INTRODUCTION TO PHYSICAL ASSESSMENT

INTRODUCTION TO PHYSICAL ASSESSMENT

 INTRODUCTION

 An accurate physical assessment requires an organized and systematic approach using the techniques of inspection, palpation, percussion, and auscultation.  It also requires a trusting relationship and rapport between the nurse and the patient to decrease the stress the patient may have from being physically exposed and vulnerable.  The patient will be much more relaxed and cooperative if you explain what will be done and the reason for doing it.  While the findings of a nursing assessment do sometimes contribute to the identification of a medical diagnosis, the unique focus of a nursing assessment is on the patient's responses to actual or potential problems.

   FACTS ABOUT PHYSICAL ASSESSMENT

  a.           Physical assessment is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination.  A physical assessment should be adjusted to the patient, based on his needs.  It can be a complete physical assessment, an assessment of a body system, or an assessment of a body part.

  b.          The physical assessment is the first step in the nursing process.  It provides the foundation for the nursing care plan in which your observations play an integral part in the assessment, intervention, and evaluation phases.

   c.            The chances of overlooking important data are greatly reduced because the physical assessment is performed in an organized, systematic manner, instead of a random manner.

. PURPOSES OF A PHYSICAL ASSESSMENT

  a.  A comprehensive patient assessment yields both subjective and objective  findings.  Subjective findings are obtained from the health history and body systems  review.  Objective findings are collected from the physical examination.

 (1)  Subjective data are apparent only to the person affected and can be described or verified only by that person.  Pain, itching, and worrying are examples of subjective data.

   (2)  Objective data are detectable by an observer or can be tested by using an accepted standard.  A blood pressure reading, discoloration of the skin, and seeing the patient in the act of crying are examples of objective data. 

    (3)  Objective data are sometimes called signs, and subjective data are sometimes called symptoms.

   (4)  Data means more than signs or symptoms; it also includes demographics, or patient information that is not related to a disease process.

 b.  The purposes for a physical assessment are:

  (1)   To obtain baseline physical and mental data on the patient.

   (2)  To supplement, confirm, or question data obtained in the nursing history.

  (3)  To obtain data that will help the nurse establish nursing diagnoses and

         plan patient care.

  (4)  To evaluate the appropriateness of the nursing interventions in resolving the patient's identified

         pathophysiology problems        

 CONSIDERATIONS IN PREPARING A PATIENT FOR A PHYSICAL 

 ASSESSMENT

  a.          Establish a Positive Nurse/Patient Rapport.  This relationship will decrease the stress the patient    may have in anticipation of what is about to be done to him.

b.             Explain the Purpose for the Physical Assessment.  The purpose of the nursing assessment is to gather information about the patient's health so that you can plan  individualized care for that patient.  All other steps in the nursing process depend on the collection of relevant, descriptive data.  The data must be factual, not interpretive.

c.           Obtain an Informed, Verbal Consent for the Assessment.  The chief source of data is usually the patient unless the patient is too ill, too young, or too confused to communicate clearly.  Patients often appreciate detailed concern for their problems and may even enjoy the attention they receive.

d.          Ensure Confidentiality of All Data.  If possible, choose a private place where others cannot overhear or see the patient.  Explain what information is needed and how it will be used.  It is also important to convey where the data will be recorded and who will see it.  In some situations, you should explain to the patient his rights to privileged communication with health care providers.

e.           Provide Privacy From Unnecessary Exposure.  Assure as much privacy as possible by using drapes appropriately and closing doors.

f.           Communicate Special Instructions to the Patient.  As you proceed with the examination, informs the patient of what you intend to do and how he can help, especially when you anticipate possible embarrassment or discomfort.

