3) Health Assessment And Physical Examination Flashcards
What dimensions are included in a holistic assessment of a patient’s health?
- Emotional
- Intellectual
- Physical
- Psychosocial
- Spiritual
- Cultural
What does the process of collecting data about a patient include?
- Thorough health history
- Physical examination
What aspects may be assessed during a physical exam beyond physiological function?
- Cognition
- Mood
- Functional status
Why is it important for nurses to detect changes in a patient’s condition?
- Nurses are often the first contact for patients.
- Critical thinking helps interpret patient behavior and physiological status.
- Enables timely intervention and care.
What are the purposes of physical assessment and examination in nursing?
- Detect subtle and obvious health changes.
- Assess patterns reflecting health problems.
- Evaluate patient progress following therapy.
What is included in a complete health assessment?
- Nursing history
- Behavioural and physical examination
- Cultural assessment
What is the purpose of a head-to-toe physical examination?
- Provides objective information about the patient.
- Aids in clinical judgment and nursing care planning.
- Influences therapy choices and evaluation of responses.
How does continuity in health care improve through physical assessment?
- Ongoing, objective, and comprehensive assessments by nurses.
What tools help nurses detect subtle changes in health?
Skills of physical assessment and examination.
What can health screenings focus on?
- Specific physical conditions (e.g., blood pressure).
- Cognition, mood, and functional status.
What is required for culturally competent health assessment?
- Nurse being culturally aware and sensitive
- Respecting patient preferences during examination
- Recognizing how social/cultural background influences health beliefs
What data facilitates a culturally competent physical exam?
- Integrating cultural assessment for every patient
- Assessing gender identity, complementary therapies, dietary needs
- Understanding caregiver relationships, past healthcare experiences
How does cultural assessment data inform physical assessment?
- Helps think critically about patient’s contexts (political, social, economic)
- Avoids stereotyping based on gender or ethnicity
- Recognizes biocultural variations of normal/healthy presentations
What are examples of biocultural health variations?
- Congenital dermal melanocytosis in some newborns
- Higher risk of hypertension/diabetes in certain populations
- Nurses must learn to recognize these common variations
What is the benefit of culturally competent care?
- Leads to greater patient satisfaction
- Improves clinical outcomes for patients
What guides the focus of a physical examination?
- Designed to address the patient’s specific needs
- For acutely ill, assess only the involved body system(s)
- Comprehensive exam done when patient is more stable
When is a complete physical exam often performed?
- As part of periodic health exams for wellness/prevention
- To determine eligibility (insurance, military, licenses)
- For pre-employment, new practitioner, pre-surgical assessment
- For admission to hospital or long-term care facility
What purposes does a thorough physical exam serve?
- Gathers baseline data on health history, status, concerns
- Supplements, confirms or refutes data from health history
- Confirms and identifies nursing diagnoses
- Enables clinical judgments on changing health status/management
- Evaluates outcomes of care provided
When is a complete exam not recommended?
- For annual exams of asymptomatic adults
- Research shows it does not improve health status
- Can lead to false positives causing anxiety and unnecessary testing
Why review anatomy and physiology for physical assessment?
- Helps identify structures and functions of the human body
- Understand interconnectedness of physiological systems
- Essential for assessing specific body systems/regions
What is needed to assess cranial nerves?
- Understanding the function of each cranial nerve
- Knowing the motor and sensory pathways innervated
- Anatomy and physiology knowledge of the nerve pathways
What is the main objective when interacting with patients?
- Find out their concerns
- Help them find solutions
- Pay close attention to their concerns
What is required for collecting health history and exam data?
- Patience
- Dedication to comprehensiveness and detail
- Following principles like relational practice
What does the interview allow?
- Formation of a partnership with the patient
- Orienting the interview to the patient, not the disease
- Referring to “a person who has X” instead of labeling
What should you be aware of during the interview?
- Your own idiosyncrasies (e.g. wanting to be liked)
- Potential fears (e.g. catching a disease)
- Prevent these from affecting the therapeutic relationship
How does a physical assessment supplement the health history?
- Can reveal information that refutes, confirms, or adds to history
- Requires critical thinking about patient information
- Methodically conducting the exam for a clear health picture
What is the importance of assessing reported symptoms?
- One finding alone does not reveal the full condition
- Need to clarify the nature of symptoms through questions
- Examine for potential sources to rule out various conditions
Why group assessment findings into clusters?
- Assists in revealing actual or potential nursing diagnoses
- Abnormal findings suggest need for more information gathering
- Allows development of individualized nursing diagnoses
What is the purpose of the initial baseline assessment?
