UNIVERSITY OF CHILD HEALTH

SCIENCES, LAHORE

HEALTH ASSESSMENT PORTFOLIO

SUBMITTED TO:

SUBMITTED BY:

CLASS:
BSN (GENERIC) 2ND YEAR
SESSION:
2020-2024

SUBMISSION DATE:

TABLE OF CONTENT
SR. CONTENT

1. INTRODUCTION

2. ASSESSMENT OF CARDIOVASCULAR SYSTEM

3. ASSESSMENT OF GASTROINTESTINAL SYSTEM

4. ASSESSMENT OF SKIN

5. ASSESSMENT OF EYE

6. ASSESSMENT OF THROAT

7. ASSESSMENT OF EAR

8. NEWBORN REFLEXES

9. APGAR SCORE

10. GCS SCALE

 INTODUCTION OF HEALTH ASSESSMENT

HEALTH
According to WHO;
“Health is a state of complete physical mental and social well-being and not
merely the absence of disease or infirmity”

ASSESSMENT
Assessment the systemic collection of all data and information relevant to the
care of patients, their problems and needs.

HEALTH ASSESSMENT
Health assessment is a plan of care that identfies patients’ specific needs and how
those needs will be addressed by the health care system.

PURPOSE OF HEALTH ASSESSMENT

 Systematic and continuous collection of client data.

 It focuses on client responses to health problems.
 The nurse carefully examines the clients the body parts to determine any
abnormalities.
 Nurse relies on data from different sources which can indicate significant
clinical problems.
 Health assessment provides baseline use to plan the client’s care.
 Health assessment helps the nurse to diagnose client’s problem and
intervention.

TYPES OF ASSESSMENT

 Initial assessment
 Focus assessment
 Time lapsed assessment
 Emergency assessment

INITIAL ASSESSMENT
An initial assessment also called an admission assessment is performed when
the client enters a health care from a health care agency

PROBLEM FOCUS ASSESSMENT

A problem focus assessment collects a data about a problem that has been
already identified.

EMERGENCY ASSESSMENT
EmergencyAssessment taHEALTHkes place in life threatening situations in which
preservation of life is the top priority.

Time Lapsed Assessment

It is another type of assessment takes place after the initial assessment to
evaluate any changes in client’s functional health.

METHODS OF ASSESSMENT
 Observing
 Interviewing
 Examining

INTERVIEWING TIPS
To make the most of patient interview, create an environment which the
patient feels comfortable. Use following techniques to make effective
communication;
 Select a quite private setting .
 Choose terms carefully and avoid using medical jargon.
 Speak slowly and clearly.
 Use effective communication techniques such as silence facilitation,
confirmation, reflection and claropen ended and closed ended questions .
 Confirm patients statement to avoid misunderstanding.
 Summarize and conclude with “is there anything else ?”

COMPONENTS OF HEALTH ASSESSMENT

There are two components of health assessment;
 Health history
  Physical assessment

Health History:
Health history gathers subjective data about the patient.

COMPONENTS OF A COMPLETE HEALTH HISTORY

 Present illness
 Past history
 Family history
 Personal and social history
 Exercise and diet
 Review of systems

PHYSICAL EXAMINATION
(Physical Examination is defined as a complete Assessment of a patient’s physical
and mental status
“(Physical assessment is a systematic collection of objective information that is
directly observed or elicited through examination”

PURPOSE OF PHYSICAL EXAMINATION

 To understand the physical and mental well-being of the patient.

To detect disease in its early stage
 To determine the cause and the extend of disease
 To understand any changes in the condition of disease
any improvement or regression.
 To determine the nature of the treatment or nursing care needed for
the patien
 METHODS OF PHYSICAL EXAMINATION
 Inspection
 Palpation
 Percussion
 Auscultation

INSPECTION
It is a deliberate, purposeful and systematic collection of data from the client
through the visual examination (that is, assessing by using the sense of sight).

PALPATION
Palpation is the process of using one’s hands to check the body, especially while
perceiving /diagnosing a disease or Illness.

PURPOSE OF PALPATION
• Examination of the body surface (skin, smoothness, dryness,
irregularities etc…)
• Examination of internal organs (shape, size, consistency etc…)
• To look for abnormal resistances.
• Detection of painful areas
• To feel movement of fluids within the body.

