Foundations of Care: Health and Physical Assessment
Foundations of Care: Environmental Setting and Communication
Establishing Rapport: The initial phase involves establishing a relationship and explaining the procedure to the client.
Ensuring Privacy and Comfort:
Maintenance of room temperature at a comfortable level.
Provision of sufficient lighting.
Avoidance of interruptions.
Removal of distractions including noise or unnecessary objects.
Interview Stance:
The nurse should sit down during the interview to avoid physical barriers such as a desk.
Maintenance of an appropriate social distance.
Maintenance of eye level with the client.
Communication Techniques: Use therapeutic communication and open-ended questions to gather data about symptoms and concerns. Nurses must allow time for the client to ask questions.
Cultural and Religious Considerations: Consider specific characteristics such as language (need for an interpreter), values, beliefs, health practices, eye contact, and touch norms.
Interview Focus: Note-taking should be kept to a minimum to keep the client as the focus. Electronic or paper standardized forms can help decrease the need for extensive note-taking.
Health and Physical Assessment Documentation
SOAP Format: A frequently used format for documenting client data. It includes:
S (Subjective): Client’s health history.
O (Objective): Physical examination findings.
A (Assessment): Official assessment or diagnosis.
P (Plan): The plan of care.
H&P (History and Physical): The initial documentation that nurses must interpret and follow through subsequent progress notes to stay abreast of changes in care plans.
Health History (Subjective Data)
General State of Health: Assessment of body features, physical characteristics, movements, posture, level of consciousness, nutritional status, and speech.
Chief Complaint and History of Present Illness (HPI): Documented using direct client quotes explaining what led them to seek care.
Family History: Health status of direct blood relatives and the client’s spouse.
Social History:
LIFESTYLE: Data focusing on factors affecting health.
SPECIFICS: Use of alcohol, drugs, and tobacco; sexual practices; tattoos and body piercings; travel history; and work setting to identify occupational hazards.
Domestic Violence Screening:
Conducted to determine if the client is experiencing any form of domestic violence.
Must be conducted during a one-on-one interview while obtaining health history.
Mental Status Examination
Integration: Mental status is assessed while obtaining subjective data during the health history interview.
Appearance:
Nurses note posture, body movements, dress, hygiene, and grooming.
Inappropriate appearance or poor hygiene may indicate depression, manic disorder, dementia, organic brain disease, or other disorders.
Behavior:
Level of Consciousness (LOC): Assessment of alertness, awareness, and the ability to interact appropriately with the environment.
Facial Expression and Body Language: Checking for appropriate eye contact and determining if expressions match the context (mood and affect).
Speech: Assessment of speech patterns for articulation and conversational appropriateness.
Cognitive Level of Functioning (Box 12-2):
Orientation: Awareness of person, place, and time ().
Attention Span: Ability to concentrate.
Recent Memory: Asking the client to recall a recent occurrence (e.g., means of transport to the clinic).
Remote Memory: Asking about a verifiable past event (e.g., a past vacation).
New Learning: Assessing ability to recall four unrelated words. The client is asked to recall these words at , , and later.
Judgment: Determining if actions or decisions discussed are realistic.
Thought Processes and Perceptions: Assessment for logical, coherent, and relevant thoughts that are consistently reality-based.
Types of Health and Physical Assessments (Box 12-1)
Complete Assessment: Includes a complete health history and physical examination to form a baseline database.
Focused Assessment: Focuses on a limited or short-term problem, such as the client’s specific complaint.
Episodic/Follow-up Assessment: Focuses on evaluating a client's progress.
Emergency Assessment: Rapid collection of data, often during lifesaving measures.
Physical Examination Techniques
Overview: Gather equipment; use senses of sight, smell, touch, and hearing.
Standard Sequence: Inspection, Palpation, Percussion, and Auscultation.
Exception: For abdominal assessments, the sequence changes to Inspection, Auscultation, Percussion, and then Palpation.
Technique Details:
1. Inspection: Uses vision and smell. Requires good lighting and adequate body exposure with proper draping. May use instruments like an otoscope or ophthalmoscope.
2. Palpation: Uses touch. Hands must be warmed after hygiene.
Identify tender areas and palpate them last.
Light Palpation: One hand, pressing skin gently with tips of or held together.
Deep Palpation: One hand on top of the other, pressing down with fingertips of both hands.
Assesses: Texture, temperature, moisture, organ location/size/symmetry, swelling, vibration/pulsation, rigidity, spasticity, crepitation, and lumps/masses.
3. Percussion: Tapping skin to assess underlying structures for vibration and sounds (intensity, duration, pitch, quality, location).
Determines presence of air, fluid, or solid masses.
Findings include: Resonance, hyperresonance, tympany, dullness, or flatness.
4. Auscultation: Listening with a stethoscope to sounds (heart, lung, bowel) for presence and quality.
Vital Signs and Physical Metrics
Core Indicators: Temperature, radial pulse (apical pulse may be used in cardiovascular assessment), respirations, blood pressure, pulse oximetry, and pain.
