HEALTHASSESEMENT

Assessi ngacl ient’

shealthi samaj orcomponentofnur singcareandhast woaspect s:
1t henur singhealthhistorydiscussedi nchapter11and2t hephysical exami nati
on
discussedi nthischapter.Aphy sical examinationcanbeanyofThr eet ypes: (
a)a
compl eteassessment(e. gwhenacl i
entisadmi t
tedt oaheal t
hcar eagency ),
(b)
exami nati
onofabodysy stem(e.g,thecar di
ovascul arsy stem),or(c)exami nati
onofa
bodyar ea( eg,thelungs,whendi fficultywit
hbr eathingisobser ved).Not e:somenur ses
consi derassessmentt obet hebr oadt erm usedonappl y i
ngthenur singpr ocesst o
heal t
hdat aandexami nationtobet hephy si
cal processusedt ogathert hedat a.Inthis
text,thet ermsassessmentandexami nat
ionaresomet i
mesusedi nterchangeabl y-
bot herreferri
ngt oacriti
cal i
nvestigati
onandev al
uationofcl i
entstatus

PHYSI
CALHEALTHASSESSMENT

Acompl etehealthassessmentmaybeconduct edstar

ti
ngattheheadandpr oceeding
i
nasy st
emat i
cmannerdownwar d(head-t
o-t oeassessment)
.Howev er
,thepr ocedure
canbev aryaccor di
ngt otheageoftheindivi
dual,t
heseveri
tyoft
hei l
l
ness, t
he
prefer
encesoft henur se,t
helocati
onoftheexami nati
onandtheagency'spriori
ti
esand
procedures.Theor derofhead-to-
toeassessmentisgiveni
nBox30- 1.Regardlessof
theprocedureused, thecli
ent'
senergyandt i
meneedt obeconsider
ed.Theheal t
h
assessmenti sthereforeconductedinasystematicandeff
ici
entmannert hatresult
sin
thefewestpositionchangesf orthecli
ent
.

Frequentl
ynursesassessaspeci fi
cbodyareainst
eadoft heenti
rebody.Thesespeci
fi
c
assessment sar
emadei nrel
ati
ont ocli
ent
'
scompl ai
nts,thenur
se'sownobservati
onof
problems,thecl
ient
'spresent
ingproblem,nur
singint
erventi
onsprovidedandmedical
therapi
es.Examplesofthesesituati
onsandassessment sareprovi
dedinTable30-1.

Thesear
esomeoft
hepur
poseoft
hephy
sical
exami
nat
ion:

 Toobt
ainbasel
i
nedat
aaboutt
hecl
i
ent
'
sfunct
ional
abi
l
iti
es

 Tosuppl
ement
,conf
ir
m,orr
efut
edat
aobt
ainedi
nthenur
singhi
stor
y.

 Toobt
aindat
athatwi
l
lhel
pest
abl
i
shnur
singdi
agnosesandpl
ansofcar
e.

 Toev
aluat
ethephy
siol
ogi
cal
out
comesofheal
thcar
eandt
hust
hepr
ogr
essofa
cl
i
ent
'sheal
thpr
obl
em.

 Tomakecl
i
nical
judgmentaboutacl
i
ent
'
sheal
thst
atus.

 Toi
dent
if
yar
easf
orheal
thpr
omot
ionanddi
seasepr
event
ion.
Nursesusenat i
onal gui del
inesandev i
dence-basedpracticetofocushealth
assessmentonspeci ficconditi
ons.Thenur se'
sjudgmenti skeywhent heevi
denceis
i
nconclusi
v eorconflicting.Forexample,whenscr eeni
ngforcancer ,
nursesshouldkeep
i
nmi ndtheAmer icancancersoci ety
'sguideli
nesforearl
ydet ect
ion(Box30-2).
Howev er,
theU.SPr ev entiveServi
cesTaskf orce(
2009)recommendsl essfr
equent
breastmammogr aphy .

