Health Assessment: Learning Outcomes
1. Identify the purposes and components of a physical examination.
2. Discuss the differences among a comprehensive, focused and ongoing physical examination.
3. Describe how to prepare for a physical examination.
4. Explain the skills used in a physical
The Nursing Physical Examination
�Part of a general health assessment
�Used to gather data about the client
�Focuses on functional abilities and responses to illness/stressor
-RN responsibility; cannot be delegated
-Always do an initial assessment; need a baseline including initial vital
Purposes
The nurse performs a physical examination to
�Establish baseline data
�Identify nursing diagnoses, collaborative problems, or wellness diagnoses
�Monitor the status of an identified problem
�Screen for health problems
-Getting a data set to evaluate patie
Types of Physical Examinations
Comprehensive-initial; upon hospitalization, or when you have an annual physical or home health visit
�Interview (health history)plus complete head-to-toe examination
-Focused-(emergency/urgent)
-client said something and now you want to focus on that pro
Organizing the Examination
Head-to-toe(always compare one side with the other side; look for symmentry)
-Starts at the head
-Progresses "down" the body, to the toes
-System-related data found throughout
�Heart sounds - chest
�Pulses - periphery
Organizing the Examination (continued)
Body systems
-Gathers system-related data all at once
-May be done in a predetermined order that mimics head-to-toe
�Neurological
�Cardiovascular
�Respiratory
�Gastrointestinal
Preparing Yourself: What the Nurse Needs
�Theoretical knowledge
�A and P, techniques
�Self-knowledge
-be comfortable with saying "I don't know"
�Skill and comfort level
�Willingness to seek help
�Knowledge about client situation
-think through be prepared; think about all the steps before enteri
Preparing the Environment
�Privacy is key
�Draping
�Use of curtains
�Noise control
�TV/radio off
�Enable visualization
�Adequate lighting
�Flashlight if needed
-ask people to leave the room
-close the door
-hang a sign on the door(please knock, patient procedure in progress)
Preparing the Client
Promote client comfort
�Develop rapport(introduce yourself, address patient by their name and title;never use their first name)
�Explain the procedure(announce when you are going to touch the client)
�Respect cultural differences
�Use proper positioning(d
Physical Assessment Skills
4 major skills used (plus 1)
�1. Inspection
�2. Palpation
�3. Percussion
�4. Auscultation
�(Sometimes Olfaction)-smelling
Inspection
�Use of sight to gather data
�Used throughout physical examination
�Tools to enhance inspection
�Otoscope(advanced nursing;might hand them to the dr)
�Ophthalmoscope(advanced nursing;might hand them to the dr)
�Penlight
�Examples: skin color, gait, genera
Palpation
�Use of touch to gather data
�Begin with light pressure, moving to deep palpation(advanced skill)
�Use caution with deep palpation
�Parts of the hands used
�Fingertips: tactile discrimination(is the ability to differentiate information received through th
Percussion
�Tapping on skin to elicit sound
�Direct(one handed; directly on patient)
�Indirect(two handed; nurse taps own finger)
�Useful for assessing abdomen, lungs, underlying structures
�Example: distended bladder
-advanced skill-not taught to 2 year nurses
Auscultation
� Use of hearing to gather assessment data
� Direct auscultation
-Listening without an instrument
-listening to someone speak
-hear lung congestion through a cough, weezing
� Indirect auscultation
-Use of a stethoscope to listen
-Diaphragm - high-pitched
Olfaction
�Use of the sense of smell
-Fruity or acetone scent indicates ketoacidosis(sign of diabetes)
-Urine scent indicates leakage or UTI
-Alcohol scent indicates imbibing(drinking alcoho), and other behavior should be evaluated(some diabetics can give off an al
The nurse would be able to gather the most complete data about a client's pedal edema using the assessment skill of
a) Inspection
b) Palpation
c) Percussion
d) Auscultation
B) Palpation
While inspection will alert the nurse to the presence of edema , palpation will determine the degree to which it has occurred (e.g. scale for pitting edema)
Age Modifications for the Physical Examination
Infants
� Parents hold(against their chest)
� Attend to safety
-if on a table the table needs to be padded, and never ever turn your back away
-take clothes and diaper off (for weight)
Toddlers(1-3 yrs old)
�Allow to explore and/or sit on parent's lap
�In
Age Modifications for the Physical Examination (continued)
Preschoolers(3-5 yrs old)
�Use doll for demonstration
�Still may want parental contact
�Allow child to help with examination
School-age children(6-12 yrs old)
�Show approval and develop rapport(ask about school)
�Allow independence
�Teach about workings o
Age Modifications for the Physical Examination (continued)
Adolescents(13-15 yrs old)
�Provide privacy(might not want parents in room w/them)
�Concerned that they are "normal"
�Use examination to teach healthy lifestyle( teach about smoking and drugs; breast and testicular exams)
�Screen for suicide risk
Young/mi
Age Modifications for the Physical Examination (continued)
Older adults
�May need special positioning related to mobility
�Adapt examination to vision and hearing changes
�Assess for change in physical ability
