Physical Health Assessment

Key Objectives

• Discuss the various types of assessments across different scenarios.
• Illustrate physical examination techniques.
• Explain how to gather patient information for a comprehensive database.
• Evaluate a patient's psychosocial and physical health by collecting data in an organized way.
• Perform essential physical exams.
• Conduct vision tests on patients.
• Perform targeted physical evaluations of the cardiovascular, respiratory, gastrointestinal, and neurological systems.
• Educate about early cancer detection through assessment methods.
• Share guidance on regular diagnostic testing.
• Help with medical exams by proper patient positioning, draping, and equipment setup.

Key Terms

• Adventitious Sounds: Unusual sounds heard during lung auscultation.
• Auscultation: Listening for sounds within the body, typically with a stethoscope.
• Bronchovesicular Sounds: Sounds heard over the central chest or back.
• Dual-energy X-ray Absorptiometry (DXA): A method to measure bone density.
• Edema: Swelling caused by fluid accumulation in body tissues.
• Kyphosis: Excessive outward curvature of the spine, resulting in a hunchback.
• Lesions: A region in an organ or tissue that has suffered damage through injury or disease, such as a wound, ulcer, abscess, or tumor.
• Lordosis: Excessive inward curvature of the lower spine.
• Nystagmus: Rapid, involuntary rhythmic eye movements.
• Olfaction: The sense of smell.
• Palpation: Examination by feeling with the hand or fingers.
• Percussion: Tapping a part of the body for diagnostic purposes.
• Quadrant: One of four sections of an area.
• Scoliosis: Lateral curvature of the spine.
• Tremors: Involuntary shaking movements.
• Turgor: The degree of elasticity of the skin.
• Vesicular Sounds: Soft, rustling sounds heard in the periphery of the lung fields.

The Importance of Assessment

• Vital in nursing to assess patient condition and progress.
• Involves assessing lung sounds, heart sounds, monitoring circulation, neurological changes, and noting skin issues.
• Illnesses often affect multiple body systems.
• Quick assessments are done at the start of each shift focusing on all body systems.
• Nurses must monitor subtle changes due to frequent patient contact.
• Strong assessment skills identify new signs/symptoms and complications.
• Crucial in home and long-term care where nurses might be the primary healthcare eyes and ears.

Physical Exams

• Usually required for school entry, insurance, employment, driver's licenses, and military induction.
• Done every 1 to 5 years for primary preventive care, depending on age and health.
• Nurses often assist in these examinations.

Initial Assessment Components

• Involves gathering patient history, demographic data, and brief physical examination upon admission to various healthcare settings.
• Health and psychosocial history provides essential information to assist in daily care.
• Knowledge of current health problems is vital, review medical records, and obtain data from the patient.
• Consider the impact of illness on a patient's life, exploring concerns beyond physical health.

Patient Interview Guide: Social Data Points

• Marital status and significant relationships
• Health insurance coverage
• Occupation
• Impact of admission on home life
• Visual or hearing deficits
• Use of dentures or prostheses
• Organizational and religious affiliations
• Cultural practices relevant to care
• Medication and substance allergies and reactions
• Prescription, OTC, and herbal medication use
• Food and substance allergies and reactions
• Dietary preferences, restrictions, and intolerances
• Tobacco use history
• Alcohol consumption patterns
• Recreational drug use
• Need for assistance with ADLs

Physical Data: Review of Systems (General Questions)

• Previous surgeries or serious injuries
• Current health problems
• Use of other care providers
• Reason for admission

Physical Data: Review of Systems (Head and Neck)

• Frequent headaches or dizziness
• Ear problems: hearing difficulty, ringing, aid use
• Vision problems: corrective lenses, glaucoma, cataracts, last eye exam
• Frequent colds, nasal allergies, sinus infections, sore throats, swallowing issues, or swollen glands
• Last dental exam, gum issues, or mouth sores
• Sleeping difficulty, needing to nap

Physical Data: Review of Systems (Chest)

• Frequent cough, sputum production description
• Lung problem history: pneumonia, asthma, wheezing, bronchitis, emphysema
• History of tuberculosis exposure
• Occupational exposure to respiratory hazards
• History of angina, chest pain, heart attack, irregular heartbeats, palpitations, murmurs, shortness of breath
• Leg pains or cramps after short walks
• Pacemaker or automatic defibrillator
• High blood pressure (hypertension)

