After completing the chapter, you will be able to accomplish the following:

1. Describe the components of a health assessment.
2. Describe and perform the components of a general survey.
3. Weigh a patient using a bed scale.
4. Describe and conduct a health history and physical assessment.
5. Use appropriate equipment while performing health assessment.
6. Position the patient correctly to perform a systematic physical assessment.
7. Verbalize the appropriate rationales for performing the specific systematic assessment techniques.
8. Assess the skin, hair, and nails.
9. Assess the head and neck.
10. Assess the thorax, lungs, and breasts.
11. Assess the cardiovascular system.
12. Assess the abdomen.
13. Assess female genitalia.
14. Assess male genitalia.
15. Assess the neurologic, musculoskeletal, and peripheral vascular systems.

• Assessment
• Clinical Decision Making/Clinical Judgment
• Communication
• Therapeutic communication

• activities of daily living (ADLs)
• adventitious breath sounds
• ascites
• auscultation
• body mass index (BMI)
• bruit
• bruits
• cyanosis
• data
• ecchymosis
• edema
• erythema
• general survey
• health assessment
• health history
• inspection
• instrumental activities of daily living (IADLs)
• jaundice
• pallor
• palpation
• percussion
• physical assessment
• precordium
• turgor

Health assessment involves gathering information about the health status of the patient, the overall level of physical, psychological, sociocultural, developmental, functional, and spiritual health of a patient. A nursing health assessment is a holistic collection of information about how a person's health status is affecting activity levels and abilities to perform tasks. A nursing health assessment also explores how patients are coping with their health issues and any related loss of function or change in ability to function (Jensen, 2019). The nurse gathers, evaluates, and synthesizes information (data). The type and amount of information obtained vary and are determined based on the patient's needs, health care setting, and circumstances. The nurse identifies actual or potential health problems and/or needs that require nursing care based on evaluation of the gathered data. Assessment data are used to plan and implement nursing interventions and evaluate patient care outcomes to deliver the best possible care for each patient. A health assessment includes a health history and a physical assessment.

A health history is a collection of subjective data that provides information about the patient's health status. Information is ideally collected during an interview with the patient. However, the patient's family members and/or caregivers may also be an important source of data. If available, the health records of the patient can be a source of additional information. Components of the health history include biographical data, the reason the patient is seeking health care, present health concerns or history of those health concerns, past health history, family health history, functional health, and a review of systems. Questions should be adapted to the individual patient, based on the setting, situation, and ongoing information as the health assessment proceeds. Be sure to use language the patient can understand; avoid using medical terms and jargon. Nurses use therapeutic communication skills, including interviewing techniques, during the health history to gather data to identify actual and potential health problems as well as sources of patient strength. In addition, during the health history, the nurse begins to establish an effective nurse-patient relationship. Fundamentals Review 3-1 summarizes major components of a health history.

Physical assessment is a collection of objective data that provides information about changes in the patient's body systems. These data are obtained through direct observation or elicited through examination techniques, such as inspection, palpation, percussion, and auscultation (Fundamentals Review 3-2). The use of percussion and deep palpation are advanced physical assessment skills, usually performed by advanced practice professionals, health care providers with advanced education. Percussion and deep palpation will not be discussed as part of physical assessment in this chapter. Refer to information on a health assessment text for details of these advanced assessment skills. To perform a physical examination, the nurse requires knowledge of anatomy and physiology, the equipment used for assessing body systems, and proper patient positioning and draping.

Nurses should be familiar with the general health beliefs of various cultural and ethnic groups to improve the effectiveness of health care services and provide care within a cultural context. Nurses should know risk factors for alterations in health that are based on racial inheritance and ethnic backgrounds. They should also be aware of the normal variations that occur within races, and should understand how cultural characteristics, such as religion and spirituality, may impact health. When working with a patient from an unfamiliar culture, inquire about preferences and practices before beginning the examination (Jensen, 2019).

Laboratory tests and diagnostic procedures provide crucial information about a patient's health. These results become a part of the total health assessment. Nurses assist before, during, and after some diagnostic tests, and complete other testing as prescribed. Refer to Chapter 18 for information related to laboratory specimen collection for commonly prescribed laboratory testing.

For a comprehensive assessment, the nurse integrates individual assessments following a systematic head-to-toe format. However, not all assessments included in a comprehensive physical assessment are covered in this chapter. Advanced practice professionals (health care providers with advanced education) typically perform some of the assessments included in a comprehensive or focused exam, such as an internal eye examination, a vaginal examination, or a rectal examination. Refer to information on a health assessment text for details of these advanced assessment skills.

It is often not necessary to perform a comprehensive assessment during each patient encounter. Assessment focused on the circumstances and the needs of a particular patient can help to prioritize care. A short, focused general assessment can be used to establish a baseline to prioritize nursing care. This basic assessment is based on the patient's diagnosis, health problems, individual circumstances, and potential complications helps to quickly identify changes in the patent's clinical status (Henley Haugh, 2015). Nursing knowledge, expertise, and clinical reasoning and judgment guide the nurse in decisions about which assessments are a priority for an individual patient. This prioritized initial assessment may also identify specific findings to follow up on later. Fundamentals Review 3-3 provides an example of a brief, general assessment to gather pertinent data to provide a basis for prioritizing nursing care. Nurses should use clinical judgment to adapt this generic assessment to the individual circumstances of an individual patient and to monitor for changes that might require further intervention (Henley Haugh, 2015).

1. Assessment of the patient's head and neck, as well as his thorax and lungs, would be most important. Examination of his head and neck will provide additional information related to his nasal symptoms as well as his cough. Assessment of his thorax and lungs will provide additional information related to his cough and possible effects of smoking.
2. Assessment of integumentary, neurologic, and peripheral vascular systems would be important to include when caring for a patient with diabetes. Major complications of diabetes include retinopathy, nephropathy, and neuropathy. Assessment of these systems would aid in identifying possible complications from diabetes that should be addressed.
3. Assessment of the patient's abdomen would be important to aid in confirming concerns related to appendicitis. In particular, you should assess for tenderness and pain, which can indicate peritoneal irritation, such as from appendicitis. Other symptoms may include nausea, vomiting, and lack of appetite.