Physical Measurements: Height, weight, and nutritional status.
Integumentary System Assessment
Subjective Data: Self-care behaviors, history of skin disease, medications, occupational hazards, changes in pigment or moles, and non-healing sores.
Objective Data: Color, temperature (hypothermia vs. hyperthermia), moisture, turgor, texture, bruising, itching, rashes, alopecia, nail pitting, lesions, scars, birthmarks, and edema.
Skin Color Characteristics (Box 12-3):
Cyanosis: Mottled bluish coloration.
Erythema: Redness.
Pallor: Pale/whitish coloration.
Jaundice: Yellow coloration.
Assessment in Dark-Skinned Clients:
Cyanosis: Check lips and tongue for gray color; nail beds, palms, and soles for blue color; conjunctivae for pallor.
Jaundice: Check oral mucous membranes; check sclera nearest the iris.
Bleeding: Look for swelling and darkening; compare affected side to unaffected.
Inflammation: Check for warmth, shiny/taut skin, or pitting edema.
Skin Turgor: Pinched fold of skin; poor turgor indicates severe dehydration or extreme weight loss.
Capillary Refilling Time (Box 12-4): Depress nail bed to blanch, release, and observe. Normal color return is within .
Pitting Edema Scale (Table 12-2):
: Slight pitting; no visible distortion; disappears rapidly.
: ( depth); deeper pit than ; disappears in .
: depth; noticeably deep; lasts more than a minute; extremity looks fuller/swollen.
: depth; very deep; lasts ; extremity is grossly distorted.
Health Teaching: Use ABCDE mnemonic (Asymmetry, Border irregularity, Color variance, Diameter > 6 \, \text{mm}, Evolving size/shape/color).
Head, Neck, and Lymph Nodes
Subjective Data: Headaches, dizziness, vertigo, injury, loss of consciousness, neck pain, range of motion limitations, swallowing difficulty.
SKULL: Size, shape, masses, symmetry.
TEMPORAL ARTERIES: Located above the cheekbone.
SINUSES: Palpate frontal (below eyebrows) and maxillary (below cheekbones) for tenderness.
TMJ (Tempromandibular Joint): Palpate while client opens/moves the mouth; check for crepitation (Tests CN V).
FACE: Check for symmetry and periorbital edema.
NECK STRENGTH: Test Cranial Nerve XI (spinal accessory) by shrugging shoulders and pushing chin against resistance.
TRACHEA: Should be midline.
THYROID: Inspect during swallowing; if enlarged, auscultate for a bruit.
LYMPH NODES: Palpate using circular motion of finger pads.
Sequence: Preauricular, posterior auricular, tonsillar, submandibular, submental, anterior cervical chain, posterior cervical chain, supraclavicular, and infraclavicular.
Note: size, shape, location, mobility, consistency, and tenderness.
Eyes
Subjective Data: Vision difficulty, diplopia, blurring, pain, redness, discharge, use of corrective lenses.
Inspection: Eyebrows, eyelashes; ptosis (drooping), exophthalmos (protrusion), or enophthalmos (recessed eyes). Sclera (white), conjunctiva (clear), iris (flat/regular), and pupils.
Vision Testing:
Snellen Eye Chart: Measures distance vision. Client stands () from chart. is normal visual acuity (Tests CN II).
Near Vision: Use handheld screener at (). Normal is .
Confrontation Test: Measures peripheral vision by comparing the client's field of vision to the nurse's.
Alignment and Muscle Function:
Corneal Light Reflex: Light held () away; reflection should be in same spot on both corneas.
Cover/Uncover Test: Checks for deviated alignment.
Diagnostic Positions Test: Moving eyes through six cardinal positions to test CN III, IV, and VI. Check for nystagmus (involuntary twitching).
Color Vision: Ishihara chart. Primarily for red-green blindness.
Pupillary Response (Box 12-5):
PERRLA: Pupils Equal, Round, Reactive to Light (direct and consensual), and Accommodation.
Light Reflex: Darken room; advance light from side. Direct reflex involves the illuminated pupil constricting; consensual involves the other pupil constricting.
Accommodation: Focus on distant object (dilates), then shift to near object ( from nose). Normal response is constriction and convergence.
Ophthalmoscopy (Funduscopy): Examine interior of eye in a darkened room.
Red Reflex: Reflection of light on the vascular retina. Absence may indicate lens opacity.
Optic Disc: Should be creamy yellow-orange/pink, round/oval with distinct margins.
Ears and Hearing
Subjective Data: Hearing loss, earaches, drainage, tinnitus, vertigo, noise exposure, hearing aids.
Hearing Assessment: Sound transmits via air conduction (takes longer) or bone conduction.
Types of Loss:
Conductive: Caused by physical obstruction to sound waves.
Sensorineural: Defect in cochlea, CN VIII, or brain.
Mixed: Combination of both.
