1. Health Assessment and Physical Examination Denise Coffey MSN, RN
Chapter 33
Health Assessment and Physical Examination
Denise Coffey MSN, RN

2. Purpose of Physical Examination
Gather a health history.
Develop nursing diagnosis and care plan.
Manage client problems.
Evaluate nursing care.

3. 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.

4. Integration of Assessment
Integrate examination during routine nursing care:
Vital signs
Bathing
Range of motion
Activities of daily living

5. Inspection Uses vision and hearing Recognizes normal and abnormal
Is the simplest of five assessment skills

6. 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

7. 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.

8. Palpation Texture Temperature Moisture Organ location and size
Swelling
Vibration or pulsation

9. Palpation Rigidity or spasticity Crepitation
Presence of lumps or masses
Presence of tenderness or pain

10. Percussion Tap body with fingertips to produce a vibration.
Sound determines location, size, and density of structures

11. Auscultation Involves listening to sounds
Learn normal sounds first before identifying abnormal or variations
Requires a good stethoscope
Requires concentration and practice

12. 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.

13. Olfaction Used to identify the nature and source of body odors
Helps to detect abnormalities
Used in conjunction with other assessments

14. Preparation for Examination
Infection control
Environment
Equipment
Physical preparation of client
Psychological preparation of client
Assessment of age-groups

15. Organization of Examination
Assessment of each body system
Follows the nursing history
Systematic and organized
Head-to-toe approach
Preventive Screenings

16. 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

17. General approach
Patient’s emotional state
Examiner’s emotional state

18. General Survey Assess appearance and behavior. Assess vital signs.
Assess height and weight

19. Assessing weight Different scales Time of day
Reasons for weight change Table 33-6
Nutritional information

20. 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