Head-t
o-t
oef
ramewor
k

1.Gener
alsur
vey

2.Vi
tal
signs

3.Head

 Hai
r,scal
p,f
ace

 Ey
esandv
isi
on

 Ear
sandhear
ing

 Nose

 Mout
handor
ophar
ynx

 Cr
ani
alner
ves

3.Neck

 Muscl
es

 Ly
mphnodes

 Tr
achea

 Thy
roi
dgl
and

 Car
oti
dar
ter
ies

 Neckv
eins

4.Upperext
remi
ti
es

 Ski
nandnai
l
s

 Muscl
est
rengt
handt
one
  Joi
ntr
angeofmot
ion

 Br
achi
alandr
adi
cal
pul
ses

 Sensat
ion

5.Chestandback

 Ski
n

 Chestshapeandsi
ze

 Lungs

 Hear
t

 Spi
nal
col
umn

 Br
east
sandaxi
l
lae

6.Abdomen

 Ski
n

 Abdomi
nal
sounds

 Femor
alpul
ses

7.Ext
ernal
geni
tal
s

8.Anus

9.Lowerext
remi
ti
es

 Ski
nandt
ienai
l
s

 Gai
tandbal
ance

 Joi
ntr
angeofmot
ion

 Popl
i
teal
,post
eri
ort
ibi
alandpedal
pul
ses

PREPARI
NGTHECLI
ENT

Mostpeopleneedanexplanati
onofthephysi
calexaminat
ion.Of
tencl
ient
sareanxious
aboutwhatthenur
sewill
f i
nd.Theycanbereassuredduri
ngtheexaminat
ionby
expl
anat
ionsateachst
ep.Thenur seshoul
dexplai
nwhenandwher et
heexaminat
ion
willt
akepl ace,whyi tisimpor tant,andwhatwi llhappen.I nstr
uctt hecli
entthatal l
i
nformat iongatheredanddocument edduri
ngthatassessmenti skeptconf i
dent ial
in
accordancewi ththeHeal t hInsurancePor tabi
li
tyandAccount abili
tyAct(HIPAA).Thus
meanst hatonlythishealthcar epr ov i
der
swhohav eal egitimateneedt oknowt he
cli
ent'
sinf ormati
onwi llhav eaccesst oit
.Healt
hexami nationar eusuallypainless;
howev er,iti
simpor tanttodet ermi neinadvanceanyposi tionsthatar econtradictedfor
apar t
icularcli
ent.Thenur seassi ststhecli
entasneededt oundr essandputonagown.
Cli
entsshoul dempt yt hei
rbl adder sbeforetheexami nati
on.Doi ngsohel pthem f el
l
mor erelaxedandf acili
tatespal pationoftheabdomenandpubi car ea.i
faur inalysi
sis
requir
ed, theuri
neshoul dbecol lectedinacont ainerforthatpur pose.

Whenassessi ngadult,i
tisimportanttorecognizethatpeopleoft hesameagedi f
fer
markedly.Box30-3pr ovi
desspecialconsider
ationsforassessingadults.Wit
hchildr
en,
al
way s proceed from t he l
ead invasi
ve oruncomf or
tablet ot he mor einvasi
ve.
Examinationoftheheadandneck,hear tandl ungs,andrangeofmot ioncanbedone
earl
yinthepr ocess,withtheear
s,mout h,abdomen,andgeni talsbeingleftf
ortheend
oftheexam .

PREPARI
NGTHEENVI
RONMENT

Iti
simpor t
anttoprepar
etheenvir
onmentbef orestar
tingassessment.Theti
mef orthe
physicalassessmentshoul
d beconv eni
entto botht heclientand thenur se.The
envir
onmentneedst obewellalightedandt heequi pmentshouldbeor ganizedf or
eff
ici
entuse.Acl i
entwhoisphysi
callyrel
axedwillusuall
yexperi
encelit
tl
ediscomf ort
.
Theroom shouldbewarm enought obecomf or
tableforthecl
ient
.

Provi
dingpr iv
acyi si mpor tant
.Mostpeopl eareembar r
assedi ft hei
rbodiesareexposed
orifotherscanov erhearorv iewt henduringt
heassessment .Cul t
ure,age,andgender
ofbotht hecl i
entandt henur seinfl
uencehowcomf ortablethecl i
entwi l
lbeandwhat
speci
alar rangement smi ghtbeneeded.Forexampl e,ift heclientandt henurseareof
dif
fer
entgender s,t henur seshouldbeaskedi fitisaccept ablet operf
or mthephysical
examinationori ft henur seoft hesamegenderi spreferred.Fami l
yandf ri
endsshould
notbepr esentunl esst hecl i
entasksf orsomeone.

POSI
TIONI
NG

Sev er
alposi t
ions aref requentl
yr equir
ed during the physi
calassessment .Itis
i
mpor tantt oconsi dertheclient
’sabil
ityt oassumeaposi ti
on.Thecl ient’
sphysical
condit
ion, energylevel
,andageshoul dbet akenintoconsider
ati
on.Someposi ti
onsare
embarr assinganduncomf ort
ableandt her
eforeshouldnotbemai nt
ainedf orl
ong.The
assessmenti sorganizedsot hatseveralbodyareascanbeassessedi noneposi t
ion,
thusmi nimizi
ngt henumberofposi ti
onchangesneeded( t
able30-2)
DRAPI
NG

Drapesshoul
dbear r
angedsothatthear
eatobeassessedisexposedandotherbody
areasar
ecovered.Exposur
eofthebodyisfr
equent
lyembarrassi
ngtocli
ent
s.Drapes
provi
denotonlyadegreeofpr
ivacybutal
sowarmth.Drapesaremadeofpapercloth,
orbedli
nen.