Acuity Tests:
Voice (Whisper) Test: Nurse stands away and whispers two-syllable words.
Watch Test: Ticking watch held () away for high-frequency sounds.
Tuning Fork Tests: Weber’s and Rinne’s tests (low sensitivity).
Vestibular Assessment (Box 12-6):
Romberg Test: Stand feet together, eyes closed; significant sway is a positive Romberg's sign.
Past Pointing: Ability to return index fingers to a reference point with eyes closed.
Gaze Nystagmus: Spontaneous jerking as eyes track sideways or up/down.
Dix-Hallpike Maneuver: Rapidly moving from sitting to supine with head turned to check for nystagmus.
Otoscopic Exam: For an adult, pull pinna UP AND BACK.
Normal TM: Transparent/opaque, pearly gray, slightly concave.
Cone of Light: At in right ear; in left ear.
Abnormal: Bulging or retracting TM; fuzzy light reflex; visible air bubbles or fluid.
Nose, Mouth, and Throat
Nose: Check patency by sniffing inward through one nostril while closing the other. Inspect for deviations, discharge, or polyps.
Mouth/Throat:
Condition: Lips for cracking; teeth number and decay; gums (pink).
Tongue: Dorsal/lateral is rough; ventral is smooth and glistening.
Uvula: Say "ahhh" - soft palate/uvula should rise midline (Tests CN X).
Gag Reflex: Touch posterior pharynx (Tests CN IX).
Hypoglossal (CN XII): Stick out tongue - should protrude midline.
Tonsil Grading Scale:
: Surgically removed.
: Hidden within pillars.
: Extending to pillars.
: Extending beyond pillars.
: Extending to midline.
Lungs and Thorax
Calculations: Smoking history in Pack-Years ().
COVID-19 Screening: Focuses on exposure, travel, fever, chills, cough, shortness of breath, loss of taste/smell, etc.
Physical Findings (Box 12-7):
Chest Excursion: Thumbs at ; they should separate symmetrically by approx ().
Tactile Fremitus: Client says "99"; nurse feels for symmetrical palpable vibrations.
Percussion:
Resonance: Normal healthy lung tissue.
Hyperresonance: Too much air (emphysema).
Dullness: Lung density (pneumonia/tumor).
Auscultation (Normal Sounds): Vesicular (over lesser bronchi), Bronchovesicular (main bronchi), Bronchial (trachea).
Adventitious Sounds (Table 12-3):
Fine Crackles: High-pitched popping, end of inspiration, not cleared by cough (Pneumonia, HF).
Coarse Crackles: Low-pitched bubbling/gurgling; early inspiration (Pulmonary edema/fibrosis).
Wheeze: High-pitched musical squeak (Asthma/narrowed airways).
Rhonchi: Low-pitched loud snoring/moaning; expiratory; may clear with cough (Bronchitis).
Pleural Friction Rub: Superficial grating sound; throughout cycle; loudest over lower anterolateral surface (Pleurisy).
Voice Sounds (Box 12-8):
Bronchophony: Repeat "99"; should be soft/muffled.
Egophony: Repeat "eeee"; should hear "eeee".
Whispered Pectoriloquy: Whisper "1, 2, 3"; should be almost inaudible.
Cardiovascular Assessment
Inspection: Pulsations from apical impulse ( or intercostal space).
Auscultation Areas (Fig 12-4):
Aortic: Right Intercostal Space (RICS).
Pulmonic: Left Intercostal Space (LICS).
Erb's Point: LICS.
Tricuspid: LICS.
Mitral (Apex): Left Midclavicular Line (LMCL).
Sounds: (LUB) and (DUB).
Murmur Grading (Box 12-9):
Grade I: Very faint.
Grade II: Faint but recognizable.
Grade III: Loud but moderate intensity.
Grade IV: Loud, with palpable thrill.
Grade V: Very loud, with thrill, heard with stethoscope partly off chest.
Grade VI: Extremely loud, heard with stethoscope slightly above chest.
Vascular Points (Box 12-10): Radial, Ulnar, Brachial (antecubital), Femoral (below inguinal ligament), Popliteal (behind knee), Dorsalis Pedis (top of foot), Posterior Tibial (behind medial malleolus).
Pulse Force Grading:
: Strong and bounding.
: Full, increased.
: Normal.
: Weak, barely palpable.
: Absent.
Carotid Artery: Palpate one at a time. Auscultate for bruit (blowing/swishing indicating turbulence). If present, notify PHCP and monitor for altered blood flow to brain.
Breasts and Axillae
Inspection: Arms above head/on hips/leaning forward. Check for flattening, retraction, dimpling, or nipple discharge.
Palpation: Client supine, arm behind head. Use finger pads in systematic pattern covering entire breast and Tail of Spence.
Nipple: Gently compress for discharge.
Axillary Lymph Nodes: Normally not palpable.
Abdomen Assessment
Sequence: Inspection -> Auscultation -