OBJECTIVES:. Correct demonstration of inspection, palpation, percussion
1. Integrated Health Assessment Putting It All
2. OBJECTIVES: Correct demonstration of inspection, palpation, percussion & auscultation
Correct use of instruments
Using correct & appropriate terminology
Ability to choreograph the complete exam in a systematic manner
Accurately & legibly record findings
Use infection control measures
Maintain dignity & privacy of client
3. Professionalism Well groomed appropriately attired professional
Lab coat, name-band, hair up, dressed appropriately, clean shaven or groomed beard
Nails cut short & no polish
4. Dignity & Privacy Respect the clients modesty
Only expose areas that are being assessed
Cover with a sheet or get them under the blankets
Client (during testing) can wear shorts & their johnny shirt. Everything else needs to be removed, including socks
5. Infection Control Wash your hands!!
When setting up your bedside work area, include a small paper bag to dispose your garbage
Keep equipment off the bed.
6. Organization Organize your thoughts!!
As you proceed through the assessment, you can gather lots of information about other systems
For example, skin & MSS assessment can be gathered throughout, as well as mental status data.
Minimize position changes for the client
7. Testing Set-up You will have 40 minutes to complete the assessment component.
After you have completed your assessment, you will switch & your partner will proceed.
After both partners have done their assessment, everyone will sit & document their findings on the provided form. You will be allowed 30 minutes to document.
If students show up late, this will cut into assessment time.
Your evaluator will schedule appointments to meet & review your recording with you.
If you fail, we will let you know right away. Retests are scheduled for Wednesday April 4.
Please refer to the School of Nursing Lab/Skills Testing Policy.
9. Assessment Focus You will select a scenario that will give you a bit of direction to the assessment.
During the health hx, use PQRST to guide the data you will ask your client.
10. Provocative or Palliative what brings it on? What were you doing when you first noticed it? What makes it better? Worse?
Quality or Quantity how does it look, feel, sound? How intense/severe is it?
Region or Radiation where is it? Does it spread anywhere?
11. Severity Scale how bad is it on a scale of 1 to 10? Is it getting better, worse or staying the same?
Timing onset (exactly when did it first occur?), duration (how long did it last?), frequency (how often does it occur?)
Also explore allergies or family hx
12. After first encountering the client, during the health hx, & throughout the assessment, observe for the following:
Level of conscious
Any obvious physical deformities
Mobility & ROM
Any involuntary movements
13. Mood & affect
14. Height & weight
Internal eye assessment
Observe gait, tandem walk
Do balance tests, Romberg, deep knee bends
Assess spine ROM (stand behind person)
15. Inspect hands & nails noninvasive to the client
Do a set of V/S at the beginning (no temp)
***If dizzy do ortho b.p.s on one side
16. Head & Face Inspect & palpate the hair, scalp, & cranium
Observe the face for symmetry (CN 7)
Test for facial sensation (CN 5)
Palpate the TMJ & temporal artery
Palpate the sinuses.
17. Eye During conversation, inspect the external eye features; then onto conjunctiva, sclera, & iris
Test visual fields by confrontation (CN 2)
Test with Snellen chart if havent done so already (CN 2)
Test EOM corneal light reflex (strabismus) & 6 cardinal gaze (CN 3,4,6)
Test pupil size, response to light & accommodation
Use ophthalmoscope for internal eye structures
***If an eye problem, test near vision
18. Ear Inspect external ear position, alignment, skin
Palpate the auricle & tragus for tenderness
Inspect internal ear with otoscope
Hearing tests voice whisper, Weber, & Rinne
19. Nose During conversation, inspect external nose for symmetry
Test patency & sense of smell (CN 1)
Use speculum to inspect nares, mucosa, septum & turbinates
20. Mouth & Throat Gloves, penlight, tongue depressor
Inspect mucosa, teeth, gums, tongue, palate, floor of mouth, & uvula
Phonates ahh & test gag (CN 9 & 10)
Stick out tongue & lingual speech (CN 12)
Palpate inside mouth
Test for taste (CN 7)
21. Neck Inspect for symmetry, lumps, & pulsations
Palpate lymph nodes
Palpate carotid pulse (1 side at a time). Listen for bruits
Palpate the trachea (?midline)
Test ROM & muscle strength (CN 11)
Observe swallow & inspection of thyroid
Move behind person palpate thyroid
22. Chest - Posterior Inspect the thoracic cage, skin & symmetry
Also, inspect & palpate spinous processes & muscles
Palpate tenderness, expansion, fremitus
Percuss resonance/dull, diaphragmatic excursion
Fist percussion at costovertebral angle (abd.)
Auscultate breath sounds
***If respir condition, do voice sounds
23. Chest - Anterior Move around to front of client
Flip johnny shirt around so that it is open in the front
Auscultate base of heart leaning forward for murmurs
Lie down, cover legs for privacy
24. Inspect skin, chest shape
Palpate for tenderness & fremitus
Percuss for resonance, dull & tympany
Auscultate breath sounds
Documentation of ant & post chest are done together
25. Heart Can landmark & mark the heart
Inspect precordium for pulsations & heaves
Palpate for pulsations, thrill, apical pulse
Percuss for general size of heart
Auscultate heart sounds in all areas with diaphragm & bell. Note rhythm & count apical heart rate (either palpated or auscultated) in one location
Turn to left side & auscultate apex. Can also lean forward & auscultate base (if not already done)
26. Abdomen Inspect shape, symmetry, skin, pulsations
Auscultate bowel sounds & bruits
Percuss for tympany
Percuss liver span & locate spleen. Check for spleen enlargement
Palpate lightly then moderately in all quads
Palpate for liver, spleen, kidneys
***If abdomen concern, do ascites & extra tests
Test abdominal reflexes
Palpate femoral pulse & inguinal lymph nodes
27. Upper Extremities Assess skin
Joint assessment inspect & palpate
Test ROM, muscle strength
Palpate epitrochlear nodes
Palpate pulses radial & brachial for sym (may have been done already with vitals)
***If numbness/tingling in hands do carpal tunnel tests AND extra neuro
28. Lower Extremities Inspect skin, symmetry, hair distribution
Palpate for temp & edema
Joint assessment inspect & palpate
Test ROM & muscle strength
Palpate popliteal, posterior tibial, & dorsalis pedis pulses for sym
***If knee problem do bulge & ballottement
***If a gait problem measure leg length
29. Neurological Test sensation on upper & lower extremities pain, light touch, & vibration
Finger to nose test, run heel down shin
30. Mental Status Gather mental status data throughout or at this time.
31. Genitalia Omit genitalia at this time
Content will be tested on the final exam!
32. Documentation DO NOT document anything that you do not do!
Must understand what you are documenting
Missing 3 sections of documented assessment data will constitute a fail grade.
Use IPPA as a guide
Be prepared to discuss both your assessment & documentation with your instructor