www.http.healthassessmentorg.in

19
.

20