ASSESSING BODY

STRUCTURES AND
SYSTEMS

Rovencio E. Apilado RN., MAN

1. Be Systematic
⮚ Top of the head way down the body. To help not skipping other areas
of the body.

2. Assessing the Elderly

⮚ An elderly client might have a sensory, memory impairment, or a
decreased attention span. They are easily distracted. Interview the
family member that knows well the client.

3. Ask specific questions

⮚ Information gained from a health history forms the basis for your
care plan and enables you to distinguish physical changes and devise
a holistic approach to treatment. (Nursing Care Plan)
4. Evaluating Symptoms
client is vague in describing his chief complaint.

Ask the client to identify the symptom that is

bothering him. If he tells you, “My stomach gets
bloated” form a first impression. Hypovolemia –
abnormal decrease blood circulating in the body.

For example, does he say the bloating developed suddenly?-

take a brief of history to gather more clues.

For example, does he have severe abdominal injury. Perform a

focused physical examination.
🞂However, if he answered “No” -HEALTH HISTORY
🞂Ask associated signs or symptoms.
Note GI disorders that can lead
to abdominal distention.
🞂Now, thoroughly examine the client to evaluate the
chief sign or symptom and to detect additional
signs and symptoms- recumbent position and
observe for abdominal asymmetry.
🞂Inspectthe skin, auscultate for bowel sounds,
percuss and palpate the abdomen, and
measure abdominal girth. (measurement of
the abdomen)
Cephalo-caudal
Assessment
1. The Head

✔ Do you get headaches?

✔ If so, how painful are they? Rate from scales of 1-10.
1-3 pain is mild , 3-6 pain is moderate, 7-10
severe pain.
✔ How often do they occur and how long do they last?
✔ Does anything trigger them and how do you relieve the
pain?
✔ Have you ever had any head injury?
✔ Do you have lumps or bumps (bukol) in your heads?
2. Eyes and Vision
✔When was your last eye examination?
✔ Do you wear eyeglasses?
✔ Do you have glaucoma, cataract, or color
blindness?
✔ Does light bothers your eyes?
✔Do you have excessive tearing; blurred
vision; double vision; or dry; itchy,
burning, inflamed, or swollen eyes?
3. Ears and Hearing
✔Do you have loss of balance, ringing your
ears, deafness, or poor hearing?
✔ Have you ever had ear surgery?
✔If so, why and when?
✔ Do you wear a hearing aid?
✔Are you having pain, swelling, or
discharge from your ears? Include the
smell and color of the discharges.
4. Nose and Smell-

✔ Have you ever had nasal surgery?

✔ If so, why and when?
✔ Have you ever had sinusitis or nose
bleeds?
✔ Do you have nasal problem that impair
your ability to smell or that cause
breathing difficulties, frequent
sneezing, or discharge?
5. Mouth and Taste-

✔ Do you have mouth sores, a dry mouth,

loss of taste, a toothache, or
bleeding gums?
✔ Do you wear dentures?
✔ Do they fit?
✔Do you have a sore throat fever, or chills?
✔ How often do you get sore throat?
✔ Do you have difficulties of swallowing?
✔If so, is the problem with solids or
liquids?
✔Is it constant problem or does it
accompany a sore throat or another
problem?
✔ What anything makes it going?
6. Neck-

✔Do you have swelling, soreness, lack of

movement, stiffness, or pain in your
neck?
✔ If so, did something specific

✔ How long have you had these

symptoms?
✔Does anything relieve it or aggravate it?
7. Respiratory system- shortness of breath,
pain of wheezing, assess for cough either
productive or non productive, assess for
history of pneumonia, asthma, emphysema, or
frequent respiratory tract infections.
Tuberculosis test and chest x-ray results.

✔ Doyou have shortness of breath on exertion

or while lying in bed?
✔
✔Does breathing cause pain or wheezing?
✔ Have you ever been treated for asthma,
emphysema, or tuberculosis? If so,
✔Have you ever been treated for
pneumonia, asthma, emphysema, or
frequent respiratory tract infections?
✔ Have you ever been

✔If so, when and what were the results?

