GENERAL HEALTH ASSESSMENT

Chapter 23 GENERAL HEALTH ASSESSMENT

KEY TERMS/CONCEPTS

A comprehensive assessment is performed on admission to a health care facility. This assessment involves a detailed review of the client’s condition, with the nurse collecting a nursing history and performing a behavioural and physical examination. Periodic assessments are performed on a regular basis in nearly every health care setting. In acute-care settings a brief assessment is performed at the beginning of each shift to identify changes in the client’s status compared with the previous assessment. Effective assessment skills can quickly identify new signs and symptoms that indicate complications of an illness or adverse side effects of medical therapy. In aged care facilities, nurses complete similar assessments weekly, monthly or more frequently when a resident’s health status changes (Elkin et al 2008). This chapter outlines how to undertake a general health assessment of clients across the lifespan.

LIVED EXPERIENCE

Over the years working as a nurse I have learnt that when admitting clients and obtaining a nursing history, the questions asked need to be specific. I once had a client tell me that her bowel habits were ‘regular’. I later found out that regular for this client was once a week! Another client told me that he only drank alcohol socially. It turned out that he went out every night of the week with friends and had two or three alcoholic drinks after work.

Stephanie, Registered Nurse for 15 years

PHYSICAL ASSESSMENT

A physical assessment of clients in a health care facility is obtained to:

• Gather baseline data about the client’s health

• Supplement, confirm or refute data obtained in the nursing history

• Confirm and identify nursing diagnoses

• Make clinical judgments about a client’s changing health status and management.

A nurse must learn how to really discern a client’s condition so that, even in passing or without conscious effort, clues to client health or ill-health are not missed. This includes being aware of clients and their general appearance, colour, expression and body posture. During closer contact with the client, no significant external feature should escape the nurse’s notice. The nurse must be able to recognise deviations from what is acceptable and usual for the client. To do this the nurse must know what to look for and what constitutes the acceptable and usual for each client.

Clients are assessed when they are first admitted to a health care institution or when community or home nursing care is initiated. Thereafter, assessment is performed continuously to evaluate client progress and to identify changing needs. Table 23.1 lists the observations to be made during the admission assessment, the acceptable findings and various deviations from the norm. In addition to the observations listed in this table, the nurse must assess the client’s:

• Degree of independence

• Ability to perform the activities of daily living

• Ability to interact with others

• Reactions and responses to treatment; for example, medications

• Basic needs; for example, for food, water, oxygen, safety, exercise and comfort

• Specific needs; for example, for wound care or pain relief

• Excretions and secretions; for example, urine, faeces, vomitus, wound drainage.