I
NSTRUMENTATI
ON

Al
lequi pmentrequi
redfort hehealt
hassessmentshouldbecl
ean,ingoodwor
king
order,andreadi
lyaccessi
ble.Equi
pmentisfrequent
lysetupontr
ays,r
eadyf
oruse.
Variousinst
rument
sareshowni ntabl
e30-3.

METHODSOFEXAMI
NING

Fourprimarytechni
quesareusedinthephysi
calexaminati
on:inspect
ion,pal
pat
ion,
per
cussion,andauscul
tat
ion.Theset
echni
quesarediscussedt
hroughouthischapter
astheyapplytoeachbodysyst
em.

I
nspect
ion

Inspecti
onisthev i
sualexami nati
on.whi chi sassessi ngbyusi ngthesenseofsi ght.I
t
shouldbedeliberate, pur poseful,andsy stemat i
c.Thenur seinspectswiththenakedey e
andwi thali
ghtedi nst r
umentsuchasanot oscope( usedt ov i
ewt heear).Inadditionto
visualobserv
ations,ol f actory( smell)andaudi tor
y( heari
ng)cuesar enot ed.Nur ses
frequentl
yusev isuali nspect iont oaccessmoi sture,col or
,andt extureoft hebody
surfaces,aswel lasshape,posi t
ion,size,color,andsy mmet ry,ofthebody .Li
ghting
mustbesuf f
ici
entf ort henur setoseecl earl
y,ei
thernat ur
alorar t
if
ici
all i
ghtcanbe
used.Whenusi ngt heaudi t
orsenses,i tisi mport
antt ohav eaqui etenv i
ronmentf or
accurateheari
ng.I nspect i
oncanbecombi nedwi t
ht heot herassessmentt echniques.

Pal
pat
ion

Palpati
oni st heexaminati
onoft hebodyusi ngt hesenseoft ouch.Thepadsoft he
fi
ngersar eusedbecauset hei
rconcent r
ationofner veendingsmakest hem highl
y
sensiti
vet ot
actil
ediscr
iminati
on.Palpati
onisusedt odetermi
ne(a)textur
e(e.g, oft
he
hair
);
(b)t emperat
ure(e.
goft heskinarea);
(c)vibrati
on(e.
gofthejoint)
;(
d)posit
ion,si
ze,
consistency,andmobili
tyoforgansormasses; (e)dist
enti
on(e.goftheuri
narybladder)
;
(f
)pulsation;and(g)andtendernessorpain.

Therearet wotypesofpalpati
on;li
ghtanddeep.Light(superf
ici
al)palpat
ionshould
al
way sprecededeeppalpati
onbecauseheav ypr
essureont hefingert
ipscandullthe
senseoft ouch.Forli
ghtpalpati
on,thenurseextendsthedomi nanthand’sfi
ngers
paral
l
eltotheskinsurf
aceandpr essesgent
lywhi
lemov i
ngt hehandi nacircl
e(fi
gure
30-1).Withli
ghtpal
pati
on,t
heskinisslightl
ydepressed.I
fiti
snecessar
ytodet
ermi
ne
thedetailsofamass,t henur
sepr esseslight
lyseveralt
imesrat
herthanhol
dingt
he
pressure.Seebox30-4fort
hecharacter
isti
csofmasses.

Deeppal pati
oni sdonewi thtwohands( bimanual
ly)oronehand.I ndeepbi manual
palpation,thenur seext endsthedomi nanthandasf orthelightpal
pati
on,t henpl aces
the fingerpads oft he non domi nanthand on t he dorsalsur f
ace oft he di stal
i
nterphal angealjointoft hemi ddlethreefingersofthedomi nanthand.(fi
gure30-2).The
tophandappl iespr essurewhi l
et helowerhandr emainsrelaxedtoperceivethet actil
e
sensat i
ons.Fort hedeeppal pati
onusi ngonehand,t hefi
ngerpadsoft hedomi nant
handpr essovert hear eat obepal pat
ed.Of t
entheotherhandi susedtosuppor tamass
ororganf rom bel ow( fi
gure30-3).Deeppal pati
onisusuallynotdonedur i
ngar out i
ne
exami nationandr equi r
essignifi
cantpr act i
ti
onerskill
.Itisper f
ormedwi thex treme
cautionbecausepr essurecandamagei nternalorgans.Itisusuallynotindicatedi n
cli
entswhohav eacut eabdomi nalpainorpai nthati
snoty etdiagonased.