8. Chest and the Heart
✔ Do you have chest pain, palpitations,
irregular heartbeat, fast heartbeat,
shortness of breath, or persistent
cough?
✔ Have you ever had an
electrocardiogram? If so, when?
✔Do you have high blood pressure,
peripheral vascular disease, swelling of
the ankles and hands, varicose veins,
cold extremities, or intermittent pain in
your legs?
9. The breast
Ask women these questions:
✔ Do you perform monthly breast
examinations or breast health
examinations?
✔Have you noticed a lump, a change in
breast contour, breast pain, or
discharge from your nipples?
✔ Have you ever had breast cancer? If
not, Has anyone else in your family had
it?
✔Have you ever had a mammogram?
✔When and what were the results?

✔Ask men these questions: do you have

pain in your breast tissue?

✔ Have you ever noticed lump or change in

breast contour?
10. Digestive system
✔ Have you had nausea, vomiting, loss of
appetite, heartburn, abdominal pain, frequent
belching, or passing of gas?
✔ Have you lost weight or gained frequently?
✔ How often do you vowel movement? What
color, odor, and consistency of your stool?
✔ Do you use laxatives (pangpatae) frequently?
✔Have you had hemorrhoids, rectal bleeding,
hernias, gallbladder disease, or liver disease?
11. Genitourinary System
✔ Do you have urinary problems, such as
burning sensation during urination,
incontinence, urgency, retention,
reduced urinary flow, and dribbling?
✔ Do you get up during the night to
urinate? If so, how many times?
✔ What is the color of your urine? 2-3 liters
of water
✔ Have you ever noticed blood in it?
✔ Have you ever been treated for kidney
stones?
12. Reproductive System
Ask women these questions:
✔ How old are you when you start menstruating?
How long does it finally last?

✔Do you have pain or pass blood clots?

✔If you are in the transitional stage, what
perimenopausal symptoms are you
experiencing?
✔ Have you ever been pregnant?How
many times?
✔ What was the method of delivery? Is it
normal or cesarian method?
✔ How many pregnancies resulted in live
births? How many resulted in
miscarriages?
✔ Have you had an abortion?
✔ What is your method of birth control?
✔ Are you involved in a long-term
monogamous relationship?
✔ Have you had a frequent vaginal
infections or asexually transmitted
diseases

✔ When was your last gynecologic

examination and Papanicolaou test?
✔ What were the results?
Ask men these questions:
✔ Do you ever perform testicular self-
examination?

✔ Have you ever had a prostate examination?

If so, when?
✔ Have you noticed penal pain, leisure, or
testicular lumps?
✔ Which form of birth control do you use?
✔ Have you had a vasectomy?
✔ Are you involved in a long-term
monogamous relationship?
✔ Have you ever had an STD?
13. Muscular System
✔ Do you have difficulty walking, sitting or
standing?

✔ Are you steady on your feet or Do you lose

your balance easily?

✔Do you have arthritis, gout, a back injury,

muscle weakness, or paralysis?
14. Nervous System
✔ Have you ever had seizures?
✔Do you ever experience tremors,
twitching, numbness, tingling, or loss of
sensation in a part of your body?

✔Are you less able to get around than you

think you should be?
15. Endocrine System
✔ Have you been unusually tired lately?
✔Do you feel hungry or thirsty more often
than usual?
✔ Have you lost weight for an unexplained
reason?
✔ How will you tolerate heat or cold?
✔Have you noticed changes in your hair
texture or color?
✔ Have you been losing hair?
✔Do you take hormone medications?
16. Circulatory System
✔ Have you ever been diagnosed for
anemia

✔Do you bruise easily or become fatigue

quickly?
✔ Have you ever had a blood transfusion?
✔ If so, did you have any type of adverse
reaction? For example, hyperthermia.
Check the client for 15 minutes.
17. Psychological Assessment
✔ Do you ever experience mood swings or
memory loss?

✔ Do you ever feel anxious, depressed, or

unable to concentrate?
✔ Are you feeling usually stress?
✔ Do you ever feel unable to cope?
Tips for assessing a severely ill
client
✔ When the client’s condition does not allow a
full assessment, for instance, if the
client is in a severe pain, get as much
information as possible from other
sources that knows the client very well.
(It’s a waste of time if you are asking an
individual that doesn’t know the client every
well.
 keep these key points in mind:

1. Identify your self to the client and his

family.
2. Stay calm to gain his confidence and
alleviate anxiety.
3. Stay on the lookout for important
information.
4. Avoid jumping to conclusions.
(Concise, comprehensive, and complete).