�Assess for ability to perform activities of daily living(grocery shopping, driving, using a phone,makin
SPICES
�S Sleep disorders
�P Problems with eating or feeding
�I Incontinence
�C Confusion
�E Evidence of falls
�S Skin breakdown
Basic Components of a Comprehensive Examination: The General Survey
�Begins at first contact
�Overall impression of client
�Deviations lead to focused assessments
�Appearance/behavior
�Grooming/hygiene
�Body type/posture
�Mental state
�Speech (Verbal/Nonverbal)
�Vital signs
�Height/weight
�Cultural/ethnic
Basic Assessments: Skin
Integumentary
�Skin characteristics
�Color
Pallor-paleness/loss of red/pink skin
Cyanosis- appearance of a blue/gray/ashen coloration
Jaundice-yellow or orange
Flushing-become red in the face
Erythema-redness caused my inflammation/infection/injury
Ecchym
It would be most important for the nurse to include the fingernails in a basic assessment for the client with
a. A neurological condition
b. A musculoskeletal condition
c. A integumentary condition
d. A respiratory condition
Answer: C
Changes in the color of the nailbed as well as the shape and texture of the nail can indicate underlying issues with oxygenation
Basic Assessments: Head (HEENT)(Head,ears,eyes,neck,throat)
Head
�Skull and face
�Size
�Shape-symmetry
�Facial features-jaw(TMJ)
�Eyes-inspect and palpate
�External eye
�Sclera
�Pupils
accommodation test part of PERRLA(pupils, equally, round, reactive to light, accommodation)
�Visual acuity-(reading an eye chart-c
Basic Assessments: Ears, Nose, Mouth
�Ears/hearing(inspect and palpate)
�External ear-placement(pinna/top of ear should be level w/ the corner of the eye)
�Inner ear(4 year degree program/advanced skill)
�Tympanic membrane
�Hearing
�Weber's test(advanced skill)
�Rinne's test(advanced skill)
Basic Assessments: Neck, Breasts
Neck-inspect and palpate
� Musculature-symmetry,ROM,skin condition
� Trachea- midline, palpate tracheal rings
� Thyroid gland-smooth, firm and tender- if enlarged osculate with bell(Bruit sounds)
� Cervical lymph nodes
Breasts-4 quadrants
�Size - unequal
Basic Assessments: Lungs
Chest and lungs-inspected, palpated, percussed(advanced skill) and osculated
�Describe size and shape of chest-symmetrical, rise and fall w/respiration equally on both sides
�Relate findings to landmarks-slope of the ribs( 90 degrees);barrel shape(COPD)
B
Basic Assessments: Heart, Vessels
Cardiovascular: Heart
-fist sized organ
- 3 different circulation: Pulmonary(through the lungs);Systemic(through the body);Coronary(feeds the heart oxygenated blood)
3rd, 4th and 5th ICS(intercostal spaces)
Heart patients tire easily
-Systole=contraction
Basic Assessments: Heart, Vessels (continued)
Cardiovascular: Vessels
�Central vessels
�Carotid arteries-bring blood to the brain
�Palpate pulsation
* Special precautions-never check right/left at the same time
�Auscultate for bruits-whooshing sound(abnormal auscultatory sounds, e.g. due to arterial
Basic Assessments: Abdomen
-patient in dorsal recumbent position(supine w/ knees flexed)
-examine painful areas last
�Different order for assessment skills
�Inspect-skin for color,symmetry, belly should be rounded, umbilicus concave, peristalsis seen in thin patients, aortic pulsat
Basic Assessments: Bones, Muscles, Joints
Body shape/symmetry
�Posture- infant can have bow legs(normal)
�Gait
�Spinal curvature
Balance
�Romberg's test
Coordination
�Finger-thumb opposition
�Movement-smooth and controlled
Joint mobility
�Color change-indicate inflammation or infection
�Deformity
Basic Assessments: Neurological
�Staff RN uses focused neurological assessment
Cerebral functioning
�Level of consciousness
�Arousal - response to stimuli
�Orientation - time, place, person
�Mental status/cognitive function
�Behavior, appearance, response to stimuli, speech, memory, com
Basic Assessments: Neurological (continued)
Reflexes
�Automatic responses
�Responses on a graded scale
�0 = No response
�+2 = Normal
�+4 = Clonus(hyper response)(is a series of involuntary, rhythmic, muscular contractions and relaxations)
�Example: deep tendon reflexes
Motor/cerebellar function
�Mo
Basic Assessments: Neurological (continued)
Sensory function
�Light touch
�Light pain
�Temperature
�Vibration
�Position sense
�Stereognosis
�Graphesthesia
�Two-point discrimination
�Point localization
Genitourinary Assessment
Male
�Includes reproductive and urinary information
�External genitalia: penis, urethral opening, scrotum, lymph nodes, pubic hair
�Examine for the presence of a hernia
�Reinforce importance of TSE(testicular self exam)
Female
�Female external genitalia:
Anus, Rectum, Prostate Assessment
�Male: at the end of genital exam, Sims'
�Female: at the end of pelvic exam, lithotomy
�Inspect, looking for hemorrhoids (dilated, usually painful blood vessels protruding from anal opening)
Documentation Activity
1. General Survey 3-5 Important inclusions
2. Integumentary
3. Head and Neck Lifespan adjustments
4. Eyes
5. ENT Good and bad examples
6. Mouth
7. Respiratory Done by HCP or ARNP
8. Cardiovascular
9. Abdomen Findings prompt more assessments
10. Musculoske
Documentation
�1. General Survey
�2. Integumentary
�3. Head and Neck
�4. Eyes
�5. ENT
�6. Mouth
�7. Respiratory
�8. Cardiovascular
�9. Abdomen
�10. Musculoskeletal
�11. Neurological
�12. Genitourinary
Critical Thinking
�Think about olfaction as an assessment technique. Give two or three additional examples of data you might collect through the use of smell.