Totestski
ntemperat
ure,i
tisbesttousethedor
sum (back)ofthehandandfi
ngers,
wheretheexami
ner’sskinthi
nnest
.Tot estf
orvibrat
ion,thenur
seshouldusethe
pal
marsurf
aceofthehand.Gener
algui
del
inesf
orpalpat
ionincl
udet
hefol
lowi
ng:

 Thenur
se’
shandshoul
dbecl
eanandwar
m,andt
hef
inger
nai
l
sshor
t.

 Ar
easoft
ender
nessshoul
dbepal
pat
edl
ast
.

 Deeppal
pat
ionshoul
dbedoneaf
tersuper
fi
cial
pal
pat
ion.

Theeffecti
venessofpal pati
ondependsl argelyonthecli
ent’
srelaxat
ion.Nur
ses
canassistacli
enttor el
axby( a)gowningand/ ordrapi
ngthecli
entappropri
ately
,
(b)posti
oningtheclientcomf ort
ably
,and( c)ensuringthatt
heirownhandsar e
warm beforebeginning.Dur i
ngpalpation,thenurseshouldbesensi ti
vetot he
cli
ent
’sverbalandfacialexpressi
onsindicati
ngdiscomfort
.

Per
cussi
on

Per cussionist heactofst ri

ki
ngt hebodysur f
acetoel
icitsoundst hatcanbehear dor
vibrationsthatcanbef elt.Therear etwotypesofpercussion:di r
ectandi ndir
ect.In
directper cussi
on,thenur sestrikestheareatobepercusseddi rectl
ywi t
hthepadsof
two, t
hree,orfourfi
ngersorwi tht hepadofthemiddl
efinger.Thest r
ikesarerapid,
and
themov ementi sfrom thewr ist.Thetechni
queisnotgener all
yusedt opercusst he
thor axbutisusef ul
inpercussinganadul t
’ssi
nuses.

I
ndi
rectper
cussi
onist
hest r
iki
ngofanobj
ect
(e.g.af
inger)hel
dagai
nstthebodyarea
t
obeexamined.I
nthetechni
que,t
hemiddl
efingerofthenondominanthand,r
efer
red
toast hepelximeter,i
spl acedfi
rmlyont heclient’
sskin.Onl ythedistalphal
anxand
j
ointofthefingershouldbei ncontactwi t
ht heskin/usingt hetipofthef l
exedmi ddl
e
fi
ngeroftheotherhand, call
edtheplexor,t
henur sestri
kest heplexi
met er,
usuall
yatthe
di
stalint
erphalangealjointorappoi ntbet weent hedistalandpr oxi
malj oi
nts/t he
str
iki
ng motion comesf rom thewr i
st;thef orear
m remai nsstati
onary.Theangl e
betweentheplexorandt heplexi
metershoul dbe90◦.andt heblowsmustbef ir
m, r
apid,
andshorttoobtainaclearsound.

Per
cussi
onsoundsandt
ones

Sound I
ntensi
ty Pi
tch Dur
ati
on Qual
it
y Example of
l
ocati
on

Fl
atness Sof
t Hi
gh Shor
t Ext
remel
y Muscl
e,bone
dul
l

Dul
l
ness Medi
um Medi
um Moder
ate Thudi
ke Li
ver
,hear
t

Resonance Loud Low Long Hol

l
ow Nor
mal
lung

Hyper
resonan Ver
yloud Ver
ylow Ver
ylong Boomi
ng Emphy
semat
o
ce usl
ung

Ty
mpany Loud High Moder
ate Musi
cal St
omachfil
l
ed
(di
sti
ngui
sh wi
thgas(
air
)
edmai nl
yby
musical
ti
mbre)

Per cussionisusedt odet er

mi nethesi zeandshapeofi nternalor gansbyest ablishing
theirborders.Itindi
cateswhet herthetissuesisflui
dfill
ed,airf i
ll
ed, orsolid.Per cussion
eli
citsfivetypesofsound:f l
atness, dull
ness,resonance, hyper r
esonance, andt ympany .
Flatnessi sanext remelydull soundpr oducesbyav erydenset i
ssue, suchasmuscl eor
bone.Dul lness isant hudikesoundpr oducedbydenset i
ssuesuchast hel iver,spleen,
orhear t
.Resonance i sahol low sound suchaspr oduced byl ungaf il
led wi th air
.
Hy perresonancei snotproducedi nthenor malbody.Itisdescr ibedasboomi ngandcan
beher d overan emphy semat ousl ung.Ty mpanyi samusi cialordr uml i
kesound
producedf rom anai rfil
ledst omach.Ont hecont i
numm,f latnessr eflect sthemost
denset issue(t heleastamountofai r)andt y
mpanyt hel eastdenset issue(t hegr eatest
amountof ai r .A percussionsound i sdescri
bed accor ding t oi tsint ensity,pi t
ch,
durat i
onandqual i
ty.

