An accurate physical assessment requires an organized and systematic approach using the techniques of inspection, palpation, percussion, and auscultation. It also requires a trusting relationship and rapport between the nurse and the patient to decrease the stress the patient may have from being physically exposed and vulnerable. The patient will be much more relaxed and cooperative if you explain what will be done and the reason for doing it. While the findings of a nursing assessment do sometimes contribute to the identification of a medical diagnosis, the unique focus of a nursing assessment is on the patient's responses to actual or potential problems.
a. Physical assessment is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination. A physical assessment should be adjusted to the patient, based on his needs. It can be a complete physical assessment, an assessment of a body system, or an assessment of a body part.
b. The physical assessment is the first step in the nursing process. It provides the foundation for the nursing care plan in which your observations play an integral part in the assessment, intervention, and evaluation phases.
c. The chances of overlooking important data are greatly reduced because the physical assessment is performed in an organized, systematic manner, instead of a random manner.
a. A comprehensive patient assessment yields both subjective and objective findings. Subjective findings are obtained from the health history and body systems review. Objective findings are collected from the physical examination.
(1) Subjective data are apparent only to the person affected and can be described or verified only by that person. Pain, itching, and worrying are examples of subjective data.
(2) Objective data are detectable by an observer or can be tested by using an accepted standard. A blood pressure reading, discoloration of the skin, and seeing the patient in the act of crying are examples of objective data.
(3) Objective data are sometimes called signs, and subjective data are sometimes called symptoms.
(4) Data means more than signs or symptoms; it also includes demographics, or patient information that is not related to a disease process.
b. The purposes for a physical assessment are:
(1) To obtain baseline physical and mental data on the patient.
(2) To supplement, confirm, or question data obtained in the nursing history.
(3) To obtain data that will help the nurse establish nursing diagnoses and plan patient care.
(4) To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems.
a. Establish a Positive Nurse/Patient Rapport. This relationship will decrease the stress the patient may have in anticipation of what is about to be done to him.
b. Explain the Purpose for the Physical Assessment. The purpose of the nursing assessment is to gather information about the patient's health so that you can plan individualized care for that patient. All other steps in the nursing process depend on the collection of relevant, descriptive data. The data must be factual, not interpretive.
c. Obtain an Informed, Verbal Consent for the Assessment. The chief source of data is usually the patient unless the patient is too ill, too young, or too confused to communicate clearly. Patients often appreciate detailed concern for their problems and may even enjoy the attention they receive.
d. Ensure Confidentiality of All Data. If possible, choose a private place where others cannot overhear or see the patient. Explain what information is needed and how it will be used. It is also important to convey where the data will be recorded and who will see it. In some situations, you should explain to the patient his rights to privileged communication with health care providers.
e. Provide Privacy From Unnecessary Exposure. Assure as much privacy as possible by using drapes appropriately and closing doors.
f. Communicate Special Instructions to the Patient. As you proceed with the examination, inform the patient of what you intend to do and how he can help, especially when you anticipate possible embarrassment or discomfort.
a. Inspection. Visual examination of a person is called inspection. This is done in an orderly manner, focusing on one area of the body at a time.
b. Palpation. Examination by touch is called palpation (figure 11-1). The nurses feels for texture, size, consistency, and location of body parts.
c. Auscultation. Examination by listening for sounds produced within the body is called auscultation. The sounds most frequently listened for are those of the abdominal and thoracic viscera and the movement of blood in the cardiovascular system. Direct auscultation, using the ear only, is seldom done. Indirect auscultation is generally carried out with a stethoscope.
d. Percussion. Examination of the body by tapping it with the fingers is called percussion (figure 11-2). Percussion is a special assessment skill that the practical nurse is not required to perform. This technique is usually performed by a registered nurse (RN) or a physician.
Figure 11-1. Palpation.