TYPES OF PALPATION

PERCUSSION
Percussion is a method of tapping the skin with the fingertips to vibrate underlying tissues and organs,
to determine the structure.
 TYPES OF PERCUSSION
 Direct percussion
 Indirect percussion

DIRECT PERCUSSION
It involves tapping lightly with the pad
of the fingers directly on the client skin.

INDIRECT PERCUSSION

It can be performed by using two finger left middle finger [Pleximeter finger] is
placed over the area and its middle phalanx is tapped with the tip of the right
middle finger or index finger [percussing finger].

AUSCULTATION
Asculatation is listening to the internal sounds of the body usually using a
stethoscope.
PURPOSE OF AUSCULATION
• Auscultation is performed for the purposes of examining the circulatory and
respiratory systems, as well as the gastrointestinal system.
• It helps to listening for body sounds typically from organs and tissues to assess
their function

DIRECT AUSCULTATION
• It involves listening to the client body sound without using any assistive instrument [eg wheezing,
chest congestion]

INDIRECT AUSCULTATION
• Involve listening to the client body sound wit

h the use of a stethoscope.

 CARDIOVASCULAR SYSTEM
Cardiovascular system consists of heart (a muscular pump) and blood vessels
• Blood vessels are arranged in two
continuous loops
– Pulmonary circulation
– Systemic circulation
• When the heart contracts, it pumps blood
simultaneously into both loops

ANATOMY & PHYSIOLOGY:

The heart itself is made up of 4 chambers, 2
atria and 2 ventricles. De-oxygenated blood
returns to the right side of the heart via the
venous circulation. It is pumped into the right ventricle and then to the lungs
where carbon dioxide is released and oxygen is absorbed.

ASSESSMENT OF CARDIOVASCULAR SYSTEM:

ASSESSMASSENT OF CARDIOVASCULAR SYSTEM
EQUIPMENTS FOR PHYSICAL EXAMINATION:
Equipment’s for the physical examination of
cardiovascular system are:
 Gloves
 Penlight
 Stethoscope
 Scale for JVP measurement
 Blood pressure cuff (sphygmomanometer)
 Small pillow
 Watch

ASSESSING THE NECK VESSELS:

ASSESSING THE NECK VESSELS:

 INSPECTION:
EVALUATING JUGULAR
VEIN DISTENTION:
 Method:
 Position the patient at 45-degree
angle.
 Turn head slightly away.
 Use a strong light tangentially.
 Observe the external jugular
vein over the
sternocleidomastoid muscle.
 Locate the internal jugular vein
pulsations.

 Determine the highest poi

Locate the “angle of Louis”
 (Sternal angel)
 Make a “T square” with
 Read the level of intersection.
 The normal jugular venous
  PALPATION:
Lightly place your fingers just medial to the trachea and below the angle of jaw.
The pulse should be regular in rhythm and have equal strength in right and left
carotid arteries.

 AUSCULTATION:

AUSCULTATING THE CAROTID ARTERY:

 Lightly place the bell of the stethoscope over the
carotid artery, first on one side of the trachea
then on the other.
 Ask the patient to hold his breath if he can while
you auscultate the artery.
 Doing so eliminate respiratory sounds that may
interfere with your findings.

ASSESSING THETHE
ASSESSING HEART
HEART

 INSPECTION:
Inspect the chest. Note landmarks to describe the findings underlying the chest
wall. Look for pulsations, symmetry of movements.
  PALPATION:

PALPATING THE APICAL IMPULSE:

To find the apical impulse, use the ball of
the hand and then fingertips, to palpate
over the pericardium. Note heaves or
thrills

 PERCUSSION:
Percuss at the anterior axillary line and continue toward the sternum along the
fifth intercostal space. The sound changes from resonance to dullness over the
left border of heart.

 AUSCULTATION:
Auscultation for heart sounds with the patient in three positions:
 Lying in supine position with the head of the bed raised 30-45 degrees
 Lying on his left
 Sitting up

AREAS FOR THE HEART ASSESSMENT

The areas for the heart assessment are following below by the help of which we
can easily auscultate heart sounds.

