HEALTH

ASSESSMENT
 TABLE OF CONTENTS

01 ASSESSMENT EQUIPMENT FOR 02

TECHNIQUE ASSESSMENT

ASSESSMENT OF THE
03 THORAX AND LUNGS
 Define and discuss the five techniques on
01 performing health assessment
 INSPECTION
Inspection involves using the
senses of vision, smell, and
hearing to observe and
detect any normal or
abnormal findings. This
technique is used from the
moment that you meet the
client and continues
throughout the examination.
PRACTICE TECHNIQUE OF INSPECTION

1. Make sure the room is a

comfortable temperature. A too
cold or too-hot room can alter
the normal behavior of the client
and the appearance of the
client’s skin.
2. Look and observe
before touching. Touch
can alter appearance
and distract you from a
complete, focused
observation.

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3. Completely expose
the body part you are
inspecting while draping
the rest of the client as
4. Note the following
appropriate.
characteristics while inspecting
the client: color, patterns, size,
location, consistency, symmetry,
movement, behavior, odors, or
sounds.
5. Compare the appearance of
symmetric body parts (e.g., eyes, ears,
arms, hands) or both sides of any
individual body part.
 PALPATION

 Palpation consists of using parts of the hand to touch

and feel for the following characteristics: texture
(rough/smooth), temperature (warm/cold), moisture
(dry/wet), mobility (fixed/movable/still/ vibrating),
consistency (soft/hard/fluid filled), strength of pulses
(strong/weak/thready/bounding), size
(small/medium/large), shape (well defined/irregular),
and degree of tenderness.
 HAND PART SENSITIVE TO

Fingerhands Fine discriminations:

pulses, texture,
size, consistency, shape,
crepitus
Ulnar or palmar surface Vibrations, thrills, fremitus

Dorsal (back) surface Temperature

 TYPES OF PALPATION
 Light palpation: To perform light
palpation, place your dominant hand
lightly on the surface of the structure.
There should be very little or no
depression (less than 1 cm). Feel the
surface structure using a circular motion.
Use this technique to feel for pulses,
tenderness, surface skin texture,
temperature, and moisture.
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 Moderate palpation: Depress
the skin surface 1 to 2 cm
(0.5 to 0.75 inch) with your
dominant hand, and use a
circular motion to feel for
easily palpable body organs
and masses. Note the size,
consistency, and mobility of
structures you palpate.

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 Deep palpation: Place your dominant
hand on the skin surface and your
non dominant hand on top of your
dominant hand to apply pressure.
This should result in a surface
depression between 2.5 and 5 cm (1
and 2 inches). This allows you to feel
very deep organs or structures that
are covered by thick muscle.
 Bimanual palpation: Use two hands,
placing one on each side of the body
part (e.g., uterus, breasts, spleen)
being palpated (Fig. 3-3). Use one
hand to apply pressure and the other
hand to feel the structure. Note the
size, shape, consistency, and
mobility of the structures you
palpate.
 PERCUSSION
 Percussion involves tapping body parts to
produce sound waves. These sound waves or
vibrations enable the examiner to assess
underlying structures.

 Percussion has several different assessment

uses, including:
 DIFFERENT ASSESMENT
USES OF PERCUSSION
 Eliciting pain: Percussion helps to detect
inflamed underlying structures. If an inflamed
area is percussed, the client’s response may
indicate or the client will report that the area feels
tender, sore, or painful.

 Determining location, size, and shape:

Percussion note changes between borders of an
organ and its neighboring organ can elicit
information about location, size, and shape.
 Determining density: Percussion helps to determine whether
an underlying structure is filled with air or fluid or is a solid
structure.

 Detecting abnormal masses: Percussion can detect

superficial abnormal structures or masses. Percussion
vibrations penetrate approximately 5 cm deep. Deep masses
do not produce any change in the normal percussion
vibrations.

 Eliciting reflexes: Deep tendon reflexes are elicited using the

percussion hammer.
 3 TYPES OF PERCUSSION

 Direct percussion –
is the direct
tapping of a body
part with one or
two fingertips to
elicit possible
tenderness.
 Blunt percussion – is
used to detect
tenderness over organs
by placing one hand flat
on the body surface
and using the fist of the
other hand to strike the
back of the hand flat on
the body surface.
 Indirect or mediate percussion - is the
most commonly used method of
percussion. The tapping done with this
type of percussion produces a sound or
tone that varies with the density of
underlying structures. As density
increases, the sound of the tone
becomes quieter. Solid tissue produces
a soft tone, fluid produces a louder
tone, and air produces an even louder
tone.
 The following techniques help to develop
proficiency in the technique of indirect
percussion:
• Place the middle finger • Keep your other fingers
of your non dominant off the body part being
hand on the body part percussed because
you are going to they will damp the tone
percuss. you elicit.