� You are caring for a woman who has no hair on her head. How might you determine the cause of her hair loss? What
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?
1) Ongoing assessment
2) Comprehensive physical assessment
3) Focused physical assessment
4) Psychosoc
3) Focused physical assessment
Rationale:
The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case shortness of breath. An ongoing assessment is performed as needed, after the initial da
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment?
1) Sitting upright
2) Lying flat on the
1) Sitting upright
Rationale:
If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows
For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques? A. Palpation
B. Auscultation
C. Inspection
D. Percussion
1) D, B, A, C
2) C, A, D, B
3) B, C, D, A
4) A, B, C, D
Answer:
2) C, A, D, B
Rationale:
Inspection begins immediately as the nurse meets the patient, as she observes the patient's appearance and behavior. Observational data are not intrusive to the patient. When performing assessment techniques involving phys
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area?
1) Sims'
2) Supine
3) Dorsal recumbent
4) Semi-
Answer:
1) Sims'
Rationale:
Sims' position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery The patient with a hip replacement can assume the supine, dorsal recumben
How should the nurse modify the examination for a 7-year-old child?
1) Ask the parents to leave the room before the examination.
2) Demonstrate equipment before using it.
3) Allow the child to help with the examination.
4) Perform invasive procedures (e.g
Answer:
2) Demonstrate equipment before using it.
Rationale:
The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The nurse should make sure parents are not present during the physical examinati
he nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination?
1) Dorsal recumbent
2) Semi-Fowler's
3) Lithotomy
4) Sims'
Answer:
2) Semi-Fowler's
Rationale:
If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic p
The nurse should use the diaphragm of the stethoscope to auscultate which of the following?
1) Heart murmurs
2) Jugular venous hums
3) Bowel sounds
4) Carotid bruits
Answer:
3) Bowel sounds
Rationale:
The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdo
The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered:
1) Obese
2) Overweight
3) Average
4) Underweight
Answer:
4) Underweight
Rationale:
For adults, BMI should range between 20 and 25; BMI less than 20 is considered underweight; BMI 25 to 29.9 is overweight; and BMI greater than 30 is considered obese.
Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply):
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9�F in the morning and
Answer:
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
3) Heart rate was 76 before eating and is 60 after eating
Rationale:
The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension.
The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has:
1) Crackles
2) Rhonchi
3) Stridor
4) Wheezes
Answer:
3) Stridor
Rationale:
Stridor is a sign of respiratory distress, possibly airway obstruction. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illne
The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the:
1) Pulse deficit
2) Blood pressure
3) Apical pulse
4) Pulse pressure
Answer:
2) Blood pressure
Rationale:
If the leg pulses are weak, the nurse should assess the blood pressure in order to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected. The pulse
Which of the following clients has indications of orthostatic hypotension? A client whose blood pressure is:
1) 118/68 when standing and 110/72 when lying down
2) 140/80, HR 82 bpm when sitting and 136/76, HR 98 bpm when standing
3) 126/72 lying down and
Answer:
4) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy
Rationale:
Orthostatic hypotension is a drop of 10 mm Hg or more in blood pressure upon moving to a standing position, with complaints of feeling dizzy and/or faint.
A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of taking a temperature would be most appropriate for this client?
1) Axillary with an electronic thermometer
2) Oral with a glass thermometer
3) Rectal
Answer:
3) Rectal with an electronic thermometer
Rationale:
The rectal route is the most accurate for assessing core temperature, especially when it is critical to get an accurate temperature. Therefore, in this situation it is preferred. Temperature is a
Which of the following clients would have the most difficulty maintaining thermoregulation?
1) Young child playing soccer during the summer
2) Middle-aged adult snow skiing
3) Young adult playing golf on a hot day
4) Older adult raking leaves on a cold da
Answer:
4) Older adult raking leaves on a cold day
Rationale:
Older adults have more difficulty maintaining body heat because of their slower metabolism, loss of subcutaneous fat, and decreased vasomotor control.
Which of the following clients should have an apical pulse taken? A client who is:
1) Febrile and has a radial pulse of 100 bpm
2) A runner who has a radial pulse of 62 bpm
3) An infant with no history of cardiac defect
4) An elderly adult who is taking a
Answer:
3) An infant with no history of cardiac defect
Rationale:
An apical pulse should be taken if the radial pulse is weak and/or irregular, if the rate is <60 or >100, if the patient is on cardiac medications, or when assessing children up to 3 years.