Figure 11-2. Percussion.
a. Demographic Data. You begin the assessment by collecting personal information, which includes name, age, sex, marital status, race, and religion. This identifies the patient and provides important demographic data.
b. Body Build. Observe the patient's general appearance and health state in relation to his age and lifestyle. Determine the patient's height, weight, and vital signs at this time.
c. Posture and Gait. Observe whether the patient is erect or slouched, steady or unsteady. Posture can indicate mood. For example, a slumped position may reflect depression; too rigid and upright a position may indicate anxiety.
d. Hygiene and Grooming. Look for cleanliness of nails, hair, skin, and overall appearance. Usually, you can assess these gradually while observing other parts of the body for data. Observe the skin for color, texture, temperature, and lesions. Lesions warrant particular attention during assessment. Some primary skin lesions are:
(1) Nodule--a solid mass extending into the dermis.
(2) Tumor--a solid mass larger than a nodule.
(3) Cyst--an encapsulated fluid-filled mass in the dermis or subcutaneous layer.
(4) Wheal--a relatively reddened, flat, localized collection of fluid. An example is hives.
(5) Vesicle--circumscribed elevation containing serous fluid or blood. An example is chickenpox.
(6) Bulla-- large fluid-filled vesicle. An example is a second-degree burn.
(7) Pustule--a vesicle or bulla filled with pus. An example is acne.
e. Dress. Observe the patient's clothing in relation to age, climate, socioeconomic status, and culture. Notice whether the clothing is clean, properly buttoned, or zipped. The patient's dress may reflect the cold intolerance of hypothyroidism. Slippers or untied shoelaces suggest edema.
f. Body and Breath Odors. Malodorous body or breath may indicate pulmonary infections, uremia, or liver failure. A breath odor of acetone may be due to diabetes. Although odors give important clues, avoid the common mistake of assuming that alcohol on a patient's breath explains neurologic or mental status findings. Alcoholic breath does not necessarily mean alcoholism.
g. Attitude. The patient's attitude is reflected in his appearance, speech, and behavior. The patient may be aloof and unwilling to participate in the interview. He may verbalize anger or fear. Some patients have a "take care of me" attitude and expect nurses and other health care personnel to magically know everything about them. Such findings should be noted as part of your general impression.
h. Affect/Mood. Affect is the emotional state as it appears to others. Mood is the emotional state as described by the patient. Observe the patient's facial expression. No part of the body is as expressive as the face. Feelings of joy, sadness, fear, surprise, anger, and disgust are conveyed by facial expression. Facial expressions generally are not consciously controlled.
i. Speech. Assess the patient's speech for loudness, clarity, pace, and coherence. Observe the patient for poor articulation of words and language difficulty. Patients who are not fluent in English or have limited education are sometimes mistakenly labeled as "indifferent" or "noncommunicative."
Health History. During this assessment step, you interview the patient to obtain a history so that the nursing care plan may be patterned to meet the patient's individual needs. The history should clearly identify the patient's strengths and weaknesses, health risks such as hereditary and environmental factors, and potential and existing health problems. Both the seating arrangement and the distance from the patient are important in establishing a relaxed and comfortable environment for data collection. Chairs placed at right angles to each other about 3 feet apart facilitate an easy exchange of information. If the patient is in bed, be seated in a chair at a 45-degree angle to the bed. If possible, communicate with the patient at eye level. State your name and status and the purpose of the interview. During the introduction, assess the patient's comfort and ability to participate in the interview. Terminate the interview when you have obtained the data you need or the patient cannot provide more information. You need the following information in order to form the subjective database.
Vital Signs. The patient's vital signs are part of the objective data that helps to better define the patient's condition and helps you in planning care. The following vital signs may be taken at the time the patient's height and weight are obtained.
- 0 = absent, without a pulse.
- +1 = diminished, barely palpable.
- +2 = average, slightly weak, but palpable.
- +3 = full and brisk, easily palpable.
- +4 = bounding pulse, sometimes visible.
