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OBJECTIVE 4 Demonstrate the nurses responsibility in the physical assessment of a patient. A.

Describe the significance of obtaining a nursing history prior to beginning a physical assessment. B. Differentiate among the examination techniques of inspection, palpation, percussion, and auscultation in reference to when used and the basic techniques of performing each. C. Identify the information that is included in a general patient survey. D. Identify measures to provide for patient safety, comfort, and privacy during a physical examination. E. Demonstrate the procedure for performing a general survey assessment of a patient. Purpose: To obtain information about a patient needed to plan appropriate patient care. Theoretical Foundation and Procedural Details Read Smith, Duell, Martin pp. 290 322, focusing on general assessment only; pp. 339-342. The nurse must be able to review information from a variety of sources and use that information to make critical judgments about a patients needs. During a nursing assessment, the nurse systematically collects, verifies, analyzes, and communicates data about the patient. The patient is considered the primary source for information. Secondary sources include the family and the chart. Data may be subjective or objective. Subjective data is what the client thinks and feels, based on what the patient says. Objective data is information that is observed or measured. The first step in establishing a database is to interview the patient. A major purpose of the interview is to obtain a health history and identify health needs. Objectives for the interview include: Establish a therapeutic relationship with the patient. Determine the patients perception of his/her illness. Gain insight about the patients concerns. Determine the patients expectations of health care providers and the health care system. Obtain cues about data that may need a more in-depth assessment. To set the stage for an effective interview, the nurse should provide a comfortable and private setting. The nurse can encourage the patient to describe perceptions and feelings by using broad opening statements and open-ended questions. The nurse should use body language that conveys acceptance, empathy, and interest in the patient. Appropriate use of silence encourages the patient to communicate. Generally the health history begins by obtaining biographical information about the patient---age, address, occupation, etc. The nurse then determines the patients reason for seeking health care and the status of any present illnesses, including the primary health problem or diagnosis and secondary diagnoses. Other important information includes the patients past health history and family health history. The nurse also obtains psychosocial, cultural, and spiritual

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information needed to provide individualized care. After obtaining this general information from the patient, the nurse proceeds with a review of systems in which the patient is asked about the functioning of each system. The data obtained is used to guide the physical assessment of the patient. The admission physical examination usually begins with obtaining the patients vital signs (See CSG Objective 14), height, and weight. The nurse should note the clothing a patient is wearing when obtaining the weight, the time of day, and the scale used. For accurate comparisons, subsequent weight measurements should be performed at the same time of the day, on the same scale, and in the same amount of clothing. After obtaining the initial data, the nurse then proceeds with a systematic assessment using a head-to-toe approach with an emphasis on gathering information to correlate with the data obtained in the health history interview. A head-to-toe assessment is also performed at the beginning of each shift by the nurse coming on duty to provide information about the patients current status. A focused assessment is a brief assessment that focuses on one body area or system to obtain data in reference to a specific problem or patient complaint. For example, if the patient complained of shortness of breath, the nurses assessment would focus on listening to the lungs and assessing the patient breathing. There are four basic techniques of assessment when performing a physical examination. These steps are normally conducted in the order listed; however, there are exceptions. Inspection: the process of observation, using the sense of sight o Make sure good lighting is available. o Position and expose the body so that all areas can be viewed. o Inspect each area for size, shape, color, symmetry, position, and any obvious abnormalities. o Compare each area with the same area on the opposite side of the body. Palpation: uses the sense of touch o Make sure patient is relaxed and in comfortable position. o If necessary, warm hands. o Apply slow and gentle tactile pressure with the palmar surface of the fingers and finger pads. Palpating for skin temperature is best determined using the back of the hand and fingers. o Areas known or suspected to be tender are palpated last. o Light palpation proceeds deep palpation. Deep palpation which is used to examine the organs is not normally done by the nurse without additional training in this technique. Percussion: involves tapping the body with the fingertips o Direct method: striking the body surface directly. o Indirect method: involves placing the middle finger of the nondominant hand against the body surface and striking it by using the middle finger of the dominant hand. o Percussion strokes should be quick, sharp stroke.

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o Sounds include tympany, resonance, hyperresonance, dullness, and flatness based on the intensity, pitch, and quality of the sound. o Different areas of the body will normally have certain percussion sounds and changes in the sounds can reflect specific abnormalities. o Adult Healh I students should know the general principles of percussion but will not be responsible for performing this technique or differentiating the sounds heard. Auscultation: listening to sounds produced by the body o Make sure the environment is quiet and that you have a good stethoscope. o The bell of the stethoscope is best for low-pitched sounds (vascular and certain heart sounds) whereas the diaphragm of the stethoscope is best for high-pitched sounds (bowel and lung sounds). o Listen not only for the presence of sounds but the quality and characteristics of sounds heard. o You must practice listening to normal sounds to be able to distinguish abnormal sounds.

