Integrated Health Assessment

1. Integrated Health Assessment Putting It All Together

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.

8. 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 Skin Posture Any obvious physical deformities Mobility & ROM Any involuntary movements Facial expression

13. Mood & affect Attention span Speech Hearing Personal hygiene

14. Height & weight Snellen chart 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 haven�t 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 Grade tonsils 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) Measure JVP

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 Test stereognosis Finger to nose test, run heel down shin DTR�s

30. Mental Status Gather mental status data throughout or at this time. Attention span Memory Knowledge Orientation Thought processes

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