Assessment

Rita Pokharel
 Definition
• Systematic and continuous collection,
organization validation and documentation of
data.
Assessment involves several steps:
• Collecting data from a variety of sources
• Validating the data
• Organizing data
• Categorizing or identifying patterns in the data
• Making initial inferences or impressions
• Two types of information are collected
– subjective and
– objective.
Eg:
 Purposes
• To collect baseline information
• To identify the problems of the client
 Methods
• History
• Physical examination
• Lab investigations
 History
• Accurate diagnosis rests firmly upon the
foundation of a thoughtful and inclusive
history.
 Personal ID
• Name, address, phone, nearest of kin. Age sex
race, occupation, marital status.
• Date of Entry and Hospital Number
• Source and Reliability of Informant
• Chief complaints ：
– Presenting complaints and duration in
patients’ own word.
– Eg:
 Present Illness(PI) ：

A ： The immediate history that brought the

patient to the hospital
B ： Background history of disease leeding to
the immediate history
C ： Significant positive and negative data
that might give clues useful in
differential diagnosis
 Family History ：

A ： Father
B ： Mother
C ： Each sibling
D ： History of disease in which heredity or
contact may play a role.
E ： Record a family tree
 Marital History ：
A ： Age and health of spouse ； year married

B ： Ages and health of children

C ： Previous marriages
 Past History ：
• A ： Hospitalization
• B ： Illness
• C ： Trauma
• D ： Operations
• E ： Childhood diseases
 Personal history
• Birth
• Development
• Age of schooling
• Work history
• Relationship
 Social History ：
• A ： residences
• B ： Education
• C ： Employment
 Habits ：
• A ： Appetite
• B ： Use alcohol ， coffee ， tea ， tobacco
• C ： Sexual habits

• Allergies ：
• Hay
fever ， asthma ， hives ， food ， skin ， dr
ugs
 Environmental Hx

• Work setting
• Exposure to hazardous materials and loud noises
• Hobbies
• Work related symptoms
• Living near farms, mines, shipyards, factories
• Housing condition
• Drug Use.
– Medicines
– Drug abuse
 Physical examination

• It is the process of examining the patient’s body to

determine the presence or absence of physical
problems

• The goal of the physical examination is to obtain valid

information concerning the health of the patient

• The examiner must be able to identify, analyze, and

synthesize the accumulated information into a
comprehensive assessment
 The four cardinal principles of physical
examination

• Inspection
• Palpation
• Percussion
• Auscultation
“teach the eye to see, the finger to feel, and the ear
to hear”
 Equipment for physical examination
• Required
– Stethoscope
– Tongue blades
– Penlight
– Tape measure
– Sphygmomanometer
– Reflex hammer
• Optional
– Depends upon condition
 Important aspects of physical
examination

• Elegant appearance
• Decent manner
• Kind attitude
• Highly responsibility
• Good morals
 Important aspects of physical
examination

• Wash hands

• Washing with soap and water is an

effective way to reduce the transmission
of disease
 Sequential

• Conducted in head to toe order: head ---

neck---chest---abdomen---spine---
extremities---anal---genital---nerve system

• Patients tire quickly when asked to “sit up”,

“lie down”, “turn on your left side”, “sit up”,
“lie down” and so on
 Important aspects of physical
examination---patient

The patient should be made as comfortable

as possible during the examination

The patient should be properly draped

 Important aspects of physical
examination

Where is the bed placed?

• When possible, the examining table/bed be

situated so that the examiner has access to both
sides of the patient

• An ideal arrangement is to have the table

located in the center of the examining room
 Important aspects of physical
examination

Where does the examiner stand?

• Stand right side of the bed

• Exam with one’ right hand

 Important aspects of physical
examination

How to perform the physical examination?

• Sequential

• Proper expose
 Important aspects of physical
examination

• The examiner should continue speaking to the

patient

• Showing care to his disease and answer to

patient’s questions

• It can not only release patient’s nervousness,

but also help to establish the good relationship
 Precaution to take

• The use of gloves should provide adequate

protection when performing the physical
examination or when handling blood-soiled or
body fluid-soiled sheets or clothing

• Gloves should be worn when examining any

individual with exudative lesions or weeping
dermatitis
 Precaution to take
• Hands or other contaminated skin surfaces
should be washed thoroughly and immediately it
accidentally soiled with blood or other body fluids

• All sharp items, such as needle, must be handled

with extraordinary care to prevent injuries

• A patient may be in isolation or on special

precautions if he/she is suffering from a
contagious disease
 Inspection
• Method of observation used during physical examination

• First step in examining a patient or body part

• It includes a general survey of the patient’s

mental status posture

body movement gait
breath odor skin
speech stature
state of nutrition
 How to inspect

• Make sure the room is in a comfortable

temperature
• Use good lighting, preferably sunlight
• Look and observe before touching
• Completely expose the body part you are
inspecting while draping the rest
• Compare symmetrical body parts
 Mental status and personal grooming

• Does the patient look well or sick?

