Chapter 15: Health Assessment and Physical Examination
Chapter 15: Health Assessment and Physical Examination
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Purposes of Physical
Examination
Gather baseline data
Supplement, confirm, or refute data
Confirm and identify nursing diagnoses
Make clinical judgments
Evaluate the outcomes of care
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Cultural Sensitivity
Cultural differences influence a patient’s
behavior
Recognition of cultural diversity helps to
respect the patient
Consider a patient’s
Health beliefs
Use of alternative therapies
Nutritional habits
Family relationships
Use of personal space
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Inspection
The use of vision and hearing to distinguish
normal from abnormal findings
Use adequate lighting
Position and expose body parts
Inspect for size, shape, color, symmetry, position,
and abnormalities
Side to side comparison
Pay attention to detail
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Palpation
Involves using the hands
Examine accessible body parts
Palpate skin
Temperature, moisture, texture, turgor,
tenderness, and thickness
Palpate abdomen
Tenderness, distention, or masses
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Percussion
Tapping the body with fingertips to produce a
vibration
Character of sound
Determines location, size, and density of
structures
Depends on the density of tissues
Abnormal sounds can be mass, air, or fluid
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Auscultation
Listening to sounds produced by the body
Assess sounds heard in the heart, lungs, and
gastrointestinal systems
Requires the use of a stethoscope
Characteristics include
Frequency
Loudness
Quality
Duration
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Olfaction
To identify nature and source of body odors
Helps to detect abnormalities
Used in conjunction with other measurements
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Preparation for
Assessment
Environment Equipment
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General Survey
Begins when you first meet a patient
Begins with review of primary health pattern
The survey provides information regarding
Characteristic of illness
Hygiene
Skin condition
Body image
Emotional state
Developmental status
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General Appearance
and Behavior
Gender and Race Age
Posture Gait
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Skin
Assessment
Nursing history
Color
Moisture
Temperature
Texture
Turgor
Vascularity
Edema
Lesions
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Hair and Scalp
Use inspection
Assess
Distribution
Thickness
Texture
Lubrication
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Nails
Inspection and palpation
Condition of nails reflects
General health
Nutritional status
Occupations
Level of self-care
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Head and Neck
Inspection and palpation
Assess
Headache, dizziness, seizures, poor vision, loss
of consciousness
Head size, shape contour of head and skull
Facial symmetry
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Eyes
Visual acuity
Ability to see small details
Visual fields
Test of peripheral vision
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Nose and Sinuses
Inspection and palpation
Assess for exposure to
Dust
Pollutants
Allergies
Nasal obstruction
Trauma
Discharge, postnasal drip
Headaches
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Mouth and Pharynx
Assesses overall health
Determine oral hygiene needs
Develop therapies for dehydration
Assess oral trauma
Assess for airway trauma
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Neck
Neck muscles
Lymph nodes
Carotid arteries
Jugular veins
Thyroid gland
Trachea
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Thorax and Lungs
Review of ventilatory and respiratory
functions of lungs
Landmarks help to locate structures
Inspection, palpation, and auscultation
Orthopnea
Dyspnea
Adventitious breath sounds
Normal breath sounds
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Heart
Compare assessment of heart function with
findings from vascular assessment
Heart function is correlated with physiological
events
Use inspection, palpation, and auscultation
Pulsations
Palpate apical pulse
Auscultate heart sounds
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Vascular System
Measure blood pressure
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Breasts
Examine both female and male breasts
Take a health history
Use inspection and palpation
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Abdomen
Use landmarks to map out the abdominal
regions
Assess both anterior and posterior
Examine the liver, stomach kidneys, bladder,
and GI tract
Conduct a nursing history
Use inspection, auscultation, and palpation
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Female Genitalia
Examination of the genitalia includes external
and internal sex organs
Must provide privacy
Need to understand cultural sensitivity
Conduct a nursing history
Use inspection and palpation
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Male Genitalia
Assess the integrity of external genitalia,
inguinal ring, and canal
Conduct a nursing history
Use inspection and palpation
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Rectum and Anus
Perform after genital examination
Explain all steps to patient
Provide privacy
Conduct a nursing history
Use inspection and palpation
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Musculoskeletal System
Visualize the anatomy of bone, muscle, and
joint placement
Conduct a nursing history
Use inspection and palpation
Assess
Range of joint motion
Muscle strength and tone
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Neurological System
Conduct a nursing history
Assess
Language
Intellectual function
Cranial nerve function
Sensory nerve function
Motor function
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Practice Questions
1. When meeting a patient for the first time, it is
important to establish a baseline assessment that will
enable a nurse to refer back to which of the
following?
A. Physiological outcomes of care
B. The normal range of physical findings
C. A pattern of findings identified when the patient is
first assessed
D. Clinical judgments made about a patient’s
changing health status
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published. Slide 35
Practice Questions (continued)
2. A patient complains of thirst and
headache. The patient appears emaciated.
On initial examination you find that the skin
does not return to normal shape. This finding
is consistent with what condition?
A. Pallor
B. Edema
C. Erythema
D. Poor skin turgor
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Practice Questions (continued)
3. A patient is admitted with pneumonia.
When auscultating the patient’s chest, you
hear low-pitched, continuous sounds over the
bronchi. These sounds are identified as
which of the following?
A. Crackles
B. Rhonchi
C. Wheezes
D. Pleural Rub
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Practice Questions (continued)
4. When conducting an abdominal
assessment, what is the first skill a nurse puts
to use?
A. Auscultation
B. Inspection
C. Palpation
D. Percussion
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published. Slide 38