- Records patient’s health status and functional abilities
- Enables comparison to future assessments for changes
- Comprehensiveness is key for determining condition changes
How should the care plan be viewed?
- As an ongoing process requiring updates
- Plan changes as conditions resolve, deteriorate or new issues arise
- Ongoing monitoring guides review of nursing diagnoses/plan
What enables nurses to judge patient health status?
- Physical assessment skills
- Allows directing management of patient care
- Recognizing changes in status is key
How should nurses respond to changes in patient status?
- Modify interventions accordingly
- Aim for achieving most desirable outcomes
- Revise written care plan with new interventions
What is challenging about performing physical assessments?
- Applying critical thinking to interpret findings
- Making appropriate care decisions based on assessments
- Mechanics of assessments are relatively simple
How do physical assessments enhance nursing accountability?
- Used to evaluate results of nursing interventions
- Monitor physiological and behavioral outcomes
- Determine if expected care outcomes are met
Give an example of using assessment for care evaluation.
- Palpating pulse to assess a condition
- Evaluating tolerance to an exercise plan
- Detailed documentation aids outcome determination
What are the four main skills used in a comprehensive physical exam?
- Inspection
- Palpation
- Percussion
- Auscultation
What other sense is an element of patient assessment?
- Olfaction (sense of smell)
- Can detect odors related to hygiene, infections, physiological processes
What must providers do before any patient interactions?
- Thoroughly clean hands
- Check patient identification
What does inspection involve?
- Using vision and hearing
- Distinguishing normal from abnormal findings
- Recognizing healthy variations for different age groups
What principles should be followed for accurate inspection?
- Ensure adequate lighting
- Position/expose areas to view all surfaces
- Inspect for size, shape, color, symmetry, position, drainage, abnormalities
- Compare bilateral areas when possible
- Use additional light for body cavities
- Take time and pay attention to detail
What may inspection findings indicate?
- The need for further examination by palpation
What is palpation used for?
- Examining all accessible body parts using the hands
- Assessing skin temperature, moisture, texture, turgor, tenderness, thickness
- Checking abdomen for tenderness, distension, masses
How should the patient be prepared for palpation?
- Help them relax and be comfortable
- Have them take slow, deep breaths with arms at sides
- Palpate tender areas last, ask about sensitive areas
- Watch for nonverbal signs of discomfort
What is required for proper palpation technique?
- Warm, clean hands with short fingernails
- Gentle, slow, deliberate approach
- Use light, intermittent pressure
What cautions should be taken during palpation?
- Avoid heavy, prolonged pressure to prevent loss of sensitivity
- Do not attempt deep palpation without supervision
- Exercise caution to avoid injuring the patient
Which hand surfaces are used for specific assessments?
- Palmar fingers/pads: position, texture, size, masses, fluid, crepitus
- Dorsal surface: temperature
- Ulnar surface: vibration
- Fingertips: position, consistency, turgor
For the skin, what criteria are measured and which hand portions are used?
- Temperature - Dorsum of hand/fingers
- Moisture - Palmar surface
- Texture - Palmar surface/pads of fingertips
- Turgor and elasticity - Grasping with fingertips
- Tenderness - Palmar surface/pads of fingertips
- Thickness - Palmar surface/pads of fingertips
For organs like the liver and intestines, what criteria are measured and which hand portions are used?
- Size - Entire palmar surface or palmar fingers
- Shape - Palmar surface/pads of fingertips
- Tenderness - Entire palmar surface or palmar fingers
- Absence of masses - Palmar surface/pads of fingertips
For glands like thyroid and lymph nodes, what criteria are measured and which hand portions are used?
- Swelling - Pads of fingers
- Symmetry and mobility - Palmar surface/pads of fingertips
For blood vessels like carotid or femoral arteries, what criteria are measured and which hand portions are used?
- Pulse amplitude - Palmar surface/pads of fingertips
- Elasticity - Palmar surface/pads of fingertips
- Rate - Palmar surface/pads of fingertips
- Rhythm - Palmar surface/pads of fingertips
For the thorax, what criteria are measured and which hand portions are used?
- Excursion - Palmar surface
- Tenderness - Finger pads/palmar surface of fingers
- Fremitus - Palmar or ulnar surface of entire hand
Give an example of a situation requiring caution during palpation.
- If the patient has a fractured rib
- Locate the painful area very gently and carefully
Why is it important to avoid obstructing blood flow?
- Applying too much pressure on vital arteries
- Can temporarily block/obstruct necessary blood flow
What is the purpose of percussion?
