Which factors should a nurse consider before performing an inspection during a physical exam?
Adventitious sounds, p. 525 Show
Alopecia, p. 504 Aphasia, p. 557 Apical impulse or point of maximal impulse (PMI), p. 527 Arcus senilis, p. 511 Atrophied, p. 554 Auscultation, p. 494 Borborygmi, p. 544 Bruit, p. 532 Cerumen, p. 513 Clubbing, p. 536 Conjunctivitis, p. 511 Cyanosis, p. 500 Distention, p. 543 Dysrhythmia, p. 530 Ectropion, p. 510 Entropion, p. 510 Edema, p. 502 Erythema, p. 501 Excoriation, p. 516 Goniometer, p. 553 Hypertonicity, p. 554 Hypotonicity, p. 554 Indurated, p. 502 Inspection, p. 493 Integumentary system, p. 498 Jaundice, p. 501 Kyphosis, p. 551 Lordosis, p. 552 Malignancy, p. 519 Murmurs, p. 530 Nystagmus, p. 509 Olfaction, p. 493 Orthopnea, p. 524 Osteoporosis, p. 552 Ototoxicity, p. 514 Palpation, p. 493 Percussion, p. 494 Peristalsis, p. 544 PERRLA, p. 511 Petechiae, p. 502 Pigmentation, p. 500 Polyps, p. 516 Ptosis, p. 510 Scoliosis, p. 552 Stenosis, p. 531 Striae, p. 543 Syncope, p. 531 Thrill, p. 530 Turgor, p. 502 Ventricular gallop, p. 530 Vocal or tactile fremitus, p. 524 The health assessment and physical examination are the first steps toward providing safe and competent nursing care. The nurse is in a unique position to determine each patient’s current health status, distinguish variations from the norm, and recognize improvements or deterioration in his or her condition. As a nurse, you must be able to recognize and interpret each patient’s behavioral and physical presentation. By performing health assessments and physical examinations, you will identify health patterns and evaluate each patient’s response to treatments and therapies. Nurses gather assessment data about patients’ past and current health conditions in a variety of ways, using a comprehensive or focused approach, depending on the patient situation. Assessments are performed at health fairs, at screening clinics, in a health provider’s office, in acute care agencies, or in patients’ homes. Depending on the outcome of an assessment, a nurse considers evidence-based recommendations for care based on a patient’s values, the health provider’s clinical expertise, or own personal experience. A complete health assessment involves a nursing history (see Chapter 16) and behavioral and physical examination. Through the health history interview you gather subjective data about a patient’s condition. You obtain objective data while observing a patient’s behavior and overall presentation. You identify additional objective data through a head-to-toe body system review during the physical examination. Your clinical judgments are based on all of the gathered data to create a plan of care for each situation. With accurate data you create a patient-centered care plan, identifying the nursing diagnoses, desired patient outcomes, and nursing interventions. Continuity in health care improves when you evaluate a patient by making ongoing, objective, and comprehensive assessments. Purposes of the Physical ExaminationA physical examination is conducted as an initial evaluation in triage for emergency care; for routine screening to promote wellness behaviors and preventive health care measures; to determine eligibility for health insurance, military service, or a new job; or to admit a patient to a hospital or long-term care facility. After considering the patient’s current condition, a nurse selects a focused physical examination on a specific system or area. For example, when a patient is having a severe asthma episode, the nurse first focuses on the pulmonary and cardiovascular systems so treatments can begin immediately. When the patient is no longer at risk for a bad outcome or injury, the nurse performs a more comprehensive examination of other body systems. For patients who are hospitalized, a nurse integrates the collection of physical assessment data during routine patient care, validating findings with what is known about the patient’s health history. For example, on entering a patient’s room a nurse may notice behavioral patient cues that indicate comfort, anxiety, or sadness; assess the skin during the bed bath; or assess physical movements and swallowing abilities while administering medications. Use physical examination to do the following: Cultural SensitivityRespect the cultural differences among patients from a variety of backgrounds when completing an examination. It is important to remember that cultural differences influence patient behaviors. Consider the patient’s health beliefs, use of alternative therapies, nutrition habits, relationships with family, and comfort with physical closeness during the examination and history. These factors will affect your approach as well as the type of findings you might expect. Be culturally aware and avoid stereotyping on the basis of gender or race. There is a difference between cultural characteristics and physical characteristics. Learn to recognize common characteristics and