Chapter 33

1. 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

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. 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 33 - 20