SR. AREA POSITION

1. Aortic Area 2nd right interspace close to the sternum.

2. Pulmonic Area 2nd left interspace.

3. ERB's Point 3rd left interspace

4. Tricuspid Area 5th left interspace close to the sternum.

5. Mitral Area 5th left interspace medial to the MCL

(Apical)
HEART SOUNDS
The normal sounds are S1 and S2 heart sounds
ABNORMAL HEART SOUNDS:
The abnormal heart sounds are S3 and S4

OVERALL, HEART SOUNDS

PERICARDIAL FRICTION RUB:
When inflamed pericardial surfaces rub together, they produce a characteristic
high-pitched friction noise known as pericardial friction rub. It is the classic sign of
pericarditis.

MURMURS:
Abnormal sounds, of longer duration as compared to normal heart sounds.
A murmur means blood is flowing abnormally across your heart valves. A
murmur may mean there's a problem with your heart.
MURMUR CONFIGRATIONS:
Configurations, or patterns, refers to change in murmur intensity.

 Crescendo
 Decrescendo:
 Crescendo-decrescendo
 Plateau shaped

Assessing the vascular system

 Inspection:
Start by general observation. Note skin color, body hair distribution. And then
observe lesions, scars, clubbing, and edema of the extremities. Check for sacrum
swelling. Examine the fingernails and toenails for abnormalities.

 Palpation:
First assess skin temperature, texture, and turgor. Then assess capillary refill time
and palpate the patient’s arms and legs for temperature and edema. Then
palpate arterial pulses.
 CAPILLARY REFILL TIME
1. Elevating one hand or foot above your heart.
2. Applying pressure to one finger or toe for up to 10 seconds.
Pressure makes the finger or toe appear pale in colour.
3. Release pressure and time how long it takes the skin to return to the same
colour as nearby tissue (Less than three seconds will be normal)

PALPATING THE ARTERIAL PULSES:

Palpate for arterial pulses by gently pressing with the pads of index and middle
fingers. Start at the top of the patient’s body at the temporal artery and work
way down. Palpate for pulses on each side, comparing pulse volume.
 AUSCULTATION:
Auscultate over each artery using the bell of the stethoscope. Assess the
upper abdomen for abnormal pulsations which indicate the presence of
abdominal aortic aneurysm. Then auscultate for the femoral and popliteal
pulses.
GRADING PULSES:
Pulses are graded on a four-point scale.

ABNORMAL PULSATION:
A weak arterial pulse may indicate decreased cardiac output or increased
peripheral vascular resistance.
ARTERIAL AND VENOUS INSUFFICIENCY:

ARTERIOR VENOUS INSUFFICIENCY

INSUFFICIENCY: WITH VENOUS INSUFFIENCY:
 WITH ARTERIAL  ULCERATIONS DEVELOP
INSUFFICIENCY:  CYANOTIC FOOT WHEN
 COOL, PALE, AND SHINY DEPENDENT
SKIN  PITTING EDEMA
 HAIR LOSS IN THE AREA  ULCER ON THE FOOT
 PAIN IN THE LEGS AND  BROWN PIGMENT
FOOT AROUND ANKLE.
 ULCERATION
 NAILS MAY BE THICK AND
RIDGED
Cyanosis and pallor:
Cyanosis and pallor may indicate poor cardiac output and tissue perfusion.

Edema:
Edema is swelling caused by too much fluid trapped in the body's tissues. Edema
can affect any part of the body. But it's more likely to show up in the legs and
feet.

Types of edema:
There are two types of edema:
 Pitting edema
 Non pitting edema

Pitting edema:
With pitting edema, pressure forces
fluid into the underlying tissues,
causing an indention that slowly fills
 Non-Pitting edema:
With non-pitting edema, pressure leaves
no indention because fluid has coagulated
in the tissues

Gastrointestinal tract
Anatomy and physiology of gastrointestinal tract

The GI tract is a hollow tube, that begins at the mouth and ends at the anus
about 25 cm long.
The GIT tract consist of smooth muscles alternating with blood vessels and nerve
tissue causing peristalsis which aids in propelling foods through the GIT track.
 Abdominal quadrants and their structures

The abdomen has four areas the right upper quadrant, left upper quadrant, right
lower quadrant and left lower quadrant.

Techniques of abdominal assessment.

 Inspection
 Auscultation
 Percussion
 Palpation
Inspection
Observe the abdomen, checking for symmetry, bumps, bulges, or masses. Note
the patient's abdominal shape and contour. Assess the umbilicus, which should be
inverted and located in the abdominal midline.

