Nursing Assessment: Physical Examination

• General Health Assessment is covered under HLTENN037.
• It involves performing clinical assessment and contributing to planning nursing care.

Principles of General Health Assessment

• Prioritize assessment based on presenting signs and symptoms.
• Use a head-to-toe approach (A-I).
• Encourage client participation.
• Record quick notes for documentation accuracy.
• Consider the client's cultural background.
• Integrate health promotion and education.

Before the Assessment

• Explain the type of assessment to the patient.
• Ensure the patient has emptied their bladder/bowel if required.
• Provide privacy for the patient.
• Ensure proper positioning of the patient.
• Assemble all necessary equipment.
• Inform the patient about the estimated duration of the assessment.

During the Assessment

• Provide physical and emotional support to the patient.
• Assist the patient with changes in position and condition.
• Assist with changes in vitals or condition.
• Maintain accurate and timely documentation and recording/reporting.

After Assessment

• Assist the patient into a comfortable position.
• Clean and remove all equipment.
• Send specimens if applicable.
• Report any concerns to the Registered Nurse (RN) or other team members.

Assessment Techniques:

• Inspection
• Palpation
• Percussion
• Auscultation
• Olfaction

Inspection

• Assess rest and activity needs
• Assess nutritional, fluid, and electrolyte needs
• Assess the need for safety and security measures
• Assess hygiene and grooming practices
• Assess oxygenation and circulation needs
• Consider the psychosocial needs of the patient
• Assess elimination

Palpation

• Detects resistance, resilience, roughness, texture, temperature, and mobility
• The back of the hand is sensitive to temperature
• Fingertips are used to detect texture, shape, size, and pulsation
• The palm is used to sense vibration

Percussion

• Examiner strikes a body surface to produce vibration and sound

Auscultation

• Listening with a stethoscope to sounds produced by the body
• Breath sounds: wheeze, crackles
• Heart sounds
• Bowel sounds can be hypoactive or hyperactive

Olfaction

• Use the sense of smell to detect telltale odors
• Fishy smelling urine
• Offensive rotting odor of wound
• Acetone breath
• Halitosis
• Fecal odor of vomitus
• Smoke and alcohol

Reasons for general body observations:

• To assess the patient's overall condition.
• To identify any problems and needs arising.
• To evaluate the effectiveness of care being given.
• To recognize the onset of complications or another condition.

Assessment Skills involve

• Interviewing patients
• Observing and examining the patient.
• Using equipment for assessment
• Evaluating diagnostic and laboratory test results

Assessment Includes:

• Assessment of Skin
• Assessment of Weight
• Assessment of Height
• Assessment of Body Mass Index (BMI)
• Assessment of Psychological/emotional state of patient

Physical observation covers

• What do you see?
• What do you hear?
• What do you feel?
• What do you smell?

Assessment using the sense of sight

• Appearance, behaviour
• Pain versus comfortable
• Eyes, limbs, abnormalities of the skin
• Color (skin, nails, feet, hands, teeth, mouth, ears)
• Expression (emotions, mood)
• Body posture, gait, height, weight
• The ability to perform ADL's
• Degree of independence
• The ability to interact with others
• Excretions and secretions

Assessment using the sense of hearing

• Abnormalities of breathing (wheezing)
• Abnormalities of heart sounds, blood pressure, bowel sounds
• Manifestation of patient's distress (coughing)
• Listening to speech and sounds
• Change of the sound of the technical equipment

Assessment using the sense of touch

• Skin textures (smooth, rough)
• Temperature of skin / dry/moist
• Rapid, slow or irregular pulse
• Rigid or flaccid muscles
• Swelling
• Assessing pain
• Assessing response/reflexes

Assessment using the sense of smell

• Odours are characteristics of certain conditions
• Mouth
• Fishy smell; infected urine
• Ammonia: concentrated
• Offensive odour: infected wound
• Alcohol – breath
• Melaena: blood in stool
• Personal hygiene/body odour

Assessment Using Equipment

• Thermometer
• Sphygmomanometer/Stethoscope
• Scales
• Urine testing equipment
• Tape measure

Skin Observations:

• Colour
• Integrity
• Turgor
• Temperature
• Dry/wet

Colour Assessment:

• Jaundice: Yellowish discolouration of skin and sclera due to excess bilirubin in the blood.
• Erythema: Redness of the skin produced by congestion of the capillaries.
• Pallor: Paleness of the skin.
• Cyanosis: Bluish discolouration of the skin and mucous
• Membranes due to low oxygen in the blood.

Lesions assessment includes:

• Ecchymosis: Bleeding into tissue under the skin, leaving small bruises.
• Petechiae: Pinpoint sized red dots under the surface of the skin
• Purpura: Purple colored spots and patches that occur on the skin

Oedema:

• Abnormal accumulation of fluid in the bodies tissues.
• Can occur in any part of the body; common areas are the feet and ankles.
• Caused by kidney or heart failure or excessive salt intake

Fluid Overload

• Symptoms include weight gain, swelling of feet/ankles/hands/fingers/face, decreased urine output, shortness of breath and collection of fluid in abdomen (ascites)

Physchological/emotional observations includes:

• Behaviour - position, being noncompliant
• Emotional state – crying
• Mood or expression

Recording an individual's height and weight: BMI is important as

• Baseline data on admission
• Calculate drug dosage
• Measure of loss or gain in body mass
• Measure of fluid retention or loss

Measuring Height and Weight

• Height measurements: Feet, Inches, Centimeters
• Weight measurements: Pounds, Ounces, Kilograms

Guidelines for weighing residents

• Use same scale each time
• Have resident void, remove shoes and outer clothing
• Weigh at same time each day
• Scales remain accurate if moved as little as possible

Available equipment for weighing a person includes:

• Floor scales
• Weigh chair
• Baby scales
• Weight bed

Basal Metabolic Index (BMI)

• BMI is an indicator of acceptable weight for the height of a person
• BMI = weight in kilograms / Height in meters²
• Indicates if a person is within an acceptable weight range for their height.
• A healthy BMI range is from 20-25
• <20 is underweight
• 25 - 30 indicates overweight

• 30 is obese

• 40 indicates morbid obesity

Conscious Level-AVPU:

• Alert
• Response to voice
• Response to pain.
• Unconscious.

Test your knowledge of physical examination techniques in nursing. Questions cover skin discoloration, edema, height, weight, BMI, and turgor assessments.