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• Use the pad of your
middle finger of the • Withdraw your
other hand (ensure that finger immediately
this fingernail is short) to to avoid damping
strike the middle finger the tone.
of your non dominant
hand that is placed on
the body part.

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  Use quick, sharp taps by quickly flexing
your wrist, not your forearm .An ostomy
• Deliver two
can be permanent or temporary, and it can
quick taps
and listen be necessary because of fecal
carefully to incontinence, an intestinal tumor, bowel
the tone. trauma, and a bowel inflammatory
disease. In these circumstances, part or
all of the intestine is removed, and the
remaining part of the intestine is brought
up through the abdominal wall to allow for
elimination of waste products.
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 AUSCULTATION
 Auscultation - Auscultation is a type of assessment technique that
requires the use of a stethoscope to listen for heart sounds,
movement of blood through the cardiovascular system, movement of
the bowel, and movement of air through the respiratory tract.

 A stethoscope is used because these body sounds are not audible to

the human ear. The sounds detected using auscultation are classified
according to the intensity (loud or soft), pitch (high or low), duration
(length), and quality (musical, crackling, raspy) of the sound.
The following guidelines should be followed as you
practice the technique of auscultation:

 Eliminate distracting or competing noises from

the environment (e.g., radio, television,
machinery).

 Expose the body part you are going to auscultate.

Do not auscultate through the client’s clothing or
gown. Rubbing against the clothing obscures the
body sounds.
 Use the diaphragm of the stethoscope to listen for
highpitched sounds, such as normal heart sounds, breath
sounds, and bowel sounds, and press the diaphragm
firmly on the body part being auscultated.

 Use the bell of the stethoscope to listen for low-pitched

sounds such as abnormal heart sounds and bruits
(abnormal loud, blowing, or murmuring sounds heard
during auscultation). Hold the bell lightly on the body part
being auscultated.
HEALTH ASSESSMENT EQUIPMENT
 Purpose and Proper use of Health Equipment
Stethoscope
 Purpose: For auscultation:
o Examination of a patient by listening to
sounds from various body systems
 cardiovascular, respiratory,
gastrointestinal
 Focuses and amplifies sounds
 Consists of 2 earpieces connected by tubing
to a chestpiece with 2 sides:
o Diaphragm—the flat side: For listening
to high-pitched sounds
Bell—the concave side: For listening to lower-
pitched sounds
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Proper use: Place earpieces in ear making sure they are
pointing forward as your nose does
Diaphragm is most frequently used—tap it to make sure
you can hear through it
Press diaphragm firmly to skin of patient to auscultate
Switching to the bell—turn chestpiece until it clicks
Press bell lightly to skin of patient to auscultate
 Spygmomanometer
 Purpose: To assess a patient’s blood
pressure

 Used with a stethoscope

 An inflatable cuff with a valve, bulb, and a

measuring gauge
o With valve closed, bulb is pumped to
inflate cuff
o Valve is opened to release pressure
o Gauge measures the pressure of the
blood flow through the artery
Stethoscope is used to listen to the tapping
sounds produced by turbulent blood flow
through the artery 29
 Spygmomanometer
 Proper use:

 Open valve to release

 Wrap the cuff around a patient’s arm
pressure at rate of 5 mm
contacting skin Hg/second
o Bottom of cuff 1 inch above elbow crease
o Line up cuff artery line with brachial artery  Listen for the first clear
“tapping” sound
 Place diaphragm of stethoscope over the o Note the number on the
brachial artery gauge: The systolic
o Earpieces in ears pressure
o Valve closed
 Listen for the moment all
o Measuring gauge at eye level “tapping” sounds disappear
o Note the number on the
 Using the Sphygmomanometer: Measuring the gauge: The diastolic
Blood Pressure pressure
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 Pulse Oximeter

 Purpose: To measure the patient’s oxygen saturation level

o The oxygen level of blood circulating through the body

 A probe with light to measure amount of oxygen in the blood

 Probe is clipped to finger over nailbed, or earlobe

 Probe will display measurement of oxygen saturation as

percentage
o Will also measure heart rate

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 Thermometer

 Purpose: To measure the patient’s temperature

 How thermometer is applied is dependent on the

type

 Various types:
o Temporal
o Tympanic
o Oral
o Rectal

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 Reflex Hammer

 Purpose: To test for deep tendon reflexes

in a comprehensive neurological
assessment
o Assesses the interaction of the
sensory and motor neurological
pathways

 Rubber ended hammers

Use one firm, brisk strike to specific tendon
area to elicit corresponding muscle reflex
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 Pen Light

 Purpose: To check the patient’s pupillary

responses during the Swinging Flashlight Test
 Assesses the function of the optic nerve and
cranial nerve III

 Use in a darkened room: Move the light is

briskly towards the eye from the side
 Observe the eye for reaction to light
Normal reaction: Pupil constriction to light and
dilation to dark

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 Medical Scissors

 Purpose: To cut bandages, clothing, gauze,

tape and other materials.

