Health Assessment and Physical Examination
Denise Coffey MSN, RN
Purpose of Physical Examination
 Gather a health history.
 Develop nursing diagnosis and care plan.
 Manage client problems.
 Evaluate nursing care.
Cultural Sensitivity
 Culture influences a client’s behavior.
 Consider health beliefs, use of alternative therapies,
nutritional habits, relationship with family, and
personal comfort zone.
 Avoid stereotyping.
 Avoid gender bias.
Integration of Assessment
 Integrate examination during routine nursing care:
 Vital signs
 Bathing
 Range of motion
 Activities of daily living
Inspection
 Uses vision and hearing
 Recognizes normal and abnormal
 Is the simplest of five assessment skills
Inspection
 Inspection
 Do not rush
 Compare patient’s right side with left side
 Use good lighting
 Obtain adequate exposure (of the patient)
 Will include instruments in many body systems
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Otoscope/ophthalmoscope
Specula: vaginal, nasal
Penlight
Palpation
 Use hands to touch body parts.
 Use different parts of hands to distinguish texture,
temperature and movement.
 Hands should be warm, fingernails should be short.
 Start with light palpation and end with deep palpation.
Palpation
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Texture
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Temperature
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Moisture
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Organ location and size
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Swelling
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Vibration or pulsation
Palpation
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Rigidity or spasticity
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Crepitation
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Presence of lumps or masses
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Presence of tenderness or pain
Percussion
 Tap body with fingertips to produce a vibration.
 Sound determines location, size, and density of
structures
Auscultation
 Involves listening to sounds
 Learn normal sounds first before identifying abnormal
or variations
 Requires a good stethoscope
 Requires concentration and practice
 Auscultation
 Fit and quality of stethoscope
 Diaphragm and bell
endpieces
 Eliminate confusing artifacts
Slide 8-12
Olfaction
 Used to identify the nature and source of body odors
 Helps to detect abnormalities
 Used in conjunction with other assessments
Preparation for Examination
 Infection control
 Environment
 Equipment
 Physical preparation of client
 Psychological preparation of client
 Assessment of age-groups
Organization of Examination
 Assessment of each body system
 Follows the nursing history
 Systematic and organized
 Head-to-toe approach
 Preventive Screenings
Safe Environment
Clean the equipment
Clean vs. used area for handling equipment
Nosocomial infections
Handwashing or alcohol-based hand rub
Wear gloves
Standard precautions
Transmission-based precautions
General approach
 Patient’s emotional state
 Examiner’s emotional state
General Survey
 Assess appearance and behavior.
 Assess vital signs.
 Assess height and weight
Assessing weight
 Different scales
 Time of day
 Reasons for weight change Table 33-6
 Nutritional information
 1.
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When meeting a client for the first time, it is important to
establish a baseline assessment that will enable a nurse to refer
back to:
A. Physiological outcomes of care
B. The normal range of physical findings
C. A pattern of findings identified when the client is first
assessed
D. Clinical judgments made about a client’s changing health
status
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