Physical Data: Review of Systems (Abdomen and Elsewhere)

• For females, inquire about last mammogram, nipple discharge, and breast lumps
• Frequent indigestion, gas, bloating, heartburn, nausea, or vomiting
• Thirst or hunger
• Bowel movement frequency, changes, diarrhea, or constipation
• Rectal bleeding or tar-colored stools
• Excess gas
• Hemorrhoids
• Gallbladder or liver problems
• Urinary issues, nighttime urination, urgency, frequency, or incontinence
• Urinary tract infections or kidney stones
• For females, assess sexual activity, vaginal issues, menstrual cycle, bleeding, last Pap smear, unusual discharge, and history of STIs
• For males, examine sexual activity, genital issues, discharge, history of STIs, and prostate problems
• Check for joint pain or stiffness
• Check for muscle pain or back problems
• Ask about the body's range of motion
• Check for any circulation problems in the legs or arms
• Check if the individual tends to bruise easily or has any skin lesions
• Check for a history of phlebitis, thrombophlebitis, gout, or arthritis
• Check for a history of fractures or injuries
• Check for any artificial joints
• Look for any signs of abuse
• Assess for history of thyroid problems, thyroid issues
• Assess for history of diabetes

Cultural Sensitivity

• Essential for individualized care plans.
• Cultural assessment involves asking about preferences for food, bathing, and personal care.
• Respect patient's beliefs about illness, treatment, and who should be consulted.
• Frame questions positively and avoid assumptions based on ethnicity.

Considerations for Older Adults

• If an older adult is forgetful, gather data from family.

Questions to Detect Potential Physical/Sexual/Alcohol Abuse

• Spousal abuse or fears
• Control by partner
• Forced uncomfortable activities
• Fear of someone close

Potential Alcohol Abuse Questions

• Thoughts of reducing alcohol intake
• Irritation at comments about drinking
• Remorseful feelings about drinking
• Drinking in the morning to feel better

Assessment of Health Status

• Involves observing patient behavior and appearance.
• Data may indicate illness, elevated temperature, or malnutrition.
• Detection of abuse signs should be included.
• Essential to measure various body functions.
• Combining physical, health, and psychosocial histories can create a health database.

Benefits of Data Collected

• Determines patient's health and physiologic functioning level.
• Helps to form a preliminary problem statement.
• Can confirm diagnoses of dysfunction, disease, or ADL inability.
• Indicates body areas for further testing.
• Evaluates treatment effectiveness and adverse effects.
• Monitors body function changes.
• Determines abuse signs.

Gathering Patient History

• Involves asking about the problem, onset, symptom progression, precipitating factors, effects on activities, frequency, circumstances, relationship to meals, relevant history, pain assessment (location, description, scale), and relieving factors.
• Conducted in settings like hospitals, health centers, clinics, schools, and provider offices.

The Importance of Touch

• Many cultures like those of India, China, and Arab countries, may restrict male nurses touching female patients.
• Male nurses should ask permission and understand if a female nurse is requested.

Signs and Symptoms of Possible Abuse in Children

• Physical injuries, neglect indicators, poor hygiene, and malnourishment
• Conflicting explanations about injuries.
• Inconsistent injuries with explanations
• Inappropriate responses to examination questions
• Frequent injury or illness-related visits to primary care
• Being overly affectionate or sexually knowledgeable for their age
• Fear of known individuals
• Resistance to removing clothing for examination
• Chronic genital itching, pain, or evidence of STIs

Older Adults: Abuse Signs

• Dehydration or malnutrition without an underlying illness
• Burns or neglected pressure injuries
• Bruises in various stages of healing
• Inadequate clothing or shoes for the weather
• Verbalization of a lack of food, medicine, or care
• Fear of the caregiver
• Poor hygiene with body odor
• Stating that someone has taken control of their finances or life

Abuse Signs in Spouses and Partners

• Frequent injuries referred to as accidents
• Clothing to hide bruises and scars
• Isolated from others
• Limited access to resources
• Considerable anxiety or depression
• Fear or anxiousness to please their partner
• Talks about the partner's anger or possessiveness