 BASIC TECHNIQUES USED IN PERFORMING A PHYSICAL ASSESSMENT

  a.          Inspection.  Visual examination of a person is called inspection.  This is done in  an orderly manner, focusing on one area of the body at a time.

 b.           Palpation.  Examination by touch is called palpation (figure 6-1).  The nurses feel for texture, size, consistency, and location of body parts.

c.           Auscultation.  Examination by listening for sounds produced within the body is called auscultation.  The sounds most frequently listened for are those of the abdominal and thoracic viscera and the movement of blood in the cardiovascular system.  Direct auscultation, using the ear only, is seldom done.  Indirect auscultation is generally carried out with a stethoscope.

d.          Percussion.  Examination of the body by tapping it with the fingers is called percussion (figure 6-2).  Percussion is a special assessment skill that the practical nurse is not required to perform. This technique is usually performed by a registered nurse (RN) or a physician

AREAS OF GENERAL APPEARANCE AND BEHAVIORAL ASSESSMENT

  a.        Demographic Data.  You begin the assessment by collecting personal information, which includes name, age, sex, marital status, race, and religion.  This identifies the patient and provides important demographic data.

 b.          Body Build.  Observe the patient's general appearance and health state in relation to his age and lifestyle.  Determine the patient's height, weight, and vital signs at this time.

  c.           Posture and Gait.  Observe whether the patient is erect or slouched, steady or unsteady.  Posture can indicate mood.  For example, a slumped position may reflect depression; too rigid and upright a position may indicate anxiety.

  d.         Hygiene and Grooming.  Look for cleanliness of nails, hair, skin, and overall appearance.  Usually, you can assess these gradually while observing other parts of the body for data.  Observe the skin for color, texture, temperature, and lesions.  Lesions warrant particular attention during assessment.  Some primary skin lesions are:

 (1)  Nodule--a solid mass extending into the dermis.

              (2)  Tumor--a solid mass larger than a nodule.

               (3)  Cyst--an encapsulated fluid-filled mass in the dermis or subcutaneous layer.

 (4)  Wheal--a relatively reddened, flat, localized collection of fluid.  An example is hives.

               (5)  Vesicle--circumscribed elevation containing serous fluid or blood.  An example is chickenpox.

(6)  Bulla--  large fluid-filled vesicle.  An example is a second-degree burn.

              (7)  Pustule--a vesicle or bulla filled with pus.  An example is acne.

 e.         Dress.  Observe the patient's clothing in relation to age, climate, socioeconomic status, and culture.  Notice whether the clothing is clean, properly buttoned, or zipped.  The patient's dress may reflect the cold intolerance of hypothyroidism.  Slippers or untied shoelaces suggest edema.

  f.          Body and Breath Odors.  Malodorous body or breath may indicate pulmonary infections, uremia, or liver failure.  A breath odor of acetone may be due to diabetes.   Although odors give important clues, avoid the common mistake of assuming that alcohol on a patient's breath explains neurologic or mental status findings.  Alcoholic breath does not necessarily mean alcoholism.

g.          Attitude.  The patient's attitude is reflected in his appearance, speech, and behavior.  The patient may be aloof and unwilling to participate in the interview.  He may verbalize anger or fear.  Some patients have a "take care of me" attitude and expect nurses and other health care personnel to magically know everything about them. Such findings should be noted as part of your general impression.

  h.        Affect/Mood.  Affect is the emotional state as it appears to others.  Mood is the emotional state as described by the patient.  Observe the patient's facial expression.  No part of the body is as expressive as the face.  Feelings of joy, sadness, fear, surprise, anger, and disgust are conveyed by facial expression.  Facial expressions generally are not consciously controlled.

  i.          Speech.  Assess the patient's speech for loudness, clarity, pace, and coherence.  Observe the patient for poor articulation of words and language difficulty.  Patients who are not fluent in English or have limited education are sometimes mistakenly labeled as "indifferent" or "noncommunicative."

