Health Assessment: Performing A Physical Examination

Assessing Health: Physical Examination Metro Community College Nancy Pares, RN, MSN Nursing Programs Health Assessment: Performing a Physical Examination An Overview 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 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 Types of Physical Examinations Comprehensive: Interview plus complete head-to-toe examination Focused:

Focused on presenting problem Ongoing: Performed as needed to assess status Evaluates client outcomes Organizing the Examination Head-to-toe Starts at the head Progresses down the body System-related data found throughout: Heart sounds - chest Pulses - periphery Organizing the Examination

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 Skill and comfort level Willingness to seek help Knowledge about client situation Purpose of examination Client diagnosis Preparing the Environment

Privacy is key Draping Use of curtains Noise control TV/radio off Enable visualization Adequate lighting Flashlight if needed Preparing the Client

Promote client comfort: Develop rapport Explain the procedure Respect cultural differences Use proper positioning Physical Assessment Skills Four major skills used: Inspection

Palpation Percussion Auscultation Inspection Use of sight to gather data Used throughout physical examination Tools to enhance inspection Otoscope Ophthalmoscope Penlight Examples: Skin color, gait, general appearance, behavior

Palpation Use of touch to gather data Begin with light pressure, moving to deep palpation Use caution with deep palpation Parts of the hands used: Fingertips: Tactile discrimination Dorsum: Temperature determination Palm: General area of pulsation Grasping (fingers and thumb): Mass evaluation Examples: Edema, moisture, anatomical landmarks, masses

Percussion Tapping on skin to elicit sound Direct Indirect Useful for assessing abdomen, lungs, underlying structures Examples: Distended bladder Auscultation Use of hearing to gather assessment data Direct auscultation:

Listening without an instrument Indirect auscultation: Use of a stethoscope to listen Diaphragm - high-pitched sounds Bell low-pitched sounds Examples: Heart sounds, lung sounds Age Modifications for the Physical Examination Infants:

Parents hold Attend to safety Toddlers: Allow to explore and/or sit on parents lap Invasive procedure last Offer choices Use praise Age Modifications for the Physical Examination

Preschoolers: Use doll for demonstration Still may want parental contact Allow child to help with examination School-Aged Children:

Show approval and develop rapport Allow independence Teach about workings of the body Age Modifications for the Physical Examination Adolescents: Provide privacy Concerned that they

are normal Use examination to teach healthy lifestyle Screen for suicide risk Young/ Middle Adults: Modify in presence of acute or chronic illness Age Modifications for the Physical Examination 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 Provide periods of rest as needed 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

Vital signs Height/weight Basic Assessments: Skin, Head Integumentary: Skin characteristics Color Temperature Moisture Lesions Hair Nails Texture

Turgor Basic Assessments: Skin, Head Head: Skull and Face Size Shape Facial features Eyes External eye Sclera Pupils Visual acuity Vision examinations

Acuity, distance, near, color, visual fields Internal structures Basic Assessments: Ears, Nose, Mouth Head: Ears/hearing External ear Inner ear Tympanic membrane Hearing Webers test Rinnes test Balance Rombergs test

Nose Smell Mouth Lips Buccal mucosa Teeth Hard and soft palates Basic Assessments: Neck, Breasts Neck:

Musculature Trachea Thyroid gland Cervical lymph nodes Breasts: Size Shape Nipple characteristics Tissue Include axillae

Basic Assessments: Lungs Chest and Lungs: Describe size and shape of chest Relate findings to landmarks Breath Sounds: Bronchial Bronchovesicular Vesicular Adventitious Diminished or misplaced Abnormal vocal sounds Basic Assessments: Heart, Vessels

Cardiovascular Heart: Inspection PMI Heaves/Lifts Palpation Thrill Heart sounds Location: Aortic, Pulmonic, Tricuspid, Mitral

Components: S1, S2, S3, S4 Murmurs Basic Assessments: Heart, Vessels Cardiovascular Vessels: Central vessels Carotid arteries Palpate pulsation * Special precautions Auscultate for bruit Jugular veins

Peripheral vessels Blood pressure Peripheral pulses Signs of inadequate oxygenation Varicosities Basic Assessments: Abdomen Different order for assessment skills Inspect Auscultate Percuss Palpate Basic Assessments: Bones, Muscles,

Joints Body shape/symmetry: Posture Gait Spinal curvature Balance: Rombergs test Coordination: Finger-thumb opposition

Movement Joint mobility: Color change Deformity Crepitus Muscle strength: Range of motion Resistance Basic Assessments: Neurological

Staff RN Uses Focused Neuro 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, communication, judgment Basic Assessments: Neurological Reflexes:

Automatic responses Responses on a graded scale 0 = No response 4 = Clonus Example: deep tendon reflexes Motor/Cerebellar Function:

Movement/coordination Tone Posture Equilibrium Proprioception Basic Assessments: Neurological Sensory Function: Light touch Light pain

Temperature Vibration Position Sense Stereognosis Graphesthesia Two-point discrimination Point localization Extinction Genitourinary Assessment

Male: Includes reproductive information External genitalia: penis, urethral opening, scrotum, lymph nodes, pubic hair Examine for the presence of a hernia Female: Female external genitalia: labia, clitoris, urethral opening, vaginal orifice, pubic hair, lymph nodes Genitourinary Assessment Other:

Kidneys (CVA tenderness) Bladder (palpation of the abdomen) NP/MD responsible for anus, rectum, prostate examination NP/MD responsible for pelvic examination

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