- Tapping the body with fingertips to produce vibrations
- Determining location, size, and density of underlying structures
- Verifying abnormalities assessed by palpation and auscultation
How does percussion work?
- Vibrations are transmitted through body tissues
- Sound character depends on density of underlying tissue
- Different densities influence the sound produced
What can percussion help identify?
- Location of organs or masses
- Mapping boundaries of organs/masses
- Determining size of organs/masses
- Presence of air or fluid within organs/cavities
What does an abnormal percussion sound suggest?
- Indicates a mass or abnormal substance present
- Such as air or fluid within an organ or body cavity
What is required for proper percussion technique?
- Dexterity and skill
- Usually performed by advanced practitioners
What is auscultation used for?
- Listening to body sounds
- Detecting variations from normal sounds
What sounds should be learned first?
- Normal sounds from cardiovascular, respiratory, and GI systems
- Such as blood flow through arteries
- Abnormal sounds are recognized after learning normal variations
What should one know to become proficient at auscultation?
- Types of sounds made by each body structure
- Locations where sounds are best heard
- Areas that normally do not emit sounds
What is required for proper auscultation?
- Good hearing ability
- Quality stethoscope
- Knowing how to use stethoscope properly
- Amplified stethoscope if hearing impaired
How is the stethoscope used?
- Placed directly on skin, not over clothing
- Bell for low-pitched sounds like heart/vascular
- Diaphragm for high-pitched sounds like lungs/bowels
What should be done before using the stethoscope?
- Become familiar with it
- Practice using it
- Recognize extraneous sounds from tubing/chestpiece
What characteristics of sounds should be recognized?
- Frequency (pitch)
- Loudness (amplitude)
- Quality (blowing, gurgling, etc.)
- Duration (short, medium, long)
What is required for effective auscultation?
- Concentration and practice
- Considering the body part being auscultated
- Understanding the cause of the sound
Give an example of the cause of a heart sound.
- Closure of the mitral valve causes the first heart sound
Where is the first heart sound best heard?
- Left fifth intercostal space along the midclavicular line
Why is it important to learn normal sound characteristics?
- To recognize abnormal sounds and their origins
- First heart sound has “lub” quality
- Second heart sound has “dub” quality
What makes it easier to identify abnormal sounds?
- Understanding the cause and character of normal sounds
- Familiarity with normal allows detection of abnormalities
What is the purpose of olfaction during patient assessment?
- Become familiar with nature and source of body odors
- Detect abnormalities that cannot be recognized by other means
Give an example of when olfaction can indicate an abnormality.
- If a patient’s cast has a sweet, heavy, thick odor
- This indicates an underlying infection
What should findings from olfaction prompt the nurse to do?
- Investigate the origin of the odor
- As it may indicate abnormalities or underlying conditions
What does proper preparation ensure for a physical examination?
- A smooth examination process
- Few interruptions during the exam
What can result from a disorganized approach to preparation?
- Errors in the examination
- Incomplete findings
What three areas require preparation for an examination?
- The environment
- Equipment
- The patient
What precautions should be taken for patients with open skin lesions or weeping wounds?
- Use standard precautions and routine practices
- Wear gloves during palpation and percussion
- Reduces contact with microorganisms
What additional protective equipment is needed for excessive wound drainage?
- Wear a gown
- Wear other personal protective equipment as needed
- Prevents exposure to spray from the wound
When should hand hygiene be practiced during a physical assessment?
- Before initiating the assessment
- After completing the assessment
What is the odor associated with the oral cavity and what are its potential causes?
- Alcohol odor - ingestion of alcohol, diabetes
- Sweet, fruity ketone odor - diabetic acidosis
- Halitosis - poor dental/oral hygiene, gum disease
What is the odor associated with urine and what are its potential causes?
- Ammonia odor - urinary tract infection, renal failure
- Stale urine odor on skin - uremic acidosis
What are the odors associated with the skin and what are their potential causes?
- Body odor - poor hygiene, excess perspiration (hyperhidrosis), foul-smelling perspiration (bromhidrosis)
- Wound site odor - wound abscess
What are the odors associated with vomitus and feces and what are their potential causes?
- Vomitus odor - abdominal irritation, contaminated food
- Fecal odor in vomitus/oral cavity - bowel obstruction
- Fecal odor in rectal area - bowel incontinence
- Foul-smelling stools in infant - malabsorption syndrome
What are the odors associated with wounds/infections and what are their potential causes?
- Sweet, heavy, thick odor from draining wound - Pseudomonas bacterial infection
- Musty odor from casted body part - infection inside cast
- Fetid, sweet odor from tracheostomy or mucous secretions - infection of bronchial tree (Pseudomonas bacteria)
What is required for a physical examination? (Environment)
- Privacy
- Well-equipped examination room or space
What is necessary for proper illumination during an examination?