Head, Eyes, Ears, Nose, and Throat. Assessment of the head begins with a general inspection. Continue the assessment by examining the eyes, ears, nose, and throat. Knowledge of the anatomy of the skull (figure 11-3) is helpful in localizing and describing physical findings.
Figure 11-3. Anatomy of the skull.
Figure 11-4. Exposing sclera and conjuctiva.
Figure 11-5. Movement of the auricle.
|NOTE: Determine the last medical
check-up in each of these areas and the patient's need for corrective devices such as
glasses, hearing aid, or braces.
Figure 11-6. Oral cavity.
Neurological Assessment. There are two approaches to assessment of the neurologic system, depending on the condition of the patient and his chief complaint. If the patient is undergoing a routine health assessment, a screening level exam is appropriate. If the patient's chief complaint relates to the neurologic system, a more detailed assessment is required. A most important consideration is the cooperation and participation of the patient. The following assessments should be made.
- Conscious--Alert, awake, aware of one's self and environment.
- Confusion--Disorientation in time. Irritability and/or drowsiness. Misjudgment of sensory input. Shortened attention span. Decrease in memory.
- Delirium--Disorientation, fear. Misperception of sensory stimuli. Visual and auditory hallucinations. Loss of contact with environment.
- Stupor--Unresponsive, but can be aroused back to a near normal state.
- Coma--Unresponsive to external stimuli.
- Akinetic mutism--Alert-appearing, immobile. Mental activity absent.
- Locked-syndrome--No effective verbal or motor communication. Consciousness may be intact. EEG indicates a preservation of cerebral activity.
- Chronic vegetative state - Vital functions preserved with no evidence of active mental processes. EEG indicates absence of cerebral activity.
- To assess strength in the upper extremities, have the patient squeeze your first two fingers with both hands. The grip should be reasonably strong, but most important; it should be equal in both hands. Apply resistance when the patient flexes the wrist and elbow. Note any pain or weakness the patient has.
- To assess shoulder and scapulae resistance, ask the patient to extend both arms out in front of him and resist the push that you will apply. Try to push the patient's arms down. This is a common site for sports injuries, arthritis, and bursitis. Ask the patient to raise both arms above his shoulders. Try to push his arms down to his sides. Instruct the patient to resist your efforts.
- Assess the lower extremities in a similar manner with the patient lying down. Ask the patient to raise his leg against your hand, which is applying pressure on the thigh, trying to flatten the leg. Ask the patient to flex his knees so that his feet are flat on the table. Place your hands laterally at both knees. Note any pain with this movement.
- Touch is tested with a wisp of cotton. Ask the patient to close his eyes and respond whenever the cotton touches his skin. Compare the sensation in symmetrical areas of the body, such as the cheeks.
- Test the sharpness or dullness of pain by using the pointed and the blunt end of a safety pin. Ask the patient to close his eyes and identify which end of the pin is touching him. Compare distal and proximal areas and note any areas of reduced or heightened sensations.
- The sense of vibration is tested with a tuning fork held firmly against a bone. Bones commonly used are located at the thumb side of the wrist, the outside of the elbow, either side of the ankle, and the knee. Test the distal bones of an extremity first. Strike the tuning fork fairly hard and hold it against the patient's skin. The patient should feel the vibration or buzz.
- The middle finger and large toe are used to test the sense of position. Ask the patient to close his eyes. While supporting the patient's arm with one hand, grasp the patient's middle finger firmly between the thumb and index finger of your other hand. Exert the same pressure on both sides of the patient's finger while moving it. To test the sense of position using the large toe, place the patient's heels on the examining table and grasp the toe in the same manner. Use a series of brisk up, down, and straight out movements before coming to rest in one of the three positions. Ask the patient to identify the position.
- Temperature sensation is determined by touching the patient's skin with tubes filled with hot and cold water. Ask the patient to identify which tube feels hot and which feels cold. This test is unnecessary if the "sensation of pain" test is normal.
