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OBJECTIVE 4 Demonstrate the nurse’s 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 patient’s 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 patient’s perception of his/her illness. • Gain insight about the patient’s concerns. • Determine the patient’s 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 patient’s 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 patient’s past health history and family health history. The nurse also obtains psychosocial, cultural, and spiritual

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using the sense of sight o Make sure good lighting is available. Deep palpation which is used to examine the organs is not normally done by the nurse without additional training in this technique. if the patient complained of shortness of breath. 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. symmetry. o Areas known or suspected to be tender are palpated last. After obtaining this general information from the patient. Palpating for skin temperature is best determined using the back of the hand and fingers. on the same scale. shape. 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. the nurse’s assessment would focus on listening to the lungs and assessing the patient breathing. • Palpation: uses the sense of touch o Make sure patient is relaxed and in comfortable position. the nurse proceeds with a review of systems in which the patient is asked about the functioning of each system. o Position and expose the body so that all areas can be viewed. however. 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. o Percussion strokes should be quick. position. sharp stroke. For accurate comparisons. There are four basic techniques of assessment when performing a physical examination. and in the same amount of clothing. The admission physical examination usually begins with obtaining the patient’s vital signs (See CSG Objective 14). and the scale used. 30 . After obtaining the initial data. o Inspect each area for size. The nurse should note the clothing a patient is wearing when obtaining the weight. These steps are normally conducted in the order listed. and weight. 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 patient’s current status. there are exceptions. color. o Compare each area with the same area on the opposite side of the body. warm hands. o If necessary. the time of day. and any obvious abnormalities. height. • Percussion: involves tapping the body with the fingertips o Direct method: striking the body surface directly. o Apply slow and gentle tactile pressure with the palmar surface of the fingers and finger pads. o Light palpation proceeds deep palpation. • Inspection: the process of observation. For example. subsequent weight measurements should be performed at the same time of the day. The data obtained is used to guide the physical assessment of the patient.information needed to provide individualized care.

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). and convex. it is normal to have longitudinal streaks of brown or black pigmentation in the nails. A prolonged capillary refill occurs in circulation problems. This skill focuses only on a general head-to-toe survey assessment. Hair may be coarse or fine. o You must practice listening to normal sounds to be able to distinguish abnormal sounds. The head should be assessed to determine the condition and distribution of the hair and the integrity of the scalp. and flatness based on the intensity. hyperresonance. The nurse should inspect for areas of hair loss (alopecia) and ask the patient if there have been any changes noted in the hair. but it should be shiny and smooth. the nurse also uses the sense of smell during an examination. with a nail bed angle of about 160 degrees. thickened nails. The nurses assesses for color. scaliness. Paronychia is the term for inflammation of the skin at the base of a nail. and quality of the sound. smooth. resonance. the pink color should return within 3 seconds. Pressure is applied to the nail bed which will cause the nail bed to appear white or blanched. Nails are normally transparent. pitch. o Listen not only for the presence of sounds but the quality and characteristics of sounds heard. Strands of hair should be separated to better assess the scalp. Yellowish. o Different areas of the body will normally have certain percussion sounds and changes in the sounds can reflect specific abnormalities.• o Sounds include tympany. the thickness and shape of the nail plate. the angle between the nail and the nail bed. Auscultation: listening to sounds produced by the body o Make sure the environment is quiet and that you have a good stethoscope. The nurse should also test for capillary refill when examining the nails. Assessment of the nails begins with an inspection of the nail bed for color. dullness. straight or curly. When the pressure is released. the expected normal findings. may be an indication of chronic fungal infections of the nails. In addition to the techniques noted. 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. A more detailed assessment. cleanliness. Problems with circulation can also cause discolorations in the nails. The hair follicles should be inspected for lice. In people of color. and length. primarily using inspection with limited palpation and auscultation as outlined in the checklist. and the condition of the cuticles and skin around the nails. 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. Abnormal odors can give a clue to a potential health problem. Common Problems 31 . or lesions. particularly of the toe.

Wojaski RN The beginning of shift head-to-toe assessment is charted in the nurse’s note as is any focused assessment performed. you would chart most data regarding the head assessment.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. This statement would not be acceptable to chart if there was not a form with the data. the data is charted primarily in the same head-to-toe order but items are grouped per body systems. When charting a head-to toe assessment. External noises should be eliminated if possible or reduced to lowest level possible. Wojaski RN Example of beginning of shift head-to-toe and systems assessment 32 . BP 132/74.K.---. If the there is any reason to question the reliability of information provided by the patient. Jacobs notified and Benadryl 50 mg given IM as ordered. 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. The environment can influence results obtained during an examination. small red papules covering abdomen and trunk approximately 20 minutes after penicillin started. In that situation the note would have to be much more detailed to include the data obtained from the history and examination. Example Documentation Most facilities will have an admission form used to record the initial interview and assessment. Physician Notification The physician is notified of any abnormal data obtained during an assessment. No respiratory distress. For example. This note with the nurse’s statement “admission assessment completed” is an example of an admission note when there is an admission form that has been completed. R 22. no acute distress. Penicillin discontinued. such as talking with family members (with patient’s permission) and reviewing old records.---you do not go back and forth from one area to another. the nurse should seek other resources to verify the data. The nurse must make sure that the examination area is a comfortable temperature. -----------------------. Skin intact. This information would be charted in with other respiratory data. Admission assessment completed. Dr. A brief summary is also included in the nurse’s notes. Example of focus assessment 1430 c/o pruritis and tingling in hands and feet. P 86. when assessing the head you might note that a patient is receiving O2 per nasal cannula. 1300 54 y/o alert and oriented white female admitted via wheelchair with chief complaint of fever of unknown origin. For example. followed by the abdominal assessment. warm and moist. then the thorax assessment.K. etc. neither too hot nor too cold. T 1020 orally. Examples of a beginning of shift assessment and a focus assessment are shown.