- Adequate lighting of body parts
What helps patients feel comfortable discussing their conditions?
- Soundproof examination room
- Eliminating noise sources
- Preventing interruptions
- Warm room temperature
What makes examinations easier when the patient is in bed?
- Raising the bed height
- Using proper body mechanics
What precautions are needed with examination tables?
- Carefully assisting patients on/off the table
- Not leaving confused/combative patients unsupervised
- Raising head of table and using pillow for comfort
What equipment is typically used for a complete physical assessment?
- Cervical devices (brush, broom, spatula)
- Cotton applicators
- Disposable pads/paper towels
- Drapes
- Eye chart
- Flashlight and spotlight
- Forms (physical, laboratory)
- Gloves (sterile and clean)
- Patient gown
- Ophthalmoscope
- Otoscope
- Pap slides/fixative or liquid cytology
- Percussion hammer
- Pulse oximeter
- Ruler
- Scale with height rod
- Specimen containers
- Sphygmomanometer and cuff
- Sterile swabs
- Stethoscope
- Tape measure
- Thermometer
- Tissues
- Tongue depressors
- Tuning fork
- Vaginal speculum
- Water-soluble lubricant
- Watch with second hand/digital display
What should be done before starting a physical examination?
- Ask if the patient needs to use the washroom
- Ensure empty bladder and bowel for abdominal/genital/rectal exams
- Collect urine or stool specimens if needed
- Explain proper specimen collection method
- Label specimens per laboratory policies
How should the patient be prepared for the examination?
- Patient should be properly dressed/draped (hospital gown or undressed with gown)
- Provide privacy and time for undressing
- Have patient sit/lie on exam table with drape over lap/trunk
- Eliminate drafts, control room temperature, provide warm blankets
- Routinely ask if patient is comfortable
What should be considered for patient positioning?
- Ask patient to assume positions for accessible body parts
- Explain positions and assist patient
- Adjust drapes to expose only area being examined
- Organize exam to minimize position changes
- Use extra care when positioning older patients
How can you help patients feel more comfortable during an examination?
- Provide a thorough explanation of the purpose and steps
- Use simple, understandable terms
- Encourage patients to ask questions and mention discomfort
- Give detailed explanations for each body system
- Convey an open, professional, and relaxed approach
When should a chaperone be present during an examination?
- When the patient and nurse are of opposite genders
- The chaperone provides protection and reassurance
- The chaperone witnesses the conduct of both parties
How should you respond to a patient’s emotional responses during an exam?
- Watch for signs of fear, concern, or anxiety
- Remain calm and clearly explain each step
- Stop the exam and ask how the patient feels
- Do not force the patient to continue if uncomfortable
- Postpone for better accuracy when the patient can relax
What should you do if a patient’s fears stem from misconceptions?
- Clarify the purpose of the examination
- Before each element, verbalize what you will assess
- Ask for the patient’s consent to proceed
How should histories be gathered for infants and children?
- Gather all or part of the histories from parents or guardians
What approach should be taken when examining children?
- Perform the examination in a non-threatening area
- Provide time for play to become acquainted
- Offer support to parents and do not pass judgment
How should children and parents be addressed?
- Call children by their first name
- Address parents as “Mr.”, “Mrs.”, or “Ms.” rather than first names
What questioning technique helps gather more information from parents?
- Use open-ended questions to allow sharing more details
- Enables observation of parent-child interactions
How should adolescents be treated during the examination?
- Treat adolescents as adults for best response
- Remember adolescents have a right to confidentiality
- Speak alone with adolescents after discussing history with parents
What areas are assessed in the sitting position?
- Head and neck
- Back
- Anterior and posterior thorax and lungs
- Breasts
- Axillae
- Heart
- Vital signs
- Upper extremities
What is the rationale for the sitting position?
- Sitting upright provides full expansion of lungs
- Provides better visualization of symmetry of upper body parts
What is a limitation of the sitting position?
- A physically weakened patient may be unable to sit
- Use supine position with head of bed elevated instead
What areas are assessed in the supine position?
- Head and neck
- Anterior thorax and lungs
- Breasts
- Axillae
- Heart
- Abdomen
- Extremities
- Pulses
What is the rationale for the supine position?
- Most normally relaxed position
- Provides easy access to pulse sites
What is a limitation of the supine position?
- If patient becomes short of breath easily, raise head of bed
What areas are assessed in the dorsal recumbent position?