- The ability to discriminate can be tested several ways. One way is stereognosis (the ability to recognize objects by touching them). Place small, familiar objects such as a coin, paper clip, or key in the patient's hand and ask him to identify it. Another way is the one- and two-point stimuli. Alternate touching the patient's fingertip with two pinpoints simultaneously and then with one pin. Have the patient discriminate between the one- and two-point stimuli.
Respiration. Respiration is assessed using inspection, palpation, and auscultation. Have the patient remove all clothing to the waist and assume a sitting position. Inspect the chest for posture, shape, and symmetry of expansion. Warm the diaphragm of the stethoscope in the palms of your hands and place it firmly against the patient's chest wall. Ask the patient to breath quietly with the mouth open.
- There are three types of normal breath sounds: vesicular, bronchial, and bronchovesicular. Vesicular sounds are soft, like a quiet rustle or swish. Bronchial sounds are loud, harsh, hollow blowing sounds usually heard over the trachea and major bronchi. Bronchial sounds are louder during expiration. Bronchovesicular sounds are a combination of the other two and are heard in the upper anterior chest on each side of the sternum and posteriorly between the scapulae. Deep breathing converts vesicular sounds into bronchovesicular sounds.
- Assess the respirations for rhythm. Note whether the patient's breathing is regular, irregular, labored, or non-labored.
- Respiratory rate is the number of breaths in one minute. Bradypnea is less than 10 breaths per minute. Dyspnea is difficult or painful breathing. Orthopnea is difficult breathing except in an upright position.
- Lung sounds include breath sounds, voice sounds, and abnormal sounds. Assess lung sounds by auscultation, using a stethoscope. Auscultate the anterior and posterior upper, middle and lower lobes. Rales are crackling, tinkling sounds that occur when fluid or secretions are trapped in the smaller bronchioles or alveoli. Rhonchi are the rumbling, rattling, or snoring sounds due to mucous and secretions in the bronchial tree. A wheeze is the raspy whistling or high-pitched sound that occurs as air moves through a constricted or obstructed passage in the upper airway or bronchioles.
- Note whether the patient has a cough and whether it is persistent, occasional, productive or nonproductive. If the cough is productive, note the amount and character of the secretions.
Cardiovascular Assessment. Palpation and auscultation are used in assessment of the cardiovascular system, which includes blood pressure, peripheral pulses, heart sounds, and circulatory perfusion. The patient's blood pressure is usually taken at the onset of the assessment and the pulses are palpated while the skin is being examined.
- To obtain an accurate blood pressure reading, you will need a stethoscope, a blood pressure cuff, and a sphygmomanometer. Be sure that the patient is relaxed and use a cuff that is not more than 20 percent wider than the diameter of the patient's limb and long enough to completely encircle it. If the patient is very obese, it may be necessary to use a thigh cuff on his arm. If possible, take the blood pressure in two positions, supine or seated and standing. Wrap the cuff around the arm so that it is about one inch above the bend of the elbow. Palpate the brachial artery and place the diaphragm of the stethoscope over the artery below, but not underneath, the cuff. Inflate the cuff 30 to 40ºmmºHg above the point at which the last sound is heard. Release the pressure slowly. Observe the pressure readings on the manometer and relate these to the sounds heard through the stethoscope. The systolic pressure is the point where the first tapping sound is heard. The diastolic pressure is the point where the sound disappears.
- Take the peripheral pulses with the patient in the supine position, using your index and middle finger. Palpate the apical, radial, dorsalis pedis, and posterior tibial pulses. The posterior tibial pulse is palpable behind and below the protuberance on the inside of the ankle.