TABLE 23.1 ADMISSION ASSESSMENT

Aspect	Normal	Deviations from normal
General physical appearance	Normal weight for age, sex, height, body build	Overweight, underweight
General physical appearance	Personal hygiene and grooming satisfactory	Appears to be neglected
Skin	Normal colour for race	Pallor, cyanosis, jaundice
	Neither dry nor moist	Excessively dry or moist
	Normal temperature	Elevated temperature, localised warmth or coldness
	Smooth	Rough, or localised changes or irregularities
	Elastic	Diminished by dehydration or oedema
	No lesions	Rashes, bruises, scars, abrasions, ulcers, nodules
Hair	Normal texture for age, race	Brittle, dry, coarse
	Normal distribution	Areas of hair loss
	Scalp clean and healthy	Dandruff, lesions, lice
	Shiny and clean	Dull, neglected
Nails	Transparent	Streaks (red or white)
	Smooth	Ridged
	Convex	Concave curves
	Pink nail beds	Cyanosed, pale
Eyes	Sclerae and corneas clear	Pale, inflamed, jaundiced
	Eyelashes turn out and away	Rubbing on eyeball
	Open eyelids do not fall over pupils	Ptosis (drooping)
	Pupils equal and reacting to light	Dilated, pinpoint, unequal, non-reactive
	No discharge	Watery or purulent discharge
	Tolerance to light	Photophobia (intolerance to light)
	Normal visual acuity	Visual impairment
Ears	Normal hearing acuity	Hearing impairment
	Ear canal clean	Inflamed, presence of excessive wax
	No discharge	Watery or purulent discharge
		Itching, pain, tinnitus
Mouth	Lips pink, moist, smooth	Pale, cyanosed, dry, cracked
	Mucosa pink, moist, glistening	Pale, cyanosed, dry, ulcers, cracks
	Gums pink, moist, smooth	Inflamed, swollen, bleeding, lesions
	Teeth white, straight, smooth	Discoloured, chalky, decayed
	Tongue pinky red, moist	Coated, cracked
	Breath fresh	Halitosis (bad breath), ketone odour
Thorax and lungs	Normal-shaped chest	Barrel-shaped chest
Thorax and lungs	Normal breath sounds	Wheezing, rales, gurgles, dry or moist cough
Abdomen	Slightly convex, symmetrical	Excessively concave, asymmetrical, distended
Posture and gait	Able to sit, stand and walk normally	Postural abnormalities, e.g. kyphosis, scoliosis; abnormal gait
Mobility	Full range of joint motion	Stiffness or instability of a joint, unusual joint movement, swelling of a joint, pain on movement
Muscle tone and strength	Normal tone and strength	Increased or decreased tone, decreased strength
Speech	Ability to speak clearly	Speech impairment, e.g. lisp or stammer
Mental and emotional status	Appropriate emotional responses	Responses inappropriate, apprehension, anxiety, depression, hostility
Level of consciousness and orientation	Alert, responsive, oriented to time, place, person	Disoriented, unresponsive to stimuli, shortened attention span
Presence of prosthesis or aids	None, although aids to sight and hearing are common	Spectacles, contact lenses, artificial eye, hearing aids, walking sticks, frames, wheelchairs, artificial limb, dentures

Information on these topics is provided in the relevant chapters; for example, Chapter 27 addresses comfort needs and Chapter 35 addresses the need for freedom from pain.

Subjective and objective data are included in the assessment of the client. Subjective data are collected by interviewing the client during the nursing history. This includes information that can only be described or verified by the client. Family members and caregivers can also contribute to subjective data about the client. Subjective data are also referred to as symptoms. Objective data are data that can be observed and measured. These types of data are obtained using inspection, palpation, percussion, auscultation and olfaction during the physical examination. Objective data are also called signs. Although subjective data are usually obtained by interview and objective data are obtained by physical examination, it is common for the client to provide subjective data while the nurse is performing the physical examination, and it is also common for the nurse to observe objective signs while interviewing the client during the history (Brown et al 2008).

ASSESSMENT TECHNIQUES

Inspection, palpation, percussion, auscultation and olfaction are the five basic assessment techniques. Each skill enables the nurse to collect a broad range of physical data about clients (Brown et al 2008).

Assessment through inspection

While observation of all the aspects mentioned in this chapter is essential, one of the most important skills a nurse develops is the ability to look at a client and determine whether they are comfortable. A client’s comfort depends on many things, the most basic of which are that needs for hygiene, posture, maintenance of body temperature and freedom from pain are met. deWit (2005) lists the following items that the nurse observes and assesses when looking at a client:

• Safety and security:

— potential risks for injury

— sensory deficits

— ability to speak and understand English

— need for side rails or safety devices

• Hygiene and grooming:

— ability to bathe, dress and groom self

— amount of assistance needed

• Psychosocial needs:

— desire for spiritual assistance

— usual coping mechanisms

— financial concerns

— fears and concerns

• Elimination:

— characteristics and amount of urinary output

— characteristics and regularity of bowel movements

— alterations in elimination

— presence of pain, burning or other discomfort.

As well as observing and assessing the client and their needs, the nurse must also use the sense of sight to assess the functioning of equipment used in client care. Nurses assess various items of equipment to determine whether they are functioning correctly when they are in use, for example:

• Intravenous fluid apparatus

• Oxygen apparatus

• Urinary drainage systems

• Wound drainage systems

• Traction apparatus.

While Enrolled Nurses (ENs) may not be directly responsible for the management of specific items of equipment, they have a responsibility to observe their functioning and report immediately to the Registered Nurse (RN) if any malfunction is suspected.