• Is he comfortable in bed?
• Does he appear in distress?
• Is he alert or is he groggy(?
• Does he look acutely or chronically ill?
poor nutrition sunken eyes temporal wasting loose skin
• Does the patient appear clean?
• Is her hair combed?
 Mental status and personal grooming

The answer to these questions may provide useful

information about the patient’s self-esteem
and mental status
 Posture

• It may reveal significant information

(Congestive heart failure: sit in a chair the entire night
Patients with body/tail of the pancreatic cancer: assuming
an upright or sitting posture)

• Thus the positions of the patient at the time of the

examination may suggest certain disease possibilities
• A history of assuming certain positions to obtain relief
from pain also may be of diagnostic importance
 Palpation
• Methods of “feeling the hands used during physical
examinations

• The examiner touches and feels the patient’s body part

with his hands to examine
size consistency
texture location
tenderness of an organ or body part

• The palpation of abdomen is particularly important

 How to perform palpation

• As with inspection, the initial step in palpation

may be facilitated by distracting conversation or
questions regarding the history

• It should be emphasized that during the

preliminary stages, muscle relaxation is the goal
ask the patient to flex the thighs and knees
 Types of palpation

• Light palpation

• Deep palpation
 Light palpation
• Using the flat part of the right hand or the pads of the
fingers, not the fingertips

• The fingers should be together

• Sudden jabs are to be avoided

• The hand should be lifted from one area to area

instead of sliding over the abdominal wall
 Light palpation
• The palpating hand should be warm, because cold
hands may produce voluntary muscular spasm called
“guarding”

• Engaging the patient in conversation often aids in

relaxing the patient’s abdominal musculature

• Ask patient to be in a supine position and to flex the

thighs and knees
 Light palpation
• During expiration, the rectus muscles usually
relax and soften

• Used to feel for pulses, tenderness, muscle

spasm, rigidity, surface skin texture,
temperature, moisture or mass, its size,
location, hardness and outline
Light palpation
 Deep palpation
• Used to determine organ size as well as the presence
of abdominal masses

• The flat portion of the right hand is placed on the

abdomen

• Pressure should be applied to the abdomen gently but

steadily

• The patient should be instructed to breathe quietly

through the mouth and to keep arms at the sides
Deep palpation
 Bimanual palpation
• Uses two hands, one on each side of the body
part being palpated

• Placing the left hand over the pack of organs to

be examined, in order to fix or elevate the
organs. It may be helpful for the right hand
palpation

• It is employed during the processes of liver,

spleen, kidney or abdominal masses examination
Bimanual palpation
Bimanual palpation
 Percussion
• A methods of “tapping” of body parts during physical
examination with fingers, hands, or small instruments to
evaluate the size, consistency, borders and presence of
fluid in body organs

• Percussion of a body part produces a sound that

indicates the type of tissue within the organ

• It is particularly important in examining the chest and

abdomen
 Percussion
• Tapping on the chest/abdominal wall is transmitted
to the underlying tissue, reflected back, and picked
up by the examiner’s tactile and auditory sense

• The sound heard and tactile sensation felt are

dependent on the air-tissue ratio
 Percussion
It is used to detect diaphragmatic
movement, the size of heart, edge of liver
and spleen and ascitis.
 Percussion

• It should be performed from upside to downside

sequential

• From one side to the other side

• Comparison
 Quality of Percussion

According to the identity of the tissue, amount of air gas

containing and distance of the organ from the skin
surface, the percussion sound include:
resonance
Tympany
Hyperresonance
Dullness
Flatness
 Quality of Percussion

• Resonance: percussion over a structure containing air

within a tissue, such as the lung, produces a resonant,
higher-amplitude, lower-pitched note

• Tympany: percussion over a hollow air-containing

structure, such as the stomach, produces a tympanic,
higher-pitched, hollow quality note
 Quality of Percussion
• Hyperresonance: the quality of percussion sound is
between the resonance and tympany. Such as in
children, pulmonary emphysema

• Dullness: percussion over a solid organ, such as the liver,

produces a dull, low-amplitude, short-duration note
without resonance.

It occurs when the air content of the underlying tissue is

decreased and its solidity is increased.
 Quality of Percussion

• Flatness: very short, and high pitched (absolute

dullness).

Flatness occurs when there is no air present in

the underlying tissue. For example, flatness is
found over the muscle of the arm or thigh.
 Sounds produced by Percussion

Record of finding Quality Where heard

Resonance Hollow Normal lung
Hyperresonance Booming Air-filled lungs
Tympany Drumlike Abdomen
Dullness Thudlike Liver
Flatness Flat Muscle, bone
 Auscultation

• A method used to “listen” to the sounds of the

body during a physical examination

• Performed by listening through a stethoscope,

and to evaluate the frequency, intensity, during,
number and quality of sounds
 How to use the stethoscope

• Do’s
warm the diaphragm or bell
explain what you’re listening for and answer patient’s
question promptly

• Don’ts
do not apply too much pressure when using the bell
do not try to listen through clothing
 How to auscultate
• Eliminate distracting noises
• Expose the body part you are going to auscultate
• Use the diaphragm to listen for normal heart
sounds, and bowel sounds
• Press the diaphragm firmly
• Use the bell to listen for abnormal heart sounds
or bruits
• Hold the bell lightly
 Smelling
• A method used to evaluate the relationship
between abnormal odor from the patient and
disease

• The odor is elicited from the exudates of skin,

mucosa, respiratory tract, GI, blood etc

• Abnormal odor may also provide important clues

for the diagnosis of the disease