disorders among members of ethnic populations within the community. It is equally important to recognize variations in physical characteristics such as in the skin and musculoskeletal system, which are related to racial variables. By recognizing cultural diversity, you show respect for each patient’s uniqueness, leading to higher-quality care and improved clinical outcomes (see Chapter 9). Preparation for ExaminationPhysical examination is a routine part of a nurse’s patient assessment. In many care settings a head-to-toe physical assessment is required daily. You perform a reassessment when a patient’s condition changes as it improves or worsens. In some health care settings such as during a home health visit a focused physical examination is preferred. Proper preparation of the environment, equipment, and patient ensures a smooth physical examination with few interruptions. A disorganized approach causes errors and incomplete findings. Safety for confused patients should be a priority; never leave a confused or combative patient alone during an examination. Infection ControlSome patients present with open skin lesions, infected wounds, or other communicable diseases. Use standard precautions throughout an examination (see Chapter 28). When an open sore or microorganism is present, wear gloves to reduce contact with contaminants. If a patient has excessive drainage or there is a risk of splattering from a wound, additional personal protective equipment such as an isolation gown or eye shield should be used. Follow agency hand hygiene policies before initiating and after completing a physical assessment. Although most health care agencies make nonlatex gloves available, it is your responsibility to identify latex allergies in patients and use equipment items that are latex free. By recognizing risk factors for latex allergies, the patient remains free of a natural rubber latex (NRL) allergy response. Two types of allergic responses appear with NRL. The most immediate is an immunological reaction type 1 response, for which the body develops antibodies known as immunoglobulin E that can lead to an anaphylactic response. Atopy occurs when there is an increased tendency for the body to form antibodies as a result of the immune response. The second is the allergic contact dermatitis type 4 response, which causes a delayed reaction that appears 12 to 48 hours after exposure (Bundesen, 2008). Both require prior exposure to the substance to which the body reacts. The severity of the response varies among individuals. Table 30-1 provides a short list of products that contain latex and suggests available alternatives. TABLE 30-1 Products Containing Latex and Nonlatex Substitutes*
*This list is intended to provide examples of products and alternatives. It is not complete. Modified from American Latex Allergy Association: Literature review on latex-food cross-reactivity, 1991-2006, 2011, www.latexallergyresources.org/topics/CrossReactiveAllergens.cfm. Accessed September 8, 2011; and Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby; EnvironmentA respectful, considerate physical examination requires privacy. In the acute setting, nurses perform assessments in a patient’s room. Examination rooms are used in clinics or office settings. In the home the examination is performed in a space where privacy can be established such as the patient’s bedroom. Examination spaces need to be well equipped for any procedures. Adequate lighting is necessary to properly illuminate body parts. The hospital patient room can be secured for privacy so patients are comfortable discussing their condition. Eliminate extra noise and take precautions to prevent interruptions from others. The room must be warm enough to maintain comfort. Depending on the body part being assessed, it may be difficult to perform a selected assessment skill when a patient is in bed or on a stretcher. Special examination tables make positioning easier and body areas more easily accessible. By assisting patients on and off the examination table, injury can be avoided, and falls prevented. Examination tables can be uncomfortable; elevate the head of the table about 30 degrees. A small pillow helps with head and neck comfort. If the examination is completed in the patient room, raise the patient’s bed to be able to reach him or her more easily. EquipmentPerform hand hygiene thoroughly before handling equipment and starting an examination. Arrange any necessary equipment so that it is readily available and easy to use. Prepare equipment as appropriate (e.g., warm the diaphragm of the stethoscope between the hands before applying it to the skin). Be sure that equipment functions properly before using it (e.g., ensure that the ophthalmoscope and otoscope have good batteries and light bulbs). Box 30-1 lists typical equipment used during a physical examination. Box 30-1 Equipment and Supplies for Physical Assessment
