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
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
Texture
Temperature
Moisture
Organ location and size
Swelling
Vibration or pulsation
Palpation
Rigidity or spasticity
Crepitation
Presence of lumps or masses
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.
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
33 - 20
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