Health Assessment

likediamond

PhysicalExaminationHealthAssessmentChapter9PowerPoint.pptx

Home >Nursing homework help >Health Assessment

Chapter 9

General Survey and Measurement

General Survey Characteristics

The general survey is a study of the whole person

Covers general health state and any obvious physical characteristics

Provides an overall impression

Includes objective parameters that apply to the whole body

Includes areas of physical appearance, body structure, mobility, and behavior

Objective Data: Physical Appearance

Age: person appears his or her stated age

Sex: sexual development appropriate for gender and age

Level of consciousness: person alert and oriented, attends to your questions and responds appropriately

Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion

Facial features: symmetric with movement

Overall appearance: provide general statement r/t presence or absence of distress

Objective Data: Body Structure

Stature: height appears within normal range for age, genetic heritage

Nutrition: weight appears within normal range for height and body build; body fat distribution even

Symmetry: body parts look equal bilaterally and are in relative proportion

Posture: person stands comfortably erect as appropriate for age

Position: description of patient’s position during assessment

Objective Data: Mobility

Gait: normally base is as wide as shoulder width

Foot placement: accurate; walk smooth, even, and well-balanced; and associated movements, such as symmetric arm swing, are present

Range of motion: note full mobility for each joint, and that movement is deliberate, accurate, smooth, and coordinated

No involuntary movement

Objective Data: Behavior (1 of 2)

Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation (e.g., thoughtful, serious, or smiling)

Note expressions both while face is at rest and while person is talking

Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly

Speech: articulation (ability to form words) clear and understandable

Stream of talking is fluent, with an even pace

Conveys ideas clearly

Word choice appropriate to culture and education

Person communicates in prevailing language easily by himself or herself or with interpreter.

Objective Data: Behavior (2 of 2)

Dress: appropriate to climate, looks clean and fits body, and is appropriate to person’s culture and age group; for example, normally:

Amish women wear clothing from nineteenth century.

Indian women may wear saris.

Culturally determined dress should not be labeled as bizarre by Western standards or by adult expectations.

Personal hygiene: person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group

Objective Data: Measurements Weight

Use a standardized balance or electronic standing scale.

Instruct person to remove his or her shoes and heavy outer clothing before standing on scale.

When sequence of repeated weights is necessary, aim for approximately same time of day and same type of clothing worn each time.

Record weight in kilograms and pounds.

Show person how his or her weight matches up to recommended range for height.

Compare person’s current weight with previous visit.

Recent weight loss may be explained by successful dieting.

Weight gain usually reflects overabundant caloric intake, unhealthy eating habits, and sedentary lifestyle.

Objective Data: Measurements

Height

Use wall-mounted device or measuring pole on scale.

Align extended headpiece with top of the head.

Person should be shoeless, standing straight, looking straight ahead, with feet and shoulders on hard surface.

Body mass index

Body mass index is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition.

Objective Data: Waist Circumference

Assesses body fat distribution as indicator of health risk.

Excess abdominal fat is an independent risk factor for disease, over and above that of body mass index (BMI).

Waist circumference measured in inches at smallest circumference below rib cage and above iliac crest

Hip circumference measured in inches at largest circumference of buttocks

Note the measurement at end of normal expiration.

General survey r/t infants and children

Interpret based on age and developmental ability

Behavior and parental bonding

Measurement—weight and length (height)

Physical growth based on CDC growth charts

Head circumference and chest circumference

General survey r/t aging adults

Normal consequence of aging changes r/t posture and gait

Measurement—weight and height

Developmental Competence

Dwarfism

Hypopituitary dwarfism

Achondroplastic dwarfism

Gigantism versus acromegaly (hyperpituitarism)

Anorexia nervosa

Endogenous obesity—Cushing’s syndrome

Marfan syndrome

Abnormalities in Body Weight and Proportion