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Upon completion of the lecture, the student will be able to do the following: Organize a nursing assessment Discuss preparation of the client and environment to foster data collection Differentiate between subjective and objective data Discuss methods to obtain subjective information during the client interview Describe the technique of inspection, palpation, percussion, and auscultation used in the physical assessment. Describe methods to obtain objective data during the physical examination
Physical health includes basic functions such as breathing, eating and walking. Psychological health includes intellect, self concept, emotions and behavior. Social dimensions of health encompass relationships and interaction s among family, friends, and coworkers. Spiritual health refers to belief in a higher being, personal interpretation of the meaning of life, and attitude toward moral decision and personal conduct.
Assessment includes collecting subjective data through interviewing the client and obtaining objective data by physically examining the client.
Subjective data are those symptoms, feelings, perceptions, pr eferences, values and information that only the client can state and validate. Objective data can be directly observed or measured such as vital sig or appearance.
Establish a database for the client’s normal abilities, risk factors, and any current alteration in function. Plan strategies to encourage continuation of healthy patterns, prevent potential health problems, and alleviate or manage existing health problems. Provide a holistic view of the client. Formulate a conclusion or a problem statement such as a nursing diagnosis. Provide an essential foundation for the care of the client.
General information about the client is obtained by using secondary data sources which include the chart or other healthcare providers that help to personalize the interview and primary data source which gathered from the client.
The client’s language, customs, beliefs, and values differ from client to client and from client to the nurse. Examination of cultural customs, beliefs, and values helps nurse and clients to avoid miscommunication.
Thoughtful preparation of the client and the environment is advantageous for both the client and the nurse since it can eliminate sources of anxiety and help the patient to provide more accurate and complete information.
The major portion of the client interview may be conducted before performing the physical examination. During most health assessment, a preprinted form is used to record information. Health assessment forms vary in title and format depending on the institution, the client population, and the purpose of the assessment.
Introduce yourself to the client, and explain the nature and purpose of the health assessment. Describe assessment as a serious of questions about the client past and present state of health followed by a physical examination.
Goals of the interview Obtain the client history and perception of past experience. Identify factors that either positively or negatively influence the health status. Describe how health status influences the client’s abilities. Identify what changes the client had made to adapt to the health status.
Reason for seeking healthcare. Health history. Pain assessment. Health perception and health management. Activity and exercise. Posture Gait and balance Decreased mobility
Nutrition and metabolism. Elimination. Sleep and rest. Cognition and perception. Self perception and self concept. Roles and relationships. Coping and stress tolerance. Sexuality and reproduction. Values and beliefs.
Inspection Inspection is the natural beginning of physical examination; it is used to make specific observation of physical features and behaviors by using vision. Inspections provide an overall impression of the client’s present state of health and when immediate interventions are indicated.
Overall appearance of health or illness. Signs of stress. Facial expression and mood. Body size. Grooming and personal hygiene.
Palpation is the use of hands and fingers to gather information through touch; it is used to discriminate position, texture, size, consistency, masses and fluid. Palpation can be superficial, light, or deep; with light palpation, three or four fingers of the dominant hand depresses an area of the client’s skin approximately 0.5 to 1 inch usually to evaluate the skin temperature and moistness. Deep palpation involves compression of an area to a depth of 1.5 to 2 inches and requires significantly more pressure than light palpation.
Percussion uses the sense of hearing, involves using the fingers and hands to tap an area on the client to produce sound. The type of percussion tone is determined by the density of the medium through which the sound is traveling, it provides information about the nature of an underlying structure, the size of an organ, and to determine if a structure is air filled, fluid filled, or solid.
Auscultation is the listening for sound and movement within the body, lungs are auscultated for moving air, the heart and blood vessels are auscultated for moving blood, and the abdomen is auscultated for the movement of gastrointestinal content. The stethoscope collects and transmits sound, selects frequencies and screens out extraneous sounds.
Assessment of cognition Objective data concerning the client’s cognitive abilities are obtained through the neurologic examination to assess brain function and motor response.
Level of consciousness: Is the awareness of and responsiveness to the surrounding environment, normally a person responds to environmental stimuli with appropriate verbal and motor activity, attentive, cooperative and completely oriented to self, time, and place Orientation: Evaluation of the orientation is obtained by asking simple questions about time, place, and person. If the client is not oriented, information he provides may not be accurate.
