11.01 Introduction to Health Assessment

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Overview

  • 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

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Video 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.

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Module 0 – Fundamentals Course Introduction

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