You are admitting a new patient that you need to interview. Why is it important to use therapeutic communication skills during an interview? 33 . O2 @ 2 L/min per NC. Bowel sounds active x 4 quad. CV: S1 S2. Denies any discomfort. c/o “some stiffness” in knees. Give an example of each of the following: a. Mouth care and denture care done.” Denies any pain or discomfort. Peripheral pulses strong and equal. Abd: Soft.” ------------------------------------------. Cap refill < 3 sec. Encouraged to ambulate with assistance at least twice this shift. draining clear yellow urine. Open ended question: Closed question: Biased or leading question: 3. non-distended. alert. States “You’ve answered my questions and I feel better. Lips slightly dry.0715 Awake. c.S. GU: Foley cath intact to BSD. Cath care done. Extremities: Moves all extremities with full ROM. What are the steps in this process? What information do you need to ask? 2. 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. Anxious about procedure. Bilateral equal breath sounds. Responds appropriately to questions. Wearing glasses. STUDY QUESTIONS 1. Denies any shortness of breath or cough. Last BM last night without difficulty. Resp: Chest movement symmetrical. States “I slept very well last night. and oriented. NPO for cardiac cath today. b. Review of procedure and expectations. Campenello RN Note: The above example reflects the type of information expected initially in Adult Health I.

What assessments should the nurse make and what information should be documented? 34 .4. How does the environment influence the success or failure of an interview? 5. Which of the major senses do you use when doing a physical assessment? 7. Why is it helpful for a nurse to have a sense of humor? 6. A patient is admitted who has a skin rash and an ulcer on the leg.

OBJECTIVE 4 PERFORMANCE CHECKLIST: GENERAL SURVEY ASSESSMENT Demonstrate the nurse’s responsibility in the physical assessment of a patient: general survey. stethoscope. 9. 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. YES NO* 1. • If this is a follow-up assessment. 3. 4. • Determine if patient is able to stand unassisted for height and weight measurement. Verbalize that a health history interview would precede the assessment. using appropriate body mechanics. 5. 7. Provide safety by using side rails as needed. Provide for nurse safety by having bed at working height. Obtain necessary preliminary information. Provide privacy by closing door and pulling curtains and draping patient as necessary. 8. and using assistance as needed. asking for assistance if needed. Identify the patient using two methods and explain the procedure. 6. • Sphygmomanometer. Gather equipment • Bath blanket or linen for draping. Verbalize that assessment of vital signs would precede the assessment. Expose only the area being examined. • If this is an admission assessment. review results of previous assessments. 35 . • Determine if assistance is needed. 2. determine if patient brought any documents that should be reviewed before beginning the interview and assessment. and wearing gloves if there is risk for exposure to body secretions. keeping restraints in place if necessary.

thickness. steady gait. slurred. proportion. unkempt Inspect for general nourished status: well-nourished. frail Head/Face/Neck Inspect overall appearance. color of sclera and conjunctiva. Auscultate for bilateral breath sounds. garbled Inspect for affect/mood: cheerful. thin. Inspect lips for color. Inspect for symmetry of chest wall and chest wall movement. weak. patency Inspect ears for symmetry. position. obese. color. braces • Inspect moisture. Have patient shrug shoulders and inspect for symmetry of movement. texture of tongue Inspect neck for any obvious abnormalities. pale. abnormal curvature. slumped posture. Palpate carotid pulses and temporal pulses. cyanotic Assess speech: clear. Auscultate apical pulse. Thorax Inspect for ease of respirations. 11. restless Inspect for hygiene: well-groomed. have patient open mouth • Inspect color and condition of gums • Inspect teeth: good hygiene. cleanliness of canal Evaluate if patient can hear normal speaking voice. emaciated Inspect body symmetry for evidence of gross abnormalities or deformities Inspect posture/mobility: full ROM. areas of loss Inspect eyes for symmetry. calm. drowsy. uses walker. symmetry Inspect hair for cleanliness. Using tongue blade and flashlight or penlight. 12. ability to open & close. moisture. dentures or plates. these are not the only terms) Assess for alertness: awake.Continued on back YES NO* 10. 13. dental caries. unresponsive Assess general skin color: pink/black/brown as appropriate for race. 14 15 16 17 General Impression of Appearance (descriptive terms are examples of type of data to look for. sad. 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Continued next page YES NO* 36 . lesions. Inspect for obvious breast abnormalities. symmetry of eyebrows Inspect nose for deformity. degree of moisture. Inspect spine for straightness.

Inspect hair distribution. Inspect umbilicus for position. Extremities Inspect for color. Palpate all peripheral pulses. or vaginal discharge. Auscultate for bowel sounds. External Genitalia: Male Inspect for obvious deformity. retract foreskin: evaluate ease in which retracts and returns. For uncircumcised patient. Inspect for symmetry of testicles. lesions. cleanliness. discoloration.35 36 37 38 39 40 41 42 43 44 Abdomen Inspect for contour (flat. Inspect for inflammation. Wash hands and/or use antiseptic solution. Dispose of linens and equipment appropriately. Palpate skin temperature. or penile discharge. Inspect nails for color. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 *Evaluator: Document unmet or incorrect action. Inspect for inflammation. lesions. lesions. convex. Inspect for distention. Inspect hair distribution. Inspect degree of ROM. External Genitalia: Female Inspect for obvious deformity. edema. concave) and symmetry. Document results of assessment and report abnormal findings. edema. Palpate for bladder distention. inflammation. 37 . Assess capillary refill. Palpate any areas of reported discomfort. hair distribution. discoloration. Inspect for obvious pulsations or peristalsis.

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