Mood: Abnormalities of mood may indicate psychological or neurologic problems. Normal mood is described as happy or pleasant, depression is being overly sad. Language and memory: Communication and memory are specific aspects of cognitive functioning that are important to effective client teaching.
Sensory aids: Document the use of glasses, contact lenses, hearing aids and other assistive device in the client health assessment to ensure proper use and care of expensive device during hospitalization. Visual acuity: Visual screening is an important part of routine health examinations, The Snellen”E” is used for assessing visual acuity, visual problems with close objects occur more frequently after the age of 40 years.
Extra ocular movement and visual fields: The oculomotor, trochlear, and abducens nerves control the horizontal, vertical, and diagonal movement of the eyes. Assessment of peripheral visual field and six ocular movement is important in comprehensive visual assessment. Pupils and papillary reflexes: Evaluate pupils bilaterally for size, shape, accommodation and reaction to light. Normally, pupils are black and round, and they constrict briskly when exposed to a bright light source. Pupils can appear cloudy when cataracts are present, dilated when glaucoma is treated with drops or neurologic impairment is present. Unilateral changes in pupil reflexes can signify increased intracranial pressure caused by tumor, trauma
Cranial nerve assessment: Intact cranial nerve function is important for normal sensory functioning. External and internal eye structures: External eye structures should be free from lesion or inflammation and blink reflex should be present. The ophthalmoscope is the instrument which is used to assess internal eye structures such as retina, optic nerve disc, macula, fovea centralis and retinal vessels. Auditory assessment: assessment of auditory function can occur simply during normal conversation to evaluate client’s ability to hear. External ear is examined for inflammation or cerumen, while the otoscope is used to visualize ear canal and ear drum. Health screening may include hearing tests using an audiometer
Examination of the mouth includes the buccal mucosa, teeth, lips, gums, tonsils, and uvula. Evaluate the lips for color, moisture, cracks or lesions. By using bright light and a tongue, inspect the mucus membrane, teeth, and gums which should appear pink and moist. Observe for lesion in the mouth tongue or gums. Observe the uvula; it should rise symmetrically and the tonsils should be pink, symmetric and slightly visible. Inspect the teeth for stability and overall hygiene. A major concern when examining the mouth is to detect any abnormalities that might impede the client’s ability to taste, chew, swallow or enjoy food.
Auscultation is used to detect bruits, abnormal arterial sound caused by increased turbulence of blood flow. Palpate the lymph node for mobility, enlargement, and tenderness in cases of inflammation or infections. Evaluate neck veins for distension which can occur with fluid volume excess. The trachea is normally in straight, vertical position, shifting of the trachea from its normal midline position may be caused by lung masses or pneumothorax. Ask the client to swallow as you palpate thyroid gland.
Skin: The skin is a reflection of the body‘s nutrition and metabolism. Some skin disorders may potentially interfere with client’s body image especially if it is present on the face. Scalp and hair: Inspect the scalp and hair for color, quantity, distribution, texture, hygiene, nodules and lesions. Examine the base of the hair for follicle for pest infestation and dandruff. Inspect nails for shape, color, and texture. Skin turgor: Check for skin turgor by pinching a small area of skin on the medial arm or anterior chest and noting how quickly is returns to position when you release poor skin turgor present if the skin remains elevated or slowly resume position which indicate dehydration, aging or weight loss.
Skin lesions: Is an abnormality in the structure of the skin as a result of injury or disease. Every skin lesion should be assessed for size, color, type, and location Wounds: Accidents, pressure, or surgeries may cause wounds. It is especially important to note the wound color, character, color, and amount of drainage if any, and the area around the wound. Nails: Clubbing of the nails (increase the angle between the nailbed and the finger) is a sign of chronic hypoxia. With advanced clubbing, the nail becomes less adherent to the base of the nail and fells spongy, the nails and fingertips appear large and swollen.
Assessment of cardiac and peripheral vascular status provides clues about circulation and oxygenation to every part of the body. The major areas for cardiovascular assessment include: Risk factors for cardiovascular disease. Signs and symptoms of cardiovascular dysfunction. The impact of cardiovascular dysfunction on activity of daily livings. Specific adaptation to cardiac or circulatory impairment.