 Need to be sharp and reliable for easy, fast

cutting

 Blunt end to prevent cutting the patient

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 Watch with Second Hand
 Purpose: To determine time in
seconds
Used when measuring a patient’s
heart rate or respiratory rate

Tuning Fork

 Purpose: To assess a patient’s hearing

Used in the Weber Test and the Rinne Test

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 Type of Test Conducted with the Tuning Fork
Weber Test
o Tuning fork is struck on firm
object to initiate vibrations
o Then placed in center of the
patient’s forehead
o Normal response is to hear
equally with both ears
Rinne Test
o Tuning fork is stuck on firm object
to initiate vibrations
o Then placed on the mastoid
process [just behind ear]
o When patient is no longer to hear
vibrations, the fork is moved
closer to the ear
o Normal response is to continue to
hear the tuning fork
 Tongue Depressor Monofilament
 Purpose: To examine the oral
cavity  Purpose: To assess sensation in peripheral
nerves
 6-inch flat smooth thin
wooden blade  A piece of nylon

 Used to hold tongue down to  Used to prod the patient’s foot

assess mouth and throat
 Normal response is the patient feeling the
strand of monofilament

 Not feeling the monofilament indicates possible

diabetic neuropathy or other neuropathic
condition
 Goniometer Otoscope

 Purpose: To measure  Purpose: To examine the patient’s ear canal and

the angles of a tympanic membrane
patient’s body’s joints. o Can also be used to assess the patient’s
nose
 Used to assess a
patient’s range of  Is a magnifier with a light source
motion
 Pointed end is inserted slowly into ear
 For baseline, progress,
or disability o Careful to not damage the ear canal
o Flat end is for viewing inside the ear
o Normal: Pearly white ear drum can be seen
Abnormal: Scars or holes may be seen on ear drum
 Opthalmoscope
 Purpose: To examine the interior
structures and retina of the eye
 Handheld tool with mirrors and lenses
and light source
 Use in dim-lit room:
o Patient looks at a point on a far wall
o Get as close to patient as possible
o Forehead almost touching patient’s
head
Look through scope into patient’s eye
Tape Measure
 Purpose: To measure various
parts of patient’s body – Ex.
waist, infant head circumference,
leg circumference
 Made of flexible material with
linear-measurement markings,
inches and centimeters
 Used to establish baseline and
monitor progress
 Scale

 Purpose: To measure a patient’s weight

 Used to establish a baseline and monitor

progress
 Also used to weigh infant diapers if monitoring
outputs
 THORAX AND LUNGS

 Thorax -identifies the

portion of the body
extending from the base
of the neck superiorly to
the level of the
diaphragm inferiorly.
 Thoracic Cage
 The outer structure of the thorax is referred to as the
thoracic cage

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Posterior Thoracic Cage
VERTICAL REFERENCE LINES
LATERAL VERTICAL REFERENCE LINES
THORACIC CAVITY
LUNGS
 Plurae membrane
The thoracic cavity is lined by a thin, double-layered serous membrane
collectively referred to as the pleura.

 Parietal pleura line the chest cavity.

 Visceral pleura covers the external surfaces of the

lungs.

 Pleural space lies between the two pleural layers.

MAJOR STRUCTURE OF THE RESPIRATORY SYSTEM
 Trachea

 Trachea - is a flexible structure that

lies anterior to the esophagus, begins
at the level of the cricoid cartilage in
the neck, and is approximately 10 to
12 cm long in an adult. C-shaped rings
of hyaline cartilage compose the
trachea; they help to maintain its
shape and prevent its collapse during
respiration.

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 Bronchi
 At the level of the sternal angle,
the trachea bifurcates into the
right and left main bronchi. Both
bronchi are at an oblique
position in the mediastinum and
enter the lungs at the hilum.

 Right main bronchus is shorter

and more vertical than the left
main bronchus, making aspirated
objects more likely to enter the
right lung than the left.
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 Mechanics of Breathing
Breathing/ Respiration
 The purpose of respiration is to maintain an
adequate oxygen level in the blood to support
cellular life. By providing oxygen and eliminating
carbon dioxide, respiration assists in the rapid
compensation for metabolic acid–base defects;
however, changes in the respiratory pattern can
cause acid–base imbalances.