COMPONENTS OF A PHYSICAL ASSESSMENT

 a.         Health History.  During this assessment step, you interview the patient to obtain a history so that the nursing care plan may be patterned to meet the patient’s individual needs.  The history should clearly identify the patient's strengths and weaknesses, health risks such as hereditary and environmental factors, and potential and existing health problems.  Both the seating arrangement and the distance from the patient are important in establishing a relaxed and comfortable environment for data collection.  Chairs placed at right angles to each other about 3 feet apart facilitate an easy exchange of information.  If the patient is in bed, be seated in a chair at a 45-degree angle to the bed.  If possible, communicate with the patient at eye level.  State your name and status and the purpose of the interview.  During the introduction, assess the patient's comfort and ability to participate in the interview.  Terminate the interview when you have obtained the data you need or the patient cannot provide more information.  You need the following information in order to form the subjective database.

 (1)       Chief complaint.  Record the chief complaint as a brief statement of whatever is troubling the patient and the duration of time the problem has existed.  The chief complaint is the signs and symptoms causing the patient to seek medical attention.   Generally, it is the answer to the question, "What brought you into the hospital (or clinic) today?"  If a well person is seeking a routine physical, there is no actual chief complaint.  Record his reason for the visit and the date of his last contact with a medical treatment facility.

  (2)     Past medical history.  This provides background for understanding the patient as a whole and his present illness.  It includes childhood illnesses, immunizations, allergies, hospitalizations and serious illnesses, accidents and injuries, medications, and habits.

 (3)       Family health history.  This enhances your understanding of the environment in which the patient lives.  Obtaining this information identifies genetic problems, communicable diseases, environmental problems, and interpersonal relationships.  Specific inquiry should be made regarding the general state of health of parents, grandparents, siblings, spouse, and children.  Record if the patient is adopted and has no access to his biological family's history.

  b.        Vital Signs.  The patient's vital signs are part of the objective data that helps to better define the patient's condition and helps you in planning care.  The following vital signs may be taken at the time the patient's height and weight are obtained.

 (1)       Blood pressure.  Blood pressure may be taken in both arms.  Record whether the patient was lying, sitting, or standing at the time the reading was obtained.

 (2)  Temperature.  Record the temperature and whether it is an oral, axillary, or rectal temperature.

 (3)  Pulse.  Peripheral pulses are graded on a scale of 0-4 by the following system.

 (a)    0 = absent, without a pulse.

 (b)  +1 = diminished, barely palpable.

                (c)  +2 = average, slightly weak, but palpable.

                (d)  +3 = full and brisk, easily palpable.

              (e)  +4 = bounding pulse, sometimes visible.

  c.         Head, Eyes, Ears, Nose, and Throat.  Assessment of the head begins with a general inspection.  Continue the assessment by examining the eyes, ears, nose, and throat.  Knowledge of the anatomy of the skull (figure 6-3) is helpful in localizing and describing physical findings.

 (1)        Observe the general size of the head.  Inspect the skull for shape and symmetry.  Note any deformities.  Become familiar with the irregularities in a normal skull, such as those near the suture lines between the parietal and occipital bones.  Part the hair in several places and inspect the scalp for scaliness, lumps, or other lesions.  Note the quantity, distribution, pattern of loss if any, and texture of the hair.  Observe the patient's facial expression and contours for asymmetry, involuntary movements, edema, and masses.  Note the color, pigmentation, texture, and any lesions of the skin.

 (2)        Inspect the eyes for symmetry, movement, and the condition of the pupil’s iris, and sclera.  Ask the patient to look up as you depress both lower lids with your thumbs, exposing the sclera and palpebral conjunctiva (lining of inner surface of the eyelids).  See figure 6-4.  Note the color and vascular pattern against the white background of the sclera.  An apparently yellow sclera indicates jaundice.  Pale palpebra conjunctiva may indicate anemia.  Look for nodules or swelling.  The pupils and iris are assessed together.  Examine the pupils for color, shape, equality, reaction to light, and accommodation.  The pupils are normally black in color, round, and equal.  If the pupil

Figure 6-4.  Exposing sclera and conjunctiva.

appears cloudy or discolored, the probable cause is a cataract.  Health of the iris is determined by noting the regularity of the pupil.  An irregular, constricted appearance to the pupil may result from edema due to inflammation of the iris.  Screen visual acuity with any available print.  If the patient cannot read the largest print, test the patient's ability to count your upraised fingers and distinguish light (such as your flashlight) from dark.

