Nursing Tips: Health Assessment

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Nociceptive pain is caused by tissue damage or inflammation. This type of pain is often described as "aching" or "throbbing". Neuropathic pain is caused by nerve damage. This type of pain is often described as "shooting" or "burning".

Nociceptive and Neuropathic Pain

Health Assessment
Nociceptive pain is caused by tissue damage or inflammation. Neuropathic pain is caused by nerve damage.
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Blood pressure may be taken in either arm except when the patient has an IV infusion running, or has had a mastectomy, PICC line, or AV fistula.

Taking Blood Pressure

Health Assessment
Blood pressure may be taken in either arm except when the patient has an IV infusion running, or has had a mastectomy, PICC line, or AV fistula.
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Cranial Nerve III (Oculomotor), IV (Trochlear), and VI (Abducens) can be assessed using the corneal light reflex, the cover test, and/or the six cardinal positions of gaze.

Cranial Nerve Assessment: III, IV, and VI

Health Assessment
Cranial Nerve III (Oculomotor), IV (Trochlear), and VI (Abducens) can be assessed using the corneal light reflex, the cover test, and/or the six cardinal positions of gaze.
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Edema is documented by the depth of the indentation left by pressing a finger over the edematous area. A score of 0 means there is no clinical edema.

Edema Scoring

Health Assessment
Edema is documented by the depth of the indentation left by pressing a finger over the edematous area. A score of 0 means there is no pitting edema.
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Cranial Nerve VIII (Vestibulocochlear/Acoustic) function can be assessed with the whisper test, Rinne test, and/or Weber test.

Cranial Nerve VIII Function Assessment

Health Assessment
Cranial Nerve VIII (Vestibulocochlear/Acoustic) function can be assessed with the whisper test, Rinne test, and/or Weber test.
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Lordosis (excessive curvature of the lumbar spine) is a common finding in pregnancy and in toddlers.

Lordosis, Kyphosis, and Scoliosis

Health Assessment
Lordosis (excessive curvature of the lumbar spine) is a common finding in pregnancy and in toddlers. Kyphosis (excessive curvature of the thoracic spine) is a common finding in the older adults. Scoliosis (lateral curvature of the spine) is always abnormal.
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Cranial Nerve I (Olfactory) can be assessed by asking the patient to identify a scent (e.g., soap, coffee) while occluding one nostril at a time.

Cranial Nerve I (Olfactory) Assessment

Health Assessment
Cranial Nerve I (Olfactory) can be assessed by asking the patient to identify a scent (e.g., soap, coffee) while occluding one nostril at a time.
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Assessing Bowel Sounds - LevelUpRN

Assessing Bowel Sounds

Health Assessment
Bowel sounds cannot be called "absent" until the nurse has listened for five minutes without hearing bowel activity.
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All assessments should involve identifying the patient with two patient identifiers (e.g., name, DOB, MRN#). Remember: room number is NOT a valid patient identifier!

Patient Identifiers

Health Assessment
All assessments should involve identifying the patient with two patient identifiers (e.g., name, DOB, MRN#). Remember: room number is NOT a valid patient identifier!
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Assessing skin turgor should be done by gently pinching/lifting the skin on the sternum. If the skin "tents," (i.e., stays lifted for a prolonged period and doesn't quickly return to its original place) it could indicate dehydration.

Assessing Skin Turgor

Health Assessment
Assessing skin turgor should be done by gently pinching/lifting the skin on the sternum. If the skin "tents," (i.e., stays lifted for a prolonged period and doesn't quickly return to its original place) it could indicate dehydration.
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When assessing the eyes, the sclera should be white. The tympanic membrane of the ears, however, should be pearly gray.

Eye and Ear Assessment

Health Assessment
When assessing the eyes, the sclera should be white. The tympanic membrane of the ears, however, should be pearly gray.
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Asking the patient to stick out their tongue and move it side to side is an effective way to assess the function of Cranial Nerve XII (Hypoglossal).

Assessing Hypoglossal Nerve Function

Health Assessment
Asking the patient to stick out their tongue and move it side to side is an effective way to assess the function of Cranial Nerve XII (Hypoglossal).
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When assessing for "Accommodation," ask the patient to focus their eyes on a distant object, then to a near object. The pupils should constrict when focusing on the near object!

Assessing for Accommodation

Health Assessment
When assessing for "Accommodation," ask the patient to focus their eyes on a distant object, then to a near object. The pupils should constrict when focusing on the near object!
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"Vesicular" breath sounds are a normal finding upon auscultation (i.e., the sound air makes flowing in and out of lungs). "Adventitious" breath sounds are always abnormal!

Breath Sounds: Vesicular and Adventitious

Health Assessment
"Vesicular" breath sounds are a normal finding upon auscultation (i.e., the sound air makes flowing in and out of lungs). "Adventitious" breath sounds are always abnormal!
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A patient is POSITIVE for orthostatic hypotension if: The SBP decreases more than 20mmHg when changing position AND/OR the DBP decreases more than 10mmHg

Orthostatic Hypotension

Cardiovascular Fundamentals Health Assessment
A patient is POSITIVE for orthostatic hypotension if: The SBP decreases more than 20mmHg when changing position AND/OR the DBP decreases more than 10mmHg
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Physical Assessment Order

Physical Assessment Order

Health Assessment
Order of physical assessment: Inspect, palpate, percuss, auscultate. EXCEPT for assessing the abdomen: Inspect, auscultate, percuss, palpate (to avoid altering bowel sounds).
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