Vocabulary for Assessment

• ADLs: Activities of Daily Living.
• Ascites: Fluid accumulation in the peritoneal cavity.
• Bruit: Abnormal auscultation sound (swishing).
• Cognitive: Related to mental processes.
• Cyanosis: Bluish skin due to low oxygen.
• Ecchymosis: Bruising.
• Erythema: Skin redness from capillary congestion.
• Extension Posture: Decerebrate posture, indicating brain damage.
• Fissure: A narrow slit.
• Flexion Posture: Decorticate posture, indicating brain damage.
• Guaiac: Test for stool blood.
• Gurgles: Low-pitched wheezes or rhonchi.
• Inspection: Visual examination.
• Integument: Skin covering.
• Jaundice: Yellowing due to hyperbilirubinemia (also called Icterus).
• Jugular Venous Distention (JVD): Protrusion of jugular veins suggesting heart failure.
• Lethargy: Drowsiness or stupor.
• Murmur: Short cardiac/vascular sound.
• Ophthalmoscope: Instrument used to view the eye interior.
• Orientation: Awareness of environment.
• Otoscope: Instrument to view the tympanic membrane and ear canal.
• Pallor: Paleness of the skin.
• Papanicolaou (Pap) Smear: Test for malignant cells.
• Patent: Freely open.
• Petechiae: Pinpoint, purplish spots from hemorrhage.
• Pigmentation: Skin coloring.
• Proctoscopic Examination: Rectum examination.
• Rinne Test: Compares bone and air conduction of sound.
• Sanguineous: Bloody.
• Scar: Mark after wound healing.
• Serosanguineous: Composed of serum and blood.
• Sigmoidoscopy: Sigmoid colon examination.
• Sign: Objective disease evidence.
• Sore: Painful skin lesion.
• Speculum: Tube to examine canals.
• Sputum: Lung secretions.
• Symptom: Subjective information.
• Tinnitus: Ear noises.
• Tuning Fork: Instrument to test hearing.
• Vertigo: Dizziness sensation.
• Weber Test: Bone sound conduction test.
• Wheeze: High-pitched respiratory sound.
• Wound: Bodily injury.

Physical Examination Techniques

• Information is gathered through sight, hearing, smell, and touch.

Inspection and Observation

• Assessing general appearance, body contours, skin, lesions, deformities, movements, and respirations.

Palpation Involves

• Using touch to detect size, shape, position, texture, temperature, and moisture.
• Ascertaining muscle spasm, pain, swelling, and restriction in movement.
• Assessing skin temperature, turgor, and edema.
• Using the backs of hands/fingers to feel skin temperature.
• Using finger pads to palpate size, position, and consistency.
• Using the palm to detect vibrations or tremors.
• Using the thumb and index finger to check skin turgor etc.
• Palpate the abdomen lightly to identify painful or tender areas or to find masses or abnormal fluid collections.

Percussion Involves

• Light, quick tapping to produce sounds that reflect characteristics of organs or structures beneath the surface.
• Determining the size, location, and density of organs.
• Using middle finger striking technique.
• Moving hands after two or three taps in each location.

Auscultation

• Involves listening through a stethoscope for bodily sounds (heart, lungs, abdomen).
• Using the diaphragm for breath, bowel, and normal heart sounds.
• Using the bell for low-pitched sounds like abnormal heart sounds.
• Placing earpieces correctly and holding the diaphragm firmly.

Olfaction

• Involves nasal identification of characteristic smells related to specific problems.
• A fruity odor may indicate diabetic acidosis.
• Alcohol may explain lethargy.

Physical Exam: Basics

• Basics are the foundation for expertise.
• Adult weight is measured via standing scale.
• Weight can be measured using built-in or chair scales.
• Consistency is key whether weighing with/without shoes.
• Infants are weighed on an infant scale with a clean cover.
• Infants must never be left unattended while weighing.
• Height is measured from sole to crown using a vertical measuring rod with the patient erect.
• Infants and children need to be measured supine.