Assessment through palpation

Palpation uses the sense of touch. Through palpation the hands make delicate and sensitive measurements of specific physical signs. Palpation detects resistance, resilience, roughness, texture, temperature and mobility. The nurse uses different parts of the hand to detect specific characteristics. For example, the back of the hand is sensitive to temperature variations. The pads of the fingertips detect subtle changes in texture, shape, size, consistency and pulsation of body parts. The palm of the hand is sensitive to vibration. The nurse measures position, consistency and turgor by lightly grasping the body part with fingertips. Assist the client to relax and position comfortably as muscle tension during palpation impairs the ability to palpate correctly. Asking the client to take slow, deep breaths enhances muscle relaxation. Palpate tender areas and ask client to point out areas that are more sensitive and note any nonverbal signs of discomfort (Elkin et al 2008).

The sense of touch should be developed so that a nurse is able to detect abnormalities such as:

• Abnormally hot, cool, moist, dry, inelastic or roughened skin

• An excessively hard or soft peripheral vein

• A rapid, slow, weak or irregular pulse

• Rigid or flaccid muscles

• Swelling of part of the body; for example, a joint.

Touch is also used when examining a client by palpation or percussion. Palpation, usually performed by a medical officer or a RN, is a technique whereby the examiner feels the texture, size, consistency and location of certain parts of the body with the hands. For example, the examiner may palpate the upper abdomen to determine the size of the liver.

Assessment through percussion

Percussion, usually performed by a medical officer or a RN, is a technique in which the examiner strikes the body surface with a finger, producing vibration and sound. An abnormal sound suggests the presence of a mass or accumulation of fluid within an organ or cavity. For example, the examiner may percuss the posterior chest wall to determine the presence of fluid in the lungs.

Assessment using the sense of hearing (auscultation)

It is important that a nurse learns to listen effectively, so that not only what a client says is registered but also the tone of voice, which often conveys a great deal. A nurse must also learn how to recognise abnormal sounds. Information on the art of effective listening in communication is provided in Chapter 29 and emphasises the importance of recognising that listening is an active process that involves much more than just hearing the spoken word. In client care, recognising abnormal sounds involves the ability to detect:

• Abnormalities of breathing; for example, respirations that are wheezing, noisy or distressed

• Abnormalities of heart sounds, blood pressure, bowel sounds or fetal heart sounds, when using a stethoscope

• Manifestations of a client’s distress; for example, coughing, expectorating sputum, vomiting, crying or moaning

• Changes in the sound or rhythm of technical equipment such as suction or artificial ventilation apparatus.

Auscultation is listening with a stethoscope to sounds produced by the body. To auscultate correctly, listen in a quiet environment. To be successful, the nurse must first be able to recognise normal sounds from each body structure, including the passage of blood through an artery, heart sounds and movement of air through the lungs (Elkin et al 2008).

Assessment using the sense of smell (olfaction)

A well-developed sense of smell enables a nurse to detect odours that are characteristic of certain conditions. Some alterations in body function and certain bacteria create characteristic odours, for example:

• The ‘fishy’ smell of infected urine

• The ammonia odour associated with concentrated or decomposed urine

• The musty or offensive odour of an infected wound

• The offensive rotting odour associated with gangrene (tissue necrosis)

• The smell of ketones on the breath in ketoacidosis (accumulation of ketones in the body)

• The smell of alcohol on the breath — due to ingestion of alcohol

• Halitosis (offensive breath) accompanying mouth infections; for example, gingivitis or certain disorders of the digestive system; for example, appendicitis

• The foul odour associated with steatorrhoea (abnormal amount of fat in the faeces)

• The characteristic odour associated with melaena (abnormal black tarry stool containing blood)

• The faecal odour of vomitus associated with a bowel obstruction

• Bromhidrosis (offensive smelling perspiration) caused by bacterial decomposition of perspiration on the skin.

GUIDELINES FOR CONDUCTING A GENERAL HEALTH ASSESSMENT

When starting a general health assessment the nurse should:

• Set priorities for assessment based on a client’s presenting signs and symptoms

• Use a head-to-toe approach, as this facilitates an effective assessment

• Encourage the client to be an active participant — the client can often let the nurse know when actual changes have occurred

• Respect the client’s race, gender, age and cultural beliefs

• Follow standard precautions for infection control

• Consider the possibility of latex allergy

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Tags: Tabbners Nursing Care Theory and Practice

Feb 12, 2017 | Posted by admin in NURSING | Comments Off

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