Auscultation

Auscultating for vascular sounds

Auscultate the abdomen for vascular sounds with the bell of the stethoscope.
Using firm pressure, listen over the aorta, as shown, as well as over the renal,
iliac, and femoral arteries.

percussion

Direct or indirect percussion is used to detect the size and location of abdominal

organs and to detect air or fluid in the abdomen, stomach and bowel.

Palpation
palpation is the examination of the abdomen for crepitus of the abdominal wall,
for any abdominal tenderness, or for abdominal masses. The liver and kidneys
may be palpable in normal individuals, but any other masses are abnormal.
Percussion of spleen
Percuss the lowest intercostal space in the left anterior axillary line; percussion
notes should be tympanic.
 Ask the patient to take a deep breath,
then percuss this area again. If the spleen
is normal in size, the area will remain
tympanic.
 If the tympanic percussion note changes
on inspiration to dullness, the spleen is
probably enlarged.
 To estimate spleen size, outline the spleen's
edges by percussing in several directions from
areas of tympany to areas of dullness.
Hooking method of palpating the liver

 Stand next to the patient's right shoulder, facing his feet. Place your hands
side by side, and hook your fingertips over the right costal margin, below
the lower mark of dullness.
 Ask the patient to take a deep breath as you push your fingertips in and up.
If the liver is palpable, you may feel its edge as it slides down in the
abdomen as he breathes in.

Checking for ascites

 Have an assistant place the ulnar edge of her hand firmly on the patient's
abdomen at its midline.
 As you stand facing the patient's head, place the palm of your left hand
against the patient's right flank, as shown below.
 Give the left abdomen a firm tap with your right hand. If ascites is present,
you may see and feel a "fluid wave" ripple across the abdomen.
  If you detect ascites, use a tape measure to measure the fullest part of the

abdomen. Mark this point on the patient's abdomen with a felt-tip pen so
you'll be sure to measure it consistently. This measurement is important,
especially if fluid removal or paracentesis is performed. If the patient is
hospitalized, perform this measurement at the same time each day.

Rebound tenderness

 Help the patient into a supine position with his knees flexed to relax the
abdominal muscles.
 Place your hands gently on the right lower quadrant at McBurney's point
(located about midway between the umbilicus and the anterior superior
iliac spine).
 Slowly and deeply dip your fingers into the area; then release the pressure
in a quick, smooth motion.
  Pain on release-rebound tenderness-is a positive sign. The pain may radiate
to the umbilicus.

Iliopsoas sign
 Help the patient into a supine position with his legs straight.
 Instruct him to raise his right leg upward as you exert slight downward
pressure with your hand on his right thigh.
 Repeat the maneuver with the left leg.
 When testing either leg, increased abdominal pain is a positive result,
indicating irritation of the psoas muscle
Obturator sign
 Help the patient into a supine position with his right leg flexed 90 degrees
at the hip and knee.
 Hold the leg just above the knee and at the ankle; then rotate the leg
laterally and medially.
 Pain in the hypogastric region is a positive sign, indicating irritation of the
obturator muscle.

Abdominal distention
Distention may result from gas, a tumor, or a colon filled with feces. It may also
be caused by an incisional hernia, which may protrude when the patient lifts his
head and shoulders.
“Five F’s” of abdomen

Bowel sounds
 SKIN
“The skin covers and protect the internal structures of the body.
It consists of two distinct layers.
 Epidermis
 Dermis

Assessment of skin
 Techniques for examination of skin:
1. Inspection
2. Palpation

INSPECTION
Observe the skin overall appearance.
Focusing on color, moisture, texture, turgor, and temperature

 Color
Brusing,Cyanosis, pallor, Erythema.
 Moisture
 Observe the skin moisture content.

 Texture and turgon

Inspect and palpate the skin’s texture nothing its thickness and mobility.

It should look smooth and be intact.

Temperature Palpate the skin bilaterally for the temperature using the dorsal
surface of your hands and fingers. The dorsal surface is the most sensitive to
temperature.
 Skin lesions
Skin lesions is the damage of skin due to some disease or injury.

•Distribution:
Anatomic location and distribution.