 External respiration, or ventilation-

is the mechanical act of breathing
and is accomplished by expansion
of the chest, both vertically and
horizontally

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Mechanics of Breathing

 Vertical expansion is accomplished

through contraction of the diaphragm

 Horizontal expansion occurs as

intercostal muscles lift the sternum and
elevate the ribs, resulting in an increase
in anteroposterior diameter

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 INSPIRATION
 As a result of this enlargement of the
chest cavity, a slight negative pressure
is created in the lungs in relation to the
atmospheric pressure, resulting in an
inflow of air into the lungs. This
process, called inspiration.

EXPIRATION
 is mostly passive in nature and occurs with relaxation
of the intercostal muscles and the diaphragm. As the
diaphragm relaxes, it assumes a domed shape. The
resultant decrease in the size of the chest cavity
creates a positive pressure, forcing air out of the
lungs.
Mechanics of Breathing

 Breathing patterns change according to cellular demands—

often without awareness on the part of the individual. Such
involuntary control of respiration is the work of the medulla
and pons located in the brain stem. The hypothalamus and
the sympathetic nervous system also play a role in
involuntary control of respiration in response to emotional
changes such as fear or excitement.
 Assessment Techniques for the thorax and Lungs
Collecting subjective data: the nursing health history

 Subjective data related to  Information about the  When collecting

the thoracic and lung
assessment provide
many clues about
underlying respiratory
problems and associated
nursing diagnoses as
well as clues about risk
for the development of
lung disorders.
client’s level of subjective data,
functioning is also
remember to follow up
important because
certain respiratory on the client’s related
problems greatly signs and symptoms to
impact a person’s determine specific
ability to perform respiratory problems
activities of daily and associated nursing
living. diagnoses.
Note! Be careful to avoid judgmental approaches to poor
health practices. Smoking, for example, has become a
stigmatized addiction in our society. Avoid conveying
feelings of intolerance when caring for a smoker with
respiratory complaints. Based on the client’s readiness for
teaching, the nurse may offer information about smoking
cessation methods.
Collecting Objective Data: Physical Examination

Examination of the thorax and lungs begins

when the nurse first meets the client and
observes any obvious breathing difficulties.
However, complete examination of the
thorax and lungs consists of inspection,
palpation, percussion, and auscultation of
the posterior and anterior thorax to evaluate
functioning of the lungs.
 PREPARING THE CLIENT
Have the client remove For the beginning of
all clothing from the waist the examination, ask
up and put on an
the client to sit in an
examination gown or
drape. The gown should upright position with
open down the back and arms relaxed at the
is used to limit exposure. sides.
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 EQUIPMENTS

• Light source
• Examination gown and
drape • Mask
• Gloves • Skin marker
• Stethoscope • Metric ruler

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 PHYSICAL ASSESSMENT
 During examination of the client, remember these key points:

• Provide privacy for the client.

• Keep your hands warm to promote the client’s
comfort during examination.
• Remain non judgmental regarding client’s
habits and lifestyle, particularly smoking. At the
same time, educate and inform about risks,
such as lung cancer and chronic obstructive
pulmonary disease (COPD), related to habits
Physical Assessment
INSPECTION
POSTERIOR THORAX
ANTERIOR THORAX
 Palpate for fremitus. Following the above sequence, use the
ball or ulnar edge of one hand to assess for fremitus (vibrations
of air in the bronchial tubes transmitted to the chest wall). As
you move your hand to each area, ask the client to say “ninety-
nine.” Assess all areas for symmetry and intensity of vibration.

• Fremitus is symmetric and easily identified in the upper regions

of the lungs. If fremitus is not palpable on either side, the client
may need to speak louder. A decrease in the intensity of
fremitus is normal as the examiner moves toward the base of
the lungs. However, fremitus should remain symmetric for
bilateral positions.
 Assess chest expansion. Place your hands on the posterior
chest wall with your thumbs at the level of T9 or T10 and
pressing together a small skin fold. As the client takes a deep
breath, observe the movement of your thumbs.

 When the client takes a deep breath, the examiner’s thumbs

should move 5 to 10 cm apart symmetrically. Because of
calcification of the costal cartilages and loss of the accessory
musculature, the older client’s thoracic expansion may be
decreased although it should still be symmetric.
 PERCUSSION

 Percuss for tone. Start at the apices of the scapulae and

percuss across the tops of both shoulders. Then percuss the
intercostal spaces across and down, comparing sides.
Percuss to the lateral aspects at the bases of the lungs,
comparing sides.

 Resonance is the percussion tone elicited over normal lung

tissue. Percussion elicits flat tones over the scapula.