- Several heart sounds can be heard by auscultation (see figure 11-7). The first two heart sounds are produced by closure of the valves of the heart. The first heart sound (S1) occurs when the ventricles have been sufficiently filled and the right and left atrioventricular (A-V) valves close. S1 is heard as one dull, low-pitched sound. After the ventricles empty their blood into the aorta and pulmonary arteries, the semilunar valves close, producing the second heart sound (S2). The second heart sound is shorter and has a higher pitch than S1. The two sounds occur within one second or less, depending on the heart rate. Systole is the period in which the ventricles are contracted. It begins with the first heart sound and ends at the second heart sound. Diastole is the period in which the ventricles are relaxed. Normally no sounds are heard during this period. The two heart sounds are audible anywhere in the region over the heart, but are best heard over specific valve areas. Rhythm is the pattern of the heartbeats and the intervals between the beats. It may be regular or irregular. Normally, equal time elapses between heartbeats. Any deviation from the normal pattern is arrhythmia. Murmurs, produced by turbulent blood flow, may occur at any cardiac auscultation site. The volume of blood flow, the force of the contraction, and the degree of valve compromise all contribute to murmur quality. Descriptive terms are used to give the murmur character. Murmurs are "whooshing" sounds. Although the mitral sound is usually loudest, a stenotic mitral valve that moves very little may produce a muffled sound.
- Circulatory perfusion is blood flow through the vessels of a specific organ or tissue. Arteries carry blood away from the heart, the capillaries serve as in-between channels, and the veins carry blood toward the heart. Close examination of the extremities will indicate the quality of the arterial and venous systems. Capillaries are the smallest blood vessels. It is through their walls that oxygen and food are supplied to the individual cells. To test capillary refill to extremities, press on a toe or fingertip, observe blanching and the time it takes the area to return to its original color. Document the time in seconds.
Figure 11-7. Areas to auscultate for heart sounds.
Gastrointestinal Assessment. Inspection, palpation, and auscultation are used in gastrointestinal (GI) assessment. The GI system comprises two major components: the alimentary canal and the accessory organs. The alimentary canal includes the pharynx, esophagus, stomach, small intestine, and large intestine. Accessory organs aiding GI function include the salivary glands, liver, gallbladder and bile ducts, and the pancreas. Assessment of the gastrointestinal system includes inspection of the oral cavity (during HEENT evaluation), auscultation and palpation of the abdomen, and examination of the rectum.
(1) To ensure accurate abdominal assessment and consistent documentation of your findings, mentally divide the patient's abdomen into four quadrants (figure 11-8). Begin by inspecting the patient's entire abdomen, noting overall contour (flat, round, concave, protruding), skin integrity, appearance of the umbilicus, and any visible pulsations. Note any localized distention or irregular contours, rashes, dilated veins, and scars.
Figure 11-8. Abdominal regions.
(2) After inspecting the patient's abdomen, use a stethoscope to auscultate for bowel and vascular sounds. Lightly press the stethoscope diaphragm on the abdominal skin in all four quadrants. The bowel may be active, hyperactive, or hypoactive. Normally, air and fluid moving through the bowel by peristalsis create soft, bubbling sounds, mixed with clicks and gurgles, every 5 to 20 seconds. Loud, gurgling irregular sounds heard about every three seconds are hyperactive and may occur normally in a hungry person. Following, or when the colon is filled with feces, hypoactive bowel sounds may occur at a rate of one every minute or longer. Abdominal auscultation should be performed before percussion and palpation, because intestinal activity and bowel sounds may be altered by the motion of percussion and palpation.
(3) Palpation elicits useful clues about the character of the abdominal wall; the size, condition, and consistency of abdominal organs; the presence and nature of abdominal masses; and the presence, degree, and location of any abdominal pain. Gently press your fingertips about ½ inch into the abdominal wall. Move your hands in a slightly circular fashion so that the abdominal wall moves over the underlying structures. Note the character of the abdomen (soft, rigid, firm, tender, or nontender). Assess for organ location, masses, and areas of tenderness or increased muscle resistance. If you detect a mass, note its location, size, shape, degree of tenderness and mobility, and the presence of pulsations. When assessing a patient with abdominal pain, always auscultate and palpate in the painful quadrant last, touching the painful area may cause the patient to tense the abdominal muscles, making further assessment difficult.