In addition to the techniques noted, the nurse also uses the sense of smell during an examination. Abnormal odors can give a clue to a potential health problem. This skill focuses only on a general head-to-toe survey assessment, primarily using inspection with limited palpation and auscultation as outlined in the checklist. A more detailed assessment, the expected normal findings, and potential abnormal data for each body system will be presented in subsequent units in this course and later courses as the systems are studied. The head should be assessed to determine the condition and distribution of the hair and the integrity of the scalp. Hair may be coarse or fine, straight or curly, but it should be shiny and smooth. The nurse should inspect for areas of hair loss (alopecia) and ask the patient if there have been any changes noted in the hair. Strands of hair should be separated to better assess the scalp. The nurses assesses for color, scaliness, or lesions. The hair follicles should be inspected for lice. Assessment of the nails begins with an inspection of the nail bed for color, cleanliness, and length; the thickness and shape of the nail plate; the angle between the nail and the nail bed; and the condition of the cuticles and skin around the nails. Nails are normally transparent, smooth, and convex, with a nail bed angle of about 160 degrees. In people of color, it is normal to have longitudinal streaks of brown or black pigmentation in the nails. Paronychia is the term for inflammation of the skin at the base of a nail. Yellowish, thickened nails, particularly of the toe, may be an indication of chronic fungal infections of the nails. The nurse should also test for capillary refill when examining the nails. Pressure is applied to the nail bed which will cause the nail bed to appear white or blanched. When the pressure is released, the pink color should return within 3 seconds. A prolonged capillary refill occurs in circulation problems. Problems with circulation can also cause discolorations in the nails. Common Problems

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A newly admitted patient may be in acute distress or discomfort and not feel like answering the questions asked during an interview or health history assessment. In this situation the nurse should obtain only sufficient information needed to provide immediate care and delay the remainder of the interview and examination until a later time. If the there is any reason to question the reliability of information provided by the patient, the nurse should seek other resources to verify the data, such as talking with family members (with patients permission) and reviewing old records. The environment can influence results obtained during an examination. The nurse must make sure that the examination area is a comfortable temperature, neither too hot nor too cold. External noises should be eliminated if possible or reduced to lowest level possible. Physician Notification The physician is notified of any abnormal data obtained during an assessment. Example Documentation Most facilities will have an admission form used to record the initial interview and assessment. A brief summary is also included in the nurses notes. This note with the nurses statement admission assessment completed is an example of an admission note when there is an admission form that has been completed. This statement would not be acceptable to chart if there was not a form with the data. In that situation the note would have to be much more detailed to include the data obtained from the history and examination. 1300 54 y/o alert and oriented white female admitted via wheelchair with chief complaint of fever of unknown origin; no acute distress. T 1020 orally, P 86, R 22, BP 132/74. Skin intact, warm and moist. Admission assessment completed. ------------------------ K. Wojaski RN The beginning of shift head-to-toe assessment is charted in the nurses note as is any focused assessment performed. When charting a head-to toe assessment, the data is charted primarily in the same head-to-toe order but items are grouped per body systems. For example, you would chart most data regarding the head assessment, then the thorax assessment, followed by the abdominal assessment, etc.---you do not go back and forth from one area to another. For example, when assessing the head you might note that a patient is receiving O2 per nasal cannula. This information would be charted in with other respiratory data. Examples of a beginning of shift assessment and a focus assessment are shown. Example of focus assessment 1430 c/o pruritis and tingling in hands and feet; small red papules covering abdomen and trunk approximately 20 minutes after penicillin started. No respiratory distress. Penicillin discontinued. Dr. Jacobs notified and Benadryl 50 mg given IM as ordered.---- K. Wojaski RN Example of beginning of shift head-to-toe and systems assessment

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0715 Awake, alert, and oriented. Responds appropriately to questions. States I slept very well last night. Denies any pain or discomfort. Wearing glasses. Lips slightly dry. Mouth care and denture care done. Resp: Chest movement symmetrical. Bilateral equal breath sounds. Denies any shortness of breath or cough. O2 @ 2 L/min per NC. CV: S1 S2. Peripheral pulses strong and equal. Cap refill < 3 sec. Abd: Soft, non-distended. Denies any discomfort. Bowel sounds active x 4 quad. Last BM last night without difficulty. GU: Foley cath intact to BSD, draining clear yellow urine. Cath care done. Extremities: Moves all extremities with full ROM. c/o some stiffness in knees. Encouraged to ambulate with assistance at least twice this shift. NPO for cardiac cath today. Anxious about procedure. Review of procedure and expectations. States Youve answered my questions and I feel better. ------------------------------------------- S. Campenello RN Note: The above example reflects the type of information expected initially in Adult Health I. Additional information and a more in-depth assessment of each system will be included in the note as you progress. CPE Requirements Students may be required to demonstrate all or any portion of the general survey assessment. STUDY QUESTIONS 1. You are admitting a new patient that you need to interview. What are the steps in this process? What information do you need to ask?