(3)         The ear has three compartments:  the external ear, the middle ear and the inner ear.  Much of the middle ear and all of the inner ear are inaccessible to direct examination.  The external ear is comprised of the auricle and ear canal.  The ear canal opens behind the tragus.  Assess the ears for hearing, symmetry, discharge, tinnitus (ringing in the ears), and vertigo (dizziness).  Inspect each auricle of the ear and surrounding tissue for deformities, lumps, or skin lesions.  If ear pain, discharge, or inflammation is present, move the auricle up and down, press the tragus, and press firmly just behind the ear.  Movement of the auricle and tragus (figure 6-5) is painful in acute external otitis, but not in otitis media.  Tenderness behind the ear may be present in otitis media.  To estimate hearing, test one ear at a time.  Ask the patient to occlude one ear with a finger.  Stand 1 or 2 feet away, and whisper softly to the enucleated ear.  Speak words with equally accented syllables, such as "homerun" or "four-nine."  Make sure that the patient does not read your lips.  Ask him to repeat what you have said.

Figure 6-5.  Movement of the auricle.

    (4)     The nose has two major functions.  It enables us to use our sense of smell and it is the air conditioner of the respiratory system.  Assess the nose for bone alignment and epitasis (nosebleeds).  Inspect the nasal mucosa and septum.  If the patient complains of nosebleeds, ask him about the frequency, amount, and color of the nosebleeds.  Inspect and palpate the outside of the nose.  By using a penlight or otoscope, you can get a partial view of each nasal vestibule.  Note unusual skin markings, obvious deviation of the septum (asymmetry), discharge, or flaring of the nares.  If the patient has a history of trauma to the nose, ask if there has been a change in his ability to smell.  The nose, in conjunction with the paranasal sinuses, filters, warms, and moistens he air.  The paranasal sinuses are air-filled cavities with ciliated mucous membrane linings.  Only the frontal and maxillary sinuses are accessible to physical examination. 

(5)          Examine the throat.  Include the lips, teeth, gums, tongue, buccal mucosa, uvula, and tonsils (figure 6-6).  Observe the color and moisture of the lips.  Note any cracking, lumps, or ulcers.  Look into the patient's open mouth.  Use a tongue blade and light to inspect the buccal mucosa for color, pigmentation, ulcers, white patches, and nodules.  Patchy brown pigmentation is normal in black people.  If the patient wears dentures, offer a container or paper towel and ask the patient to remove them so that you can look at the mucosa underneath.  Look for swelling, bleeding, retraction, discoloration, and inflammation of the gums.  Look for loose, missing, or carious teeth.  Note abnormalities in the position or shape of the teeth.  Inspect the back, sides, and undersurface of the tongue.  Explain what you plan to do and put on gloves.  Ask the patient to stick out his tongue.  With one hand, grasp the tip of the tongue with a square of gauze and gently pull it to the side.  Inspect the side of the tongue, and then palpate it with your other gloved hand, feeling for any hardening of tissue.  Reverse the procedure for the other side of the tongue.  With the patient's mouth still open, press the tongue blade down upon the midpoint of the arched tongue and inspect the uvula and tonsils.  Note any evidence of pus, swelling, ulceration, or tonsillar enlargement.  Whitish spots of normal tissue may sometimes be seen on the tonsils.  White patches with redness and swelling, however, suggest pharyngitis.  Break and discard the tongue blade after use.  Inspect the neck, noting its symmetry and any masses or scars.  Look for enlargement of the parotid or submaxillary glands, and note any visible lymph nodes.