ASCULTATI
ON
Ascult
at i
onisthepr ocessofl i
steningtosoundspr oducedwi t
hinthebody.
Auscultati
onmaybedi r
ectori ndirect
,Dir
ectascultat
ioni st
heuseoftheunaidedear,
forexampl e,
toli
stentoar espiratorywheezeorthegr atingofamov i
ngjoi
nt.Indir
ect
ascult
ationI'
dtheusofast ethoscope, whi
chtransmi tthesoundstothenurse'
sears.A
stet
hoscopei susedpr i
mar i
lytolistntosoundwi thinthebody,suchasbowel sounds
orvalvasoundsoft heheartandbl oodpressur
e.

Thest ethoscopet ubi

ngshoul dbe30t o35cm( 12to14in)l ong, wi
thaninternal
diamet erofabout0. 3cm( 1/8in) .I
tshouldhav ebothaf l
at-diaphragm andabel l
-
shapedampl ifi
er(seefigure4i nski l
l29-3onpage553) .Thedi aphragm besttransmits
high-pitchedsounds( e.
g,br onchialsounds),andthbellbesttransmitslow-pitched
soundssuchassomehear tsounds.Theear piecesofthest ethoscopeshouldf i
t
comf ortablyint
ot henurse'sears, f
acingforward.Theampl i
f i
erofthestethoscopei s
placedf i
rmlybutl i
ghtl
yagai nsttheclient'
sskin.I
fthecli
enthasexcessi vehai r
,itmay
benecessar ytodampent hathairswi t
hthemoi stclot
hsot hatt heywil
lli
eflatagainst
theskinandnoti nter
fer
ewi thclearsoundt r
ansmission.

Ascult
atedsoundsaredescr i
bedaccor di
ngtotheirpit
chintensity,
dur ati
onandqual i
t y.
ThePitchisthefr
equencyoft hevibrati
ons(t
henumberofv ibrati
onspersound) .Low
pit
chedsounds,suchassomehear tsounds,
hav efewervibrati
onspersecondt hanhi gh
pit
chedsounds,suchasbr onchialsounds.Theintensi
ty(ampl i
tude)referstothe
l
oudnessorsof t
nessofthesound.Somebodysoundsar eloud,forexampl e,br
onchi al
soundsheardfrom t
hetrachea,othersaresoft,
forexampl e,normal breathsounds
heardinthel
ungs.TheDur ati
onofasoundi sit
'slengt
h(l ongorshor t).Thequal i
tyof
soundisasubjecti
vedescript
ionofasound, forexampl e,
whi stl
i
ng, gurgli
ng,or
snappi
ng.

VI
TALSI
GNS

Vit
alsignsaremeasured(a)t
oestabli
shbaseli
nedat aagai
nstwhichiscomparefut
ure
measur ementsand(b)yodet
ectactualandpotenti
alheal
thprobl
ems.Seechapter29
formeasur ement
softemperat
ure,pul
se,respi
rat
ions,bl
oodpressur
e,andoxygen
satur
ation.Seechapt
er46forpai
nassessment .

HEI
GHTANDWEI
GHT

Inadul
ts,t
her ati
oofwei ghtt
oheightpr
ov i
desagener al measuresofhealt
h.Byasking
cli
ent
saboutt hei
rheightandweightbeforemeasur i
ngt hem,thenurseobtainssome
i
deaiftheperson'sself-i
mage.Excessi
vediscrepanciesbetweent hecl
ient
'sresponses
andmeasur ementsmaypr ovi
decl
uestoactual orpotenti
alproblemsinself
-concept.
Takenoteofanyuni ntenti
onalwei
ghtgainorlosslastingorprogressi
ngoversev er
al
weeks.
Thenur semeasur esheightwithameasur ingsti
ckat tachedtowei ghtscalesortoa
wall.Thecli
entshouldremov etheshoesandst ander ect,
withheelstogether,andthe
heels,butt
ocks,andbacki fheadagainstthemeasur ingst i
ck,eyesshouldbel ooki
ng
str
aightahead.Thenur seraisestheL-shapedsl idi
ngar m sl
idingarm unti
l i
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