Auscultation: Listening to the heart sound can provide valuable information. Normal heart sounds include S1 and S2; systole (ventricular contraction) is the period from the beginning of the first heart sound (S1) to the beginning of the second heart sound (S2) while diastole (ventricular relaxation) is the period from the beginning of the second heart sound to the beginning of the next ventricular contraction.
Inspection: Inspect the entire precordium for movement; a visible pulsation occurs with ventricular contraction as the left heart strikes the anterior chest wall. Palpation: Palpate in the precordial area, noting any vibration or pulsation, normal point of maximal impulse is a light tap, located at the medial to midclavicular line, confined to the area of one intercostals space.
Respiratory assessment focus on four main areas: Risk factors for lung disease Signs and symptoms of respiratory dysfunction Impact of respiratory status on activity of daily living Adaptive measures for any respiratory dysfunction
Inspection: Inspection related to the respiratory examination focuses on: Configuration of the thorax Breathing pattern Signs of labored breathing Observation of the skin and nails
Normally; the anterior posterior diameter of the chest drawn as a straight line through the thorax, normal breathing is silent, effortless smooth, regular, symmetric, rhythmic and occurs at a rate of 12 to 20 times per minute Palpation: Is used to evaluate painful or abnormal areas on the chest wall, to test for symmetry of chest expansion, and to detect tracheal deviation, note tenderness, masses or bulges or crackling feeling that indicate air leakage into subcutaneous tissues.
Percussion: Percussion of the lung normally reveals a hollow, loud, low-pitched resonant sound because the lung is air filled. Auscultation: Lung auscultation involves listening with the stethoscope over anterior and posterior chest wall for variation in breath sound.
Inspection: Teach the client to do a breast self examination while you are performing the breast examination, normal breast appear round and essentially symmetric, although one breast is often slightly larger than the other, the skin should be smooth and intact with the areola darker in color, round and symmetric, the nipple should be everted and without discharge or lesions. Palpation: Palpation is done to determine if masses or lumps are present in the breast, Palpate each breast for tenderness, nodules or masses, during the palpation teach the women how to perform breast self palpation.
The abdomen contains organs for digestion for food, elimination of waste, major arteries and veins, and organs of production in the female.
Inspection: During inspection, note the contour, skin and movement of the abdomen, normal abdomen is flat and rounded, abdominal skin should be similar in color and texture to skin on other area of the body, note the presence and location of scars, rashes, lesions, petechiae, or striae, wavelike movement of intestinal peristalsis may be present in thin client, normal aortic pulsation is frequently present visible in epigastrium.
Auscultation: Bowel sounds are created as air and fluid mix in the intestine, normal bowel sounds are tinkling, gurgling noises that occur between 5 to 34 times per minute, only after listening to a quadrant for 5 minutes and hearing no sounds can the nurse conclude absence of bowel sounds. Percussion: Is used to detect the location of organs not normally palpable, and to give clues about the characteristics of the masses underlying the skin. Palpation: Light palpation is performed to obtain information about pain or discomfort, relaxation of the abdominal wall is necessary for accurate assessment.
Inspection: Assessment of the bladder for distension due to urinary retention is warranted when a client complains of lower abdominal discomfort or reports a history of difficulty urination, or when a prolonged time has elapsed since the last voiding occurred. Percussion: To determine the presence of distended bladder, percussion begins at the umbilicus and proceeds toward the symphysis pubis.
Inspection: Examine the skin for color, and temperature, observes varicosities (swollen, twisted veins), edema or fluid. Palpation: Is important in peripheral vascular assessment. Arterial pulses: Palpate arterial pulses, noting rate, rhythm, amplitude, and symmetry, comparing pulses between sides to evaluate for differences in circulation.
Capillary refill: Palpation is also used to assess capillary refill to test circulatory status using nailbed, normally refill time is 3 second or less. Edema: Is fluid accumulation in the tissues and evaluated through palpation, assess edema in dependent area such as the hands, feet, ankles, and lower leg. Joint mobility: Joint movement is important to activity and exercise function; all joints should have appropriate range of motion. Muscle strength: Perform a simple screening of motor function in the arms and legs, evaluate symmetry of strength.
Circulation, movement and sensation: Assess circulation by color, temperature, pulses, and capillary refill; assess movement by asking the client voluntarily to move the extremity, assess sensation by asking the client to say when he feels the touch. Deep tendon reflexes: Testing deep tendon reflexes by using the hummer to tap various tendons in the body to see if this action elicits the appropriate reflex arc through the spinal cord.