Physical Preparation of the PatientTo show respect for a patient, ensure that physical comfort needs are met. Before starting, ask if the patient needs to use the restroom. An empty bladder and bowel facilitate examination of the abdomen, genitalia, and rectum. Collection of urine or fecal specimens occurs at this time if needed. Physical preparation involves making certain that patient privacy is maintained with proper dress and draping. The patient in the hospital likely is wearing only a simple gown. In the clinic or health care provider’s office the patient needs to undress and usually is provided a disposable paper cover or paper gown. If the examination is limited to certain body systems, it is not always necessary for the patient to undress completely. Provide the patient privacy and plenty of time to undress to avoid embarrassment. After changing into the recommended gown or cover, the patient sits or lies down on the examination table with a light drape over the lap or lower trunk. Make sure that he or she stays warm by eliminating drafts, controlling room temperature, and providing warm blankets. Routinely ask if he or she is comfortable. Positioning.During the examination ask the patient to assume proper positions so body parts are accessible and he or she stays comfortable. Table 30-2 lists the preferred positions for each part of the examination and contains figures illustrating the positions. Patients’ abilities to assume positions depend on their physical strength, mobility, ease of breathing, age, and degree of wellness. After explaining the positions, help the patient to assume them. Take care to maintain respect and show consideration by adjusting the drapes so that only the area examined is accessible. During the examination a patient may need to assume more than one position. To decrease the number of position changes, organize the examination so all techniques requiring a sitting position are completed first, followed by those that require a supine position next, and so forth. Use extra care when positioning older adults with disabilities and limitations. TABLE 30-2 Positions for Examination
*Some patients with arthritis or other joint deformities are unable to assume this position. Psychological Preparation of a PatientMany patients find an examination stressful or tiring, or they experience anxiety about possible findings. A thorough explanation of the purpose and steps of each assessment lets a patient know what to expect and how to cooperate. Adapt explanations to the patient’s level of understanding and encourage him or her to ask questions and comment on any discomfort. Convey an open, professional approach while remaining relaxed. A quiet, formal demeanor inhibits the patient’s ability to communicate, but a style that is too casual may cause him or her to doubt an examiner’s competence (Seidel et al., 2011). Consider cultural or social norms when performing an examination on a person of the opposite gender. When this situation occurs, another person of the patient’s gender or a culturally approved family member needs to be in the room. By taking this step you demonstrate cultural awareness for a patient’s individual needs. As a side benefit, the second person acts as a witness to the conduct of the examiner and the patient should any question arise. During the examination, watch the patient’s emotional responses by observing whether his or her facial expressions show fear or concern or if body movements indicate anxiety. When you remain calm, the patient is more likely to relax. Especially if the patient is weak or elderly, it is necessary to pace the examination, pausing at intervals to ask how he or she is tolerating the assessment. If the patient feels alright, the examination can proceed. However, do not force the patient to cooperate based on your schedule. Postponing the examination is advantageous because the findings may be more accurate when the patient can cooperate and relax. Assessment of Age-GroupsIt is necessary to use different interview styles and approaches to physical examination for patients of different age-groups. Your approach will vary with each group. When assessing children, show sensitivity and anticipate the child’s perception of the examination as a strange and unfamiliar experience. Routine pediatric examinations focus on health promotion and illness prevention, particularly for the care of well children who receive competent parenting and have no serious health problems (Josephson and AACAP Work Group, 2007). This examination focuses on growth and development, sensory screening, dental examination, and behavioral assessment. Children who are chronically ill or disabled and foster, foreign-born, or adopted children sometimes require additional examination visits. When examining children, the following tips help in data collection: A comprehensive health assessment and examination of older adults includes physical data, developmental stage, family relationships, religious and occupational pursuits, and