NOTE: Do not palpate a pulsating midline mass; it may be a dissecting aneurysm, which can rupture under the pressure of palpation. Report the mass to a doctor.
(4) Gather information about the patient's appetite during the interview. Ask the patient if he has lost weight.
(5) Gather information about the patient's elimination patterns and the character of his stools. Ask the patient when he had his last bowel movement and if he has nausea, vomiting, diarrhea, or constipation.
(6) A routine rectal examination is performed if the patient is over age 40, if the patient has a history of bowel elimination changes or anal discomfort, and for an adult male with a urinary problem.
(7) If the patient is ambulatory, ask him to stand and bend his body forward over the examination table. If the patient is unable to stand, place him in a left lateral Sims' position with the knees drawn up and the buttocks near the edge of the bed or examination table.
(8) Put on a glove and spread the patient's buttocks to expose the anus and surrounding area. Asks the patient to strain as though defecating. Inspect for inflammation, discharge, lesions, scars, rectal prolapse, skin tags, and external hemorrhoids. Apply lubricant to your index finger. Explain to the patient that you will insert your gloved, lubricated finger a short distance into the rectum. Have the patient breathe through the mouth and relax.
(9) Once you have inserted your finger, rotate it to palpate all aspects of the rectal wall for nodules, tenderness, and fecal impaction. The rectal wall should feel smooth and soft. In a male patient, assess the prostate gland when palpating the anterior rectal wall; the prostate should feel firm and smooth.
Genitourinary Assessment. The male genitalia may be examined with the patient either standing or supine. However, the patient should stand as you check for hernias or varicoceles. Examine the female genitalia with the patient in a dorsal recumbent position.
NOTE: During the examination, the male patient may have an erection and probably be embarrassed about it. Explain to him that this is a normal response, and finish your examination in an unruffled manner.
Musculoskeletal Assessment. Musculoskeletal assessment begins the instant you see the patient. Good observation skills will enable you to gain information about muscle strength, obvious physical or functional deformities or abnormalities, and movement symmetry. If the patient's chief complaint involves a different body system, the musculoskeletal assessment should represent only a small part of the overall assessment. If the health history or physical findings suggest musculoskeletal involvement, analyze the patient's complaints and perform a complete musculoskeletal assessment.
(8) Assess muscle mass. Muscle mass is the actual size of a muscle. Assessment involves measuring the circumference of the thigh, the calf, and the upper arm. Measure at the same location on each area. Abnormal findings include circumferential differences of more than ½ inch between opposite thighs, calves and upper arms, decreased muscle size (atrophy), excessive muscle size (hypertrophy) without a history of muscle building exercises, flaccidity (atony), weakness (hypotonicity), spasticity (hypertonicity), and involuntary twitching of muscle fibers (fasciculations).
(9) Assess muscle strength and joint ROM. Have the patient perform active ROM as you apply resistance. Normally, the patient can move joints a certain distance (measured in degrees) and can easily resist pressure applied against movement. Strength is normally symmetrical. If the patient cannot perform active ROM, put the joints through passive ROM. Use a goniometer (figure 11-9) to measure the angle achieved. Place the center or zero point on the patient's joint. Place the fixed arm perpendicular to the plane of motion. As the patient moves the joint, the movable arm indicates the angle in degrees.
Figure 11-9. Goniometer.
Assessment of the Integument. Physical assessment of the skin, hair, and nails requires inspection and palpation. Be sure the room is warm to prevent cold-induced vasoconstriction, which may affect skin color.
As you learn the techniques of performing a comprehensive patient assessment, list these techniques in the order in which they are performed. Organize the assessment in a way that limits the number of times the patient must change positions, and the number of times you must change your own position. Once you have developed an organized and systematic approach and performed the assessment a number of times, you will be able to gather both subjective and objective information quickly and effectively. This approach will provide you with the information you need to develop your nursing diagnoses and care plans.