- Head and neck
- Anterior thorax and lungs
- Breasts
- Axillae
- Heart
- Abdomen
What is the rationale for the dorsal recumbent position?
- For abdominal assessment
- Promotes relaxation of abdominal muscles
What is a limitation of the dorsal recumbent position?
- Patients with painful disorders are more comfortable with knees flexed
What area is assessed in the lithotomy position?
- Female genitalia and genital tract
What is the rationale for the lithotomy position?
- Provides maximal exposure of genitalia
- Facilitates insertion of a vaginal speculum
What are the limitations of the lithotomy position?
- Can be embarrassing and uncomfortable for patient
- Examiner should minimize time patient spends in this position
- Patient should be kept well draped
What areas are assessed in the modified left lateral recumbent position?
- Rectum and vagina
What is the rationale for the modified left lateral recumbent position?
- Flexion of hip and knee improves exposure of rectal area
What is a limitation of the modified left lateral recumbent position?
- Joint deformities hinder the patient’s ability to bend hip and knee
What area is assessed in the prone position?
- Musculoskeletal system
What is the rationale for the prone position?
- For assessing extension of hip joint, skin, and buttocks
What is a limitation of the prone position?
- Patients with respiratory difficulties do not tolerate this well
What area is assessed in the left lateral recumbent position?
- Heart
What is the rationale for the left lateral recumbent position?
- Aids in detecting murmurs
What is a limitation of the left lateral recumbent position?
- Patients with respiratory difficulties do not tolerate this well
What area is assessed in the knee-chest position?
- Rectum
What is the rationale for the knee-chest position?
- Provides maximal exposure of rectal area
What is a limitation of the knee-chest position?
- This position can be embarrassing and uncomfortable
What makes up a complete physical examination?
- Assessments for each body system
When do patients typically require a focused examination?
- Patients with specific symptoms or returning for follow-up care
- Focused on relevant body systems related to their symptoms
Give an example of when a focused examination would be performed.
- A patient with severe chest cold symptoms requires focused assessment of ears, nose, throat, respiratory and cardiovascular systems
- Would not routinely require a neurological assessment
When is a complete examination performed?
- When a patient is admitted to the hospital
What guides the preventive screenings for a routine health promotion examination?
- The patient’s age or health risk factors
What do nurses need to use to ensure proper examination?
- Judgement to assess relevant body systems
- Document correct observations
What tools help assess the health of older persons?
- Tools that identify functional, cognitive, and affective status
- Tools that screen for health risks like falls, polypharmacy, and elder abuse
What is functional independence?
- The ability to perform basic personal care
- The ability to perform activities that support independent living (ADLs and IADLs)
Who are functional assessment tools used for?
- Can also be used for younger individuals with functional limitations like spinal cord or traumatic brain injuries
What do functional status assessment tools help nurses assess?
- A person’s independence in the home
- A person’s level of functioning on return home from the hospital
Give an example of a tool to assess independence with ADLs.
- The Katz Index is a common screening tool
Give an example of a tool to assess independence with IADLs.
- The Lawton-Brody IADL scale assesses tasks necessary for independent community functioning
Name some other examples of functional assessment tools.
- Functional Analysis Screening Tool (FAST)
- Global Assessment of Functioning (GAF) Scale
- Barthel Index
Why is screening for elder abuse important?
- An important consideration when working with older persons
Give examples of tools to screen for elder abuse/maltreatment.
- Elder Abuse Suspicion Index (EASI)
- Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST)
- Vulnerability to Abuse Screening Scale (VASS)
What is a good online resource for geriatric assessment tools?
- The Hartford Institute for Geriatric Nursing (https://hign.org/consultgeri/resources)
How should a complete health assessment be performed?
- Follows the format of the nursing history interview review of body systems
- Obtain information from history to focus on specific examination areas
- Findings from history reveal patterns of related signs and symptoms
- Physical examination supplements history to confirm or refute data
Why is it important for nurses to be systematic during an examination?
- To avoid missing important assessment findings
- A head-to-toe approach includes all body systems
- Helps anticipate each step of the examination
How does an adult examination typically begin?
- By assessing head and neck structures, including hair and skin
- Then progressing methodically down the body to incorporate all systems
What tip helps keep the examination organized?
- Compare both sides of the body for symmetry
- Some asymmetry is normal (e.g. dominant arm muscle development)
For a seriously ill patient, what should be done first?
- Assess the body systems most at risk of being abnormal first
- For example, chest pain patient gets cardiovascular assessment first
What should be offered if the patient becomes fatigued?
- Offer rest periods between assessments
When should painful procedures be performed?
- Perform painful procedures near the end of the examination
