General Health Assessment
This article is for the public, for new nursing students and for individuals who are caring for ill members in their family. It is specifically prepared using simple terminology so that the contents can be easily understood.
The Health Assessment of a patient is an important part of caring for a patient. Upon receiving responsibility for caring for him/her a care giver must do an initial assessment so that the carer or subsequent carers can evaluate the client’s progress and condition. The carer must assess the patient/client/relative under his care so that a “baseline condition” is recorded. Subsequent assessments can be compared against this assessment.
Each profession carries out its own assessment as the level of assessment is different for the different professions. Most of the time a health care worker will do a basic health assessment of the patient. The health care workers assessment is different from a medical assessment. Also, a Registered Nurses Assessment is different from a health care giver’s assessment.
This article and level of assessment is for persons who are giving direct care to patients. It is simple and easy to do but does not go into much depth. Detailed assessments are the responsibilities of Doctors and Registered Nurses.
Many systems are used for assessing the health of a patient. Doctors normally use the body system approach. Registered Nurses use the head to toe method. This is the method which is used in this article.
| Area of assessment | Normal expectations | Significant deviations from normal |
| General Health and physical appearance. | Normal build: Height and weight are in normal proportions Personal hygiene and grooming, culturally appropriate |
Underweight; Overweight, Obese, Morbidly obese. Appears neglected; dirty clothing, offensive smell (unshaved in some cultures), |
| Assessment of skin | (Be aware of normal color for racial groups). Pink is normal. Neither dry nor scaly or moist. Right temperature (warmth) Smooth. |
Pale skin may be due to low hemoglobin. Cyanosis – blue lips etc. jaundice, albinos Dry, scaly, moist, discharging Febrile state, localized warmness or coolness Rough or localized injury, scabs |
| Hair | Normal texture for age, race Normal hairline and distribution Scalp is clean and health Normal texture? shiny & clean |
Brittle, dry, coarse, lice, dandruff, color. Alopecia, areas of hair loss, Dandruff and lesions are noted Dull, dirty, presence of vermin pests. |
| Nails | Transparent Shinny smooth Convex Pink nail beds and clean cuticles |
Streaks: horizontal or vertical (red or white) Presence of ridges Concave, thin and papery Cyanosed, pale |
| Eyes | Normal eyes: clear sclera & cornea Eyelashes turn out and away from the eyeball. When eyes are open the black of is just touching the upper eyelid. Both pupils are of equal size and constrict when light is pointed. No discharge of any type. Clear & shiny eyeball. Tolerate normal light. Normal visual acuity |
Pink, reddened, inflamed, jaundiced Eyelashes rubbing on eyeball Ptosis – weakness of the eye muscle leading to drooping upper eye lid. |
| Area of assessment | Normal expectations | Significant deviations from normal |
| Ears | Normal ability to hear Free of discharges / inflammation Free of pain, itching, and tinnitus |
Hearing impediments Swollen, Inflamed; wax, pus, blood, CSF discharge. Itching, pain, tinnitus |
| Mouth | Lips are pink, moist, smooth and glistening (cultural awareness important) Gums pink, smooth and moist Teeth are white, straight, smooth Normal tongue is red, moist Breath is fresh |
In white skinned people it will be possible to detect paleness, cyanosis, Dryness, cracks & ulcers in all cultures. Inflamed, swollen, bleeding, lesions, trauma Discolored, chalky, yellow, decayed Furry, coated, cracked, dry Bad breath is called halitosis, Ketosis in patients suffering from DKA or diet. |
| Chest, Thorax, Lungs & Heart. | Normal shaped chest cavity Normal breath sounds Absence of cough |
Pigeon breasted, barrel-shaped chest Inspiratory or expiratory wheeze, rales. Cough is present, may be productive |
| Abdomen | Flat, symmetrical, non-tenderness, No-masses |
Distended, asymmetrical due to hernias etc Tenderness, guarding Masses may be present. |
| Gait & Posture | Steady, walk normally Posture |
Unsteady gait, walk with limp, Spina bifida, unusual spinal curvature. |
| Mobility | Full range of movement in joints | Stiffness and contracture, swelling, pain |
| Mental and emotional status | Appropriate emotional response | Apprehension, anxiety, depression, anger and hostility. |
| Level of Consciousness | Alert and conscious. Orientated to time person and place. (situation) | Disorientated, inappropriate response, responds to speech, pain, or no response. |
| Presence of Prosthesis/Aids | None | Presence of eye glasses, hearing aids, contact lens, dentures, walking sticks, |
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