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Give an example of each of the following: a. b. c. Open ended question: Closed question: Biased or leading question:

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Why is it important to use therapeutic communication skills during an interview?

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4.

How does the environment influence the success or failure of an interview?

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Why is it helpful for a nurse to have a sense of humor?

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Which of the major senses do you use when doing a physical assessment?

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A patient is admitted who has a skin rash and an ulcer on the leg. What assessments should the nurse make and what information should be documented?

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OBJECTIVE 4 PERFORMANCE CHECKLIST: GENERAL SURVEY ASSESSMENT Demonstrate the nurses responsibility in the physical assessment of a patient: general survey.
YES NO*

1.

2.

3. 4. 5. 6. 7. 8. 9.

Obtain necessary preliminary information. If this is an admission assessment, determine if patient brought any documents that should be reviewed before beginning the interview and assessment. If this is a follow-up assessment, review results of previous assessments. Determine if assistance is needed. Determine if patient is able to stand unassisted for height and weight measurement. Gather equipment Bath blanket or linen for draping. Sphygmomanometer, stethoscope, and thermometer Scales for height/weight and ruler or book if height scale does not have swing bar Paper towel Light source such as penlight or flashlight Tongue depressor Clean gloves Wash hands and/or use antiseptic solution. Identify the patient using two methods and explain the procedure. Provide privacy by closing door and pulling curtains and draping patient as necessary. Expose only the area being examined. Provide safety by using side rails as needed, keeping restraints in place if necessary, and using assistance as needed. Provide for nurse safety by having bed at working height, using appropriate body mechanics, asking for assistance if needed, and wearing gloves if there is risk for exposure to body secretions. Verbalize that a health history interview would precede the assessment. Verbalize that assessment of vital signs would precede the assessment.

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Continued on back
YES NO*

10. 11. 12. 13. 14 15 16 17

General Impression of Appearance (descriptive terms are examples of type of data to look for; these are not the only terms) Assess for alertness: awake, drowsy, unresponsive Assess general skin color: pink/black/brown as appropriate for race, pale, cyanotic Assess speech: clear, slurred, garbled Inspect for affect/mood: cheerful, sad, calm, restless Inspect for hygiene: well-groomed, unkempt Inspect for general nourished status: well-nourished, obese, thin, emaciated Inspect body symmetry for evidence of gross abnormalities or deformities Inspect posture/mobility: full ROM, steady gait, uses walker, slumped posture, weak, frail Head/Face/Neck Inspect overall appearance, proportion, symmetry Inspect hair for cleanliness, thickness, areas of loss Inspect eyes for symmetry, ability to open & close, color of sclera and conjunctiva, degree of moisture, symmetry of eyebrows Inspect nose for deformity, patency Inspect ears for symmetry, position, cleanliness of canal Evaluate if patient can hear normal speaking voice. Inspect lips for color, moisture, lesions. Using tongue blade and flashlight or penlight, have patient open mouth Inspect color and condition of gums Inspect teeth: good hygiene, dental caries, dentures or plates, braces Inspect moisture, color, texture of tongue Inspect neck for any obvious abnormalities. Have patient shrug shoulders and inspect for symmetry of movement. Palpate carotid pulses and temporal pulses. Thorax Inspect for ease of respirations. Inspect for symmetry of chest wall and chest wall movement. Inspect for obvious breast abnormalities. Inspect spine for straightness, abnormal curvature. Auscultate for bilateral breath sounds. Auscultate apical pulse.

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YES NO*

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Abdomen Inspect for contour (flat, convex, concave) and symmetry. Inspect for distention. Inspect umbilicus for position. Inspect for obvious pulsations or peristalsis. Auscultate for bowel sounds. Palpate for bladder distention. Palpate any areas of reported discomfort. External Genitalia: Female Inspect for obvious deformity. Inspect hair distribution. Inspect for inflammation, discoloration, edema, lesions, or vaginal discharge. External Genitalia: Male Inspect for obvious deformity. Inspect hair distribution. Inspect for symmetry of testicles. Inspect for inflammation, discoloration, edema, lesions, or penile discharge. For uncircumcised patient, retract foreskin: evaluate ease in which retracts and returns. Extremities Inspect for color, lesions, hair distribution. Inspect degree of ROM. Inspect nails for color, cleanliness, inflammation. Palpate skin temperature. Palpate all peripheral pulses. Assess capillary refill. Dispose of linens and equipment appropriately. Wash hands and/or use antiseptic solution. Document results of assessment and report abnormal findings.

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*Evaluator: Document unmet or incorrect action.

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