Introduction to Health Assessment

While it is impossible to list every possible disorder of the various body systems, this course will attempt to provide the outline for a basic physical assessment to allow the nurse the ability to determine if the patient has any outlying abnormalities. This is not intended to be a complete guide to pathophysiology but to provide a framework for completing a thorough head to toe assessment.

- - - Checklist for General Assessment
      Body Structure/Mobility
      Behavior
      Health History
      
      Vital Signs
      Height Weight
      Pulse Rate
      Respirations
      Temperature
      Blood Pressure
      Pain
      
      Integumentary
      Inspect: color, moisture, hair, rashes, lesions, pallor, edema
      Palpate: temperature, turgor, lesions, edema, texture
      
      Scalp
      Inspect: shape, symmetry
      Palpate: tenderness, deformity
      
      Nails
      
      Inspect: shape, color
      Palpate: capillary refill
      
      Head
      
      Inspect: symmetry, shape, size, uniformity
      
      Neck
      
      Inspect: symmetry, lesions, scars
      Palpate: tenderness, lymph nodes, thyroid gland, TMJ
      
      Eyes
      
      Inspect: interior and exterior, visual fields, acuity, reflexes
      
      Ears
      
      Inspect: color, shape, symmetry, interior inspection
      Palpate: tenderness, deformity
      
      Nose
      
      Inspect: shape, symmetry, interior inspection
      Palpate: frontal sinus, maxillary sinuses
      
      Mouth and Throat
      Inspect: exterior and interior
      
      Thorax and Lungs (anterior and posterior)
      Inspection: respiration quality, symmetry, deformity, tracheal location
      Palpation: tenderness, fremitus, chest expansion
      Percussion: percussive tones, diaphragmatic excursion
      Auscultation: breath sounds and quality
      
      Heart and Great Vessels
      Inspection: jugular venous pulse
      Palpate: pulses, PMI
      Auscultate: heart sounds (bell and diaphragm)
      
      Peripheral Vascular System
      Inspect: color, edema
      Palpate: temperature, edema
      
      Abdomen
      Inspect: discomfort, uniformity, color, symmetry, scars, hernia, peristalsis, pulsations
      Auscultate: bowel sounds, bruits
      Percussion: four quadrants, liver, spleen, renal tenderness
      Palpation: light to deep, liver, spleen, aorta, rebound tenderness, fluid wave
      
      Musculoskeletal
      Inspection: asymmetry, deformity, atrophy
      Palpation: major joints, tenderness, deformity, range of motion
      
      Neurological
      Inspect: mental status (health history), cranial nerves, coordination, movement, senses
      Palpate: motor strength, muscle tone, reflexes, senses
      
      Genitourinary
      Inspect: general appearance, lesions, scars
      Palpate: breast exam, testicular exam, prostate exam, vaginal exam, Pap smear
      
      Lymphatic
      Palpate: assess lymph node locations

Unlock the Complete Study System

Used by 300,000+ nursing students. 99.25% NCLEX pass rate.

200% NCLEX Pass Guarantee.
No Contract. Cancel Anytime.

Transcript

Hey there! This is Jon Haws and I wanted to welcome you to this assessment module of our Fundamentals course. The purpose of this module is to really give you a framework for how to conduct a thorough assessment on your patient. We’re not gonna list every abnormality you can find. We’re gonna talk about that more in the different courses, in the Med Surg course, Cardiac Course, OB course, etc. With this module, it’s really designed to do is it’s designed to help you develop a framework, develop a step by step process for conducting an assessment and then to help you kinda determine, does the patient have any abnormalities? Does the patient deviate from the norm? And if it deviate from the norm, then we need to investigate that further. So, I want you to dive into this course. I want you to use this checklist, use this method, because it’s really gonna help you conduct a thorough head to toe complete assessment on your patient. So, go ahead and dive in and I’m excited to cover all this.