•Configuration
Arrangement of lesion, linear,
clustered

Type of lesions
 Primary lesions
 Secondary lesions.
 Pressure Ulcer
“Pressure Ulcers are the localized area that cause skin breakdown due to
prolonged pressure”.

STAGES OF PRESSURE ULCER

Stage1:
Ulcers have not yet broken through the skin.
Stage 2:
Ulcers have a break in the top two layers of skin.
Dermis, epidermis
Stage 3:
Ulcers affect the top two layers (dermis, epidermis) of skin, as well as fatty tissue
(Subcutaneous tissues).
Stage 4:
Ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone.
 Eye Assessment

Anatomy of eye
The eye is made up of three coats, which enclose the optically clear aqueous
humor, lens, and vitreous body. The outermost coat consists of the cornea and
the sclera; the middle coat contains the main blood supply to the eye and
consists, from the back forward, of the choroid, the ciliary body, and the iris.

Visual acuity test

The visual acuity test is used to determine the smallest letters you can read on a
standardized chart (Snellen chart) or a card held 20 feet (6 meters) away. Special
charts are used when testing at distances shorter than 20 feet (6 meters)
The most common types of visual acuity tests
include:
 The Snellen eye chart: The Snellen visual acuity test is probably what you're
picturing if you think of a vision test.
 Snellen alphabet chart.

 Snellen alphabet chart is for literate people

 Therandom E chart: The random E visual acuity test is
similar to the Snellen eye chart.
 Assessment of Neck

Anatomy of neck
Neck consists of cervical vertebrae the major neck and shoulder muscles and their
ligaments
Other important structures of neck include
 Trachea
 Thyroid gland

Chain of lymph nodes.

Assessment of neck

Assessment techniques for neck:

1-Inspection
2-Palpation
3-Auscultation

Inspection of neck
Inspect the patients neck .it should be symmetrical and skin should be intact, note
any scar, no thyroid gland and lymph node enlargement should be present. Ask
the patient to move the neck trough entire range of motion.
 Palpation
Palpate the patient’s neck using the finger pads of both hands.
Assess the lymph nodes for size, shape, mobility, consistency
Temperature and tenderness comparing nodes bilaterally.

Palpating the thyroid

To palpate the thyroid stand behind the patient and put your hands around his
neck with fingers of both hands-on lower tracheae.
Ask the patient to swallow as you feel the thyroid thymus.

The isthmus should rise with swallowing because it lies across the trachea .
Auscultation of neck:
Using light pressure on the bell of stethoscope listen over carotid arteries. Ask the
patient to hold breath while you listen to prevent

Breath sounds from interfering with sounds of circulation.

 Assessment of ear

Anatomy of hear
The ear is the organ of hearing and balance. It consists of a cavity in the skull
structure lined with soft tissue, which encloses three distinctive spaces filled with
air or liquid (external, middle and inner ear); these distinctive spaces host both
sound transmission mechanisms and sensory apparatuses

Hearing acuity tests:

Weber’s test
Rinne test

Weber’s test

In Weber’s test, a tuning fork is used

To evaluate bone conduction. Tuning fork should be tuned to the frequency of
normal human speech ,512cycles/second.

To perform Weber’s test:

1-Strike the tuning fork lightly against your head.
2-Place the vibrating fork on the patients for head at the midline or on the top of his head.

Rinne test:
Rinne test is used to compare air conduction with bone conduction of sound.
To perform this test:
1-strike the tuning fork against your hand.
2-place the vibrating fork over the patient’s mastoid process.

Test results:
 Newborn Reflexes

Reflexes are involuntary movements or actions in which some are

spontaneous, occurring as a part baby usual activity and other are
responses to certain actions.
These reflexes aid newborns to identify brain function and nerve
activities over their body. Specific focus should be given to newborns’
alertness, muscle tone and strength, head control, and response to
manipulation and handling.
Here are simple maneuvers for 11 newborn reflexes.
1. Blink Reflex

Blink reflex is the rapid eye closure exhibited by newborns upon coming
of objects near it. Similar with adults, this reflex serves a protective
function against hurting the eye. This is important in assessing
newborns’ visual attentiveness.

2. Rooting Reflex
Brushing the cheek or stroking near the mouth of the newborn will
cause the head of the newborn to turn to that direction. This reflex is
called rooting reflex, which helps the baby find the source of food.