Practical Steps

• Check scale calibration.
• Apply clean paper cover.
• Assist the patient onto scale, no shoes.
• Record weight immediately.
• Assist getting off the scale.

Considerations for Height Measurement

• Use a vertical measuring rod.
• Person stands erect.
• Position them with feet together centered under rod.
• Lower extension rod to 90 degrees until it rests level on patient’s head.

Pediatric Considerations

• Infants under 3 are measured supine.
• Approximate length on the examining table.
• Measure the distance between head position marks.
• A second person is often necessary.
• Measuring devices are marked in inches and centimeters.

Height and Weight charts

• Historically, they were used to determine weight limits
• Now, they are replaced by body mass index charts.
• Children are frequently measured to track growth.
• Older adults need yearly measuring to track potential spine changes.

Vital Signs Measurement

• Measure vital signs during the physical examination.
• Compare current vital signs against previous.
• Measure blood pressure on both arms after 5 minutes' rest.

Factors Affecting The Accuracy of Blood Pressure Readings

• Inaccurate readings due to unsupportive feet.
• Artery being misaligned
• The patient talking. Assess blood pressure on both arms while standing and when abnormal.
• Never take blood pressure on the arm containing a shunt, IV site, or on the side where a mastectomy was performed as it can cause inaccurate findings or even put your patient in an unsavory situation.
• A second blood pressure reading should be taken before the patient leaves if the blood pressure is elevated.

Steps for Visual Acuity Testing

• The Snellen eye chart is used.
• Have patients stand 20 ft from the Snellen chart.
• Patients are tested with and without glasses.
• Vision tested one eye at a time.
• Record fraction and note missed letters.
• If the top number cannot be read, position closer to chart.

Reviewing Body Systems: Head and Neck Assessments

• Assess general appearance, skin color/tone, eyes, and hair condition.
• Note any nose congestion or drainage.
• Does the patient have clean teeth?
• Assess for hearing difficulty.
• Check that the pupils are equal and reactive.
• Assess eye movement, clarity of corneas and lens, last eye exam.
• Is the patient alert, oriented, and thinking logically?
• Assess the neck for swelling, alignment, and stiffness. Use an audioscope to test hearing.

Reviewing Body Systems: Chest, Heart, and Lungs Assessments

• The chest should rise symmetrically with respiration.
• Observe chest excursion by placing thumbs over posterior vertebrae.
• Inspect spine from the rear/side for alignment/curves.
• Assess shoulder height.
• Is lordosis, kyphosis, or scoliosis present?
• Inspect the anterior chest for PMI.
• Listen for S1 and S2 heart sounds using the stethoscope diaphragm.
• Count apical pulse for one minute.
• Master listening to valve sounds with the bell piece.

Lung Auscultation Points

• Use diaphragm to ascultate
• Lung sounds are created by air moving through airways.
• Sounds vary depending on the region
• Sounds over the trachea are loud and coarse.
• Upper chest sounds over the bronchi are shorter on inspiration.
• Bronchovesicular sounds central chest or back during inspiration and expiration with medium sounds.
• Vesicular sounds are longer on inspiration without any pauses.

Heart Sound Assessment Steps

• Evaluate heart sounds upon admission and once per shift.
• A quiet room and silenced devices (TV's) are imperative for auscultation.
• Explain the procedure to the patient and provide privacy - reducing anxiety and potential embarrassment.
• Ensure the patient is seated upright at a 45-90 degree angle with their head elevated.
• All anatomic landmarks are to be identified and then stethescope application directly to the skin.
• Check for “lub/dub” sounds with the diaphgram at the apex.
• Lower bed, raise side rails.
• Lastly, any abnormal sounds or murmurs are to be reported immediately for the best patient outcomes.

Assessing the Skin & Extremities

• Look for any rashes or lesions on the skin
• Includes Braden Scale use for predicting pressure sore risk. Examine skin for flaking/dryness.
• To evaluate turgor, gently pinch skin.
• Ask about lesion changes. Inspect nails for discoloration/unusualness.

