Health Assessment and Physical Examination Denise Coffey MSN, RN Chapter 33 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 Ask yourself, “What am I actually hearing? What should I be hearing at this spot?” Some newer stethoscopes have one surface that functions as diaphragm and bell, depending on the pressure applied.

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

A. Physiological outcomes of care 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 Answer: C 33 - 20