a review of the patient’s cognitive, affective, and social level (Kresevic, 2008). An important aspect is to assess the patient’s ability to perform basic activities of daily living (e.g., bathing, grooming) and complex instrumental activities of daily living (e.g., making phone call). Throughout the examination recognize that with advancing age the body does not demonstrate obvious injury or disease as vigorously as younger patients and older adults do not always exhibit the expected signs and symptoms (Meiner, 2011). Characteristically older adults present with subtle or atypical signs and symptoms. Principles to follow during examination of an older adult include the following: Organization of the ExaminationYou will conduct a physical examination by assessing each body system. Use judgment to ensure that an examination is relevant and includes the correct assessments. Patients with focused symptoms or needs require only parts of an examination; thus, when a patient comes to a clinic with symptoms of a severe chest cold, a neurological assessment should not be required. A patient entering the emergency department with acute abdominal symptoms requires assessment of the body systems most at risk for being abnormal. However, when a patient is admitted to the hospital, you will perform a complete examination at the time of admission and at least once each day. Agency guidelines may define the components of a complete examination (see agency policy). A patient in the community seeks screening for specific conditions, often dependent on the patient’s age or health risks listed in Table 30-3. TABLE 30-3 Recommended Preventive Screenings
*Data from American Cancer Society: Cancer facts and figures 2011, Atlanta, 2011, The Society; website for further information on preventative screenings: Guide to clinical preventive services, AHRQ Publication No. 05-0570, Rockville, Md, 2011, Agency for Healthcare Research and Quality, www.ahrp.gov/. Any physical examination should follow a systematic routine to avoid missing important findings. A head-to-toe approach includes all body systems, and the examiner recalls and performs each step in a predetermined order. For an adult the examination begins with an assessment of the head and neck and progresses methodically down the body to incorporate all body systems. The following tips help keep an examination well organized: Techniques of Physical AssessmentThe four techniques used in a physical examination are inspection, palpation, percussion, and auscultation. InspectionTo inspect, carefully look, listen, and smell to distinguish normal from abnormal findings. To do so, you must be aware of any personal visual, hearing, or olfactory deficits. It is important to deliberately practice this skill and learn to recognize all of the possible pieces of data that can be gathered through inspection alone. Inspection occurs when interacting with a patient, watching for nonverbal expressions of emotional and mental status. Physical movements and structural components can also be identified in such an informal way. Most important, be deliberate and pay attention to detail. Follow these guidelines to achieve the best results during inspection: While assessing a patient, recognize the nature and source of body odors (Table 30-4). An unusual odor often indicates an underlying pathology. Olfaction helps to detect abnormalities that cannot be recognized by any other means. For example, when a patient’s breath has a sweet, fruity odor, assess for signs of diabetes. Continue to inspect various parts of the body during the physical examination. Palpation may be used concurrently with inspection, or it may follow in a more deliberate fashion. TABLE 30-4 Assessment of Characteristic Odors
Only gold members can continue reading. Log In or Register to continue What are the 4 components of a physical assessment?WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation.
What is the first thing you should do before a physical assessment?You should gather the following paperwork before your physical examination:. list of current medications you take, including over-the-counter drugs and any herbal supplements.. list of any symptoms or pain you are experiencing.. results from any recent or relevant tests.. medical and surgical history.. What are the 3 components of physical assessment?Inspection- refers to the examination of the physical aspect of the patient. Palpation- a type of examination that involves physical contact. Percussion- refers to the examination of the body by tapping some part with the fingers.
What are the 6 components of the physical assessment?Terms in this set (6). Inspection. Is the intial part of the exam. ... . Palpation. Examination by roughing with the fingers or hands. ( ... . Percussion. Producing sounds by tapping various parts of the body. ... . Auscultation. Listening to sounds made by patient body , indirectly with stethoscope. ... . Mensuration. ... . Manipulation.. |