Steps to Auscultate Lungs Effectively

• Educate the patient about the process at hand - making sure they are fully aware of next steps.
• Eliminate extreneous noise within the chamber as this can be extremely distracting
• Create a safe & private space for patients ensuring windows are adjusted & doors/currtains are checked.
• Help the patient remain with the back away from beds/chairs, using pillows for comfort.
• Clothing should be removed and loosened as much as possible.
• Use warm hands to handle equipment - to further the patient's comfort.
• Breathing should be slow

Assessing Capillary Refill and Peripheral Pulses

Assess both the nailbeds to examine the current blood flow and any other issues at hand. Document all findings immediately. Pulse assessment is extremely important to examine the circulation of the lower extremeties.

Steps to Ascultate Lungs

• Ask the patient to take slow, deep breaths.
• Listen in each posterior chest location for a full breath.
• Move the stethoscope from side to side.
• Ask the patient to cough to clear passageways.
• Compare sounds from right to left for each area.
• Document thoroughly.

Assessment of Edema

• Check for generalized edema through weight gain, shoe/ring tightness.
• Dependent edema is assessed by pressing fingers over the tibia.
• Edema is described as taut, tight, puffy, indented, or pitting.
• Pitting is classified by depth from 1+ to 4+ in 2-mm increments

Older Adult: Skin Differences

• Less elastic and dry skin
• Decreased accuracy of skin turgor
• Prone to age-related lesions: lentigines and actinic keratoses

Considerations In Extremities Examination

• Inquire about sensations in the skin.
• Is there tingling or twitching?
• Can the patient distinguish warm and cold?
• Are there any changes related to any muscle strength?

Abdomen Assessment

• Focus is place to bowel sound for all current patients, at least once per shift.
• Bowel sounds are created by the small and large intestine contracts.
• Sounds are usually 5 to 30 per minute and clicks.
• Sounds can help diagnose a patient with issues.
• Documenting is of utmost importance - and must be accurate at all times.
• If gas or gastrointestinal issues persit - the sounds can be used to measure the amount of blockage.

Lifespan Considerations for Abdomen Assessment

• Skin sensation decreases as the patient gets older.
• Joint flexibility and muscle stability also decreases as age increases.

Anus and Rectum Assessment

• The areas of the lower end must be visually inspected and assessed.

Assessment for problem Identification & Analyzing Issues

• Registered nurses always synthesize and prioritize problems immediately.
• Goals should then be implemented
• And proper solutions should be taken into consideration for patient success
• Acronym - "RNS HOPE" should be considered for every step.
• The nursing process provides valuable insights to plan for patients' well-being
• Data and observations are the foundation for identifying risks

Shift Assessment Basics: Review the Body with "RNS HOPE"

• Rest and Activity Needs: Body proportion, ROM, strength, ADLs, sleep patterns, pain
• Nutritional, Fluid, and Electrolyte Needs: Height/weight, diet, appetite, fluid balance, labs
• Safety and Security: Risks, senses, abuse indications, security devices
• Hygiene and Grooming: Ability, amount of care, preferred routines
• Oxygenation and Circulation Needs: Breathing, breath sounds, cough, consciousness, BP, heart sounds, pulses, JVD, skin color, labs
• Psychosocial and Learning: Desire for spiritual aid, support, outlook, coping, consults, worries, knowledge
• Elimination: Output, bowel movements, control, alterations, sounds, pain, dehydration signs

Key elements for Shift Head-to-Toe

• Initial observation: including appearance, affect and their breathing.
• Then, checking their head, consciousness
• Followed by the body's proper signs: pulse, temperature, saturation and BP
• Pain: The level of their pain, any medication and the proper delivery method.
• Chest: Check the heart rate at key points.
• Also, review the patient's abdomen as well.
• Examining the extremities and checking for their stability.

Physical Examination: Step-By-Step

• Step 1: Collect everything including past issues, complaints, and issues that can place the patient in danger.
• Step 2: Gown needs to be place for ease of check.
• Step 3: Weight and any needed components are checked
• Step 4: Head and beck to help stabilize any issues.
• Step 5: Extremities
• Step 6: Blood and important vital signs are to be checked constantly.
• Step 7: Abnormatlites need to have their sounds to further assess the condition.
• Step 8: Equal chest movements.
• Step 9: Patient position
• Step 10: Check the samples/specimens for any order.
• Step 11: Any important issue that needs to be at hand should be addressed and followed.