3. Sucking Reflex
 • Touching the newborn’s lips causes the baby to make sucking
motions. Like rooting reflex, sucking reflex helps the baby find
food. For an instance, when the lips of the baby touch the
mother’s breast or a bottle, the baby would begin sucking and so
food is taken in. Sucking reflex disappears at six months of age.

4. Extrusion Reflex

Until four months of age, any food placed on the anterior portion of
the tongue of babies will be expelled by them. This serves a protective
function by preventing the baby from swallowing substances that are
toxic or poisonous. This is also the reason why complementary feeding
or introduction of solid food is done at about six months of age.

6. Walk-in-Place Reflex

If newborns are held in a vertical position with their feet touching

a hard solid surface, newborns will take few, alternating steps. This
can last until three months of age, the time where they start to
bear a good portion of their weight without being hindered by this
reflex.

7. Tonic Neck Reflex

• Turning a newborn’s head to one side will cause the

extremities to on that side extend s while the
opposite extremities contracts or flexes. This is also
called boxer of fencing reflex because of the position
of the newborn. Of all reflexes, this is the one which
 appears to have no function. However, it is being
linked to eye stimulation and handedness. This
disappears between 8-12 weeks.

8. Moro Reflex
 The Moro reflex is often called Startle reflex because
it usually occurs when a baby startled by a sound or
movement. In response to the sound, the baby
throws back his head, extends out the arms and legs
back in this reflex lasts about five to six months.

9. Babinski Reflex
• When the nurse strokes the sole of the foot in an inverted “J”
curve from the heel upward, the newborn’s toes fan. It is only in
newborns that positive Babinski reflex is considered normal. It
rd
normally disappears after the 3 month.

10. Reflexes of spinal cord integrity

There are three reflexes to test spinal cord integrity of newborns.
First on the list is magnet reflex, which can be elicited by
applying pressure on the soles of the foot of newborns lying in
supine position. As a response, the newborns would push
back against the pressure.
• The second reflex to test spinal cord integrity is called crossed
extension reflex. This is exhibited by the newborn in supine
position by raising his other leg and extending it when the
other leg is extended and, the sole of that foot is irritated or
rubbed by a sharp object (e.g., thumbnail). This is like the act
of the newborn trying to push the hand away that irritates the
other leg.
• Lastly, newborns lying in prone position would flex their trunk
and swing their pelvis towards the direction of the touch
 when their paravertebral area is touched by a probing finger.
This reflex is called trunk incurvation reflex.

11. Landau Reflex

• Babies will exhibit some degree of muscle tone if they were made
to lie in a prone position with the nurse’s hand supporting the
trunk. Babies who will sag into an inverted “U” position show
extremely poor muscle tone. In such cases, further assessment
and management is needed.
 Apgar score

“It is a quick test to performed on a baby at 1 to 5 minutes after birth”

The 1-minute shows score determine how well the baby tolerated the
birthing process. The 5-minute score tells the health care provider how
well the baby is doing outside the mother womb. In rare cases the test
will be done 10 minutes after birth.

Components:
The scoring system provide a standardized
assessment for infants after delivery. The Apgar score compromise five
components:
1. Color
2. Heart rate
3. Reflexes
4. Muscle tone
5. Respiration
 Apgar score sign:
The Apgar score measure 5 things to check baby health.
Each is scored on a scale 0 to 2 with 2 being the best score:
A: Appearance (skin color)
P: Pulse rate (heart rate)
G: Grimace response (reflexes)
A: Activity (Muscle tone)
R: Respiration (breathing rate and effort)

Scoring system:

Apgar scores of 0-3 are critically low. Apgar scores of 4-6 are below
normal. Apgar scores of 7are consider as normal.
 Glasgow’s coma scale (GCS)

Glasgow coma scale (GCS) is used to describe the general level of

consciousness in patient with traumatic brain injury (TBI) and to define broad
categories of head injuries. GCS are devided into 3 categories:
. Eye opening(E)
. Motor response(M)
. Verbal response (V)
The score is determined by the sum of the score in each of the 3 categories,
with a maximum scor of 15 and a minimum score of 3

Responses guided by GCS:

The 3 responses measured are:

. Best motor response – maximum scor of 6

. Best verbal response -maximum score of 5

. Eye opening -maximum score of 4