NOTE:   Determine the last medical check-up in each of these areas and the patient's need for corrective devices such as glasses, hearing aid, or braces.

d.             Neurological Assessment.  There are two approaches to assessment of the neurologic system, depending on the condition of the patient and his chief complaint.  If the patient is undergoing a routine health assessment, a screening level exam is appropriate.  If the patient's chief complaint relates to the neurologic system, a more detailed assessment is required.   A most important consideration is the cooperation and participation of the patient.  The following assessments should be made.

   (1)  Mental status.  Assess the patient’s level of consciousness and orientation to time, place, and person.  Much of the mental status exam can be done during the interview.  The patient's orientation to person, place, and time are intact if he knows who he is, where he is, and the time of day.  Altered states of consciousness are:

                  (a)  Conscious--Alert, awake, aware of one's self and environment.

  (b)  Confusion--Disorientation in time.  Irritability and/or drowsiness.  Misjudgment of sensory input.  Shortened attention span.  Decrease in memory.

  (c)  Delirium--Disorientation, fear.  Misperception of sensory stimuli.  Visual and auditory     hallucinations.  Loss of contact with environment

                 (d)  Stupor--Unresponsive, but can be aroused back to a near normal state.

  (e)  Coma--Unresponsive to external stimuli.

   (f)  Akinetic mutism--Alert-appearing, immobile.  Mental activity absent.

                 (g)  Locked-syndrome--No effective verbal or motor communication.  Consciousness may be intact.  EEG indicates a preservation of cerebral activity.

      (h)    Chronic vegetative state - Vital functions preserved with no evidence of active mental processes.  EEG indicates absence of cerebral activity.

   (2)         Pupillary reaction.  Examine the pupils for briskness, symmetry, and accommodation.  Pupils are normally round and can range in size from "pinpoint" to occupying the entire space of the iris.  Pupils normally constrict with increasing light and accommodation (ability of the lens to adjust to objects at varying distances).

 (3)          Strength.  Muscle strength is tested against the resistance of the examiner. Strength will vary from person to person.  Symmetrical responses are significant and permit you to use the patient as his own control.  Assess strength in all extremities, the neck, and back.

                  (a)  To assess strength in the upper extremities, have the patient squeeze your first two fingers with both hands.  The grip should be reasonably strong, but most important; it should be equal in both hands.  Apply resistance when the patient flexes the wrist and elbow.  Note any pain or weakness the patient has.

(b)  To assess shoulder and scapulae resistance, ask the patient to extend both arms out in front of him and resist the push that you will apply.  Try to push the patient’s arms down.  This is a common site for sports injuries, arthritis, and bursitis.  Ask the patient to raise both arms above his shoulders.  Try to push his arms down to his sides.  Instruct the patient to resist your efforts.

 (c)  Assess the lower extremities in a similar manner with the patient lying down.  Ask the patient to raise his leg against your hand, which is applying pressure on the thigh, trying to flatten the leg.   Ask the patient to flex his knees so that his feet are flat on the table.  Place your hands laterally at both knees.  Note any pain with this movement.

 (4)         Sensation.  The sensory functions include touch, pain, vibration, position, temperature, and discrimination.  If the patient complains of numbness, peculiar sensations, or paralysis, sensation should be checked more carefully over flexor and extensor surfaces of the extremities.  Generally the face, arms, legs, hands, and feet are tested for touch and pain.

                (a)  Touch is tested with a wisp of cotton.  Ask the patient to close his eyes and respond whenever the cotton touches his skin.  Compare the sensation in symmetrical areas of the body, such as the cheeks.

 (b)  Test the sharpness or dullness of pain by using the pointed and the blunt end of a safety pin.  Ask the patient to close his eyes and identify which end of the pin is touching him.  Compare distal and proximal areas and note any areas of reduced or heightened sensations.

 (c)  The sense of vibration is tested with a tuning fork held firmly against a bone.  Bones commonly used are located at the thumb side of the wrist, the outside of the elbow, either side of the ankle, and the knee.  Test the distal bones of an extremity first.  Strike the tuning fork fairly hard and hold it against the patient's skin.  The patient should feel the vibration or buzz.