Physical health assessment

 Physical Health Assessment: Methods and Steps (theworldbook.org)

 

The Four Methods of Health Assessment

The four basic methods or techniques for physical health assessment are:

1. Inspection,
2. Palpation,
3. Percussion and
4. Auscultation. 

   3 Steps of Health Assessment

1. A complete medical history,
2. A general survey and
3. A complete physical assessment.

1. A Complete Medical History

History taking is the first step of Physical Health Assessment. The general framework for history taking is as follows:

• Presenting complaint.
• History of presenting complaint, including investigations, treatment, and referrals already arranged and provided.
• Past medical history: significant past diseases or illnesses, surgery, including complications, trauma.
• Drug history: now and past, prescribed and over-the-counter, allergies.
• Family history: especially parents, siblings, and children.
• Social history: smoking, alcohol, drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets, and hobbies.
• Systems review: cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, genitourinary system

2. A General Survey

After collecting the health history and before going through the complete head to toe examination, some information or baseline data is collected which is called a general survey.

The general survey includes the person’s weight, height, body build, posture, gait, obvious signs of distress, level of hygiene and grooming, skin integrity, vital signs, oxygen saturation, and the person’s actual age compared and contrasted to the age that the person actually appears like.

For example, does the person appear to be older than his actual age? Does the person appear to be younger than his actual age?

3. A Complete Physical Assessment

A thorough physical assessment consists of the following:

• Vital Signs: The pulse, blood pressure, body temperature, and respiratory rate are measured.
• The Assessment of The Thorax and Lungs Including Lung Sounds: The size, symmetry, shape, and for the presence of any skin lesions and chest movements are observed. As well the breath sounds are observed and documented.
• The Assessment of The Cardiovascular System Including Heart Sounds: By listening to the heart sound it is observed that the heart is normal or not.
• The Assessment of The Head: The head movement is visualized over here.
• The Assessment of The Neck: The neck is visualized and the thyroid gland is inspected for any swelling and also for normal movement during swallowing.
• The Integumentary System Assessment: The color of the skin, the quality, distribution and condition of the bodily hair, the size, the location, color and type of any skin lesions are assessed and documented, the color of the nail beds, and the angle of curvature where the nails meet the skin of the fingers are also inspected.
• The Assessment of The Peripheral Vascular System: The peripheral veins are gently touched to determine the temperature of the skin, the presence of any tenderness, and swelling.
• The Assessment of The Breast and Axillae: The breasts are visualized to assess the size, shape, symmetry, color, and the presence of any dimpling, lesions, swelling, edema, visible lumps, and nipple retractions. The nipples are also assessed for the presence of any discharge, which is not normal for either gender except when the female is pregnant or lactating.
• The Assessment of The Abdomen: The abdomen is visualized to determine its size, contour, symmetry, and the presence of any lesions.
• The Assessment of The Musculoskeletal System: The major muscles of the body are inspected by the nurse to determine their size, and strength, and the presence of any tremors, contractures, muscular weakness and/or paralysis. All joints are measured for their full range of motion.
• The Assessment of The Neurological System: The Balance, gait, gross motor function, fine motor function and coordination, sensory functioning, temperature sensory functioning, kinesthetic sensations, and tactile sensory-motor functioning, as well as all of the cranial nerves, are measured.
• The Assessment of The Male and Female Genitalia and Inguinal Lymph Nodes: The skin and the pubic hair are inspected. The labia, clitoris, vagina and urethral opening are inspected among female clients. The penis, urethral meatus, and the scrotum are inspected among male clients.
• The Assessment of The Rectum and Anus: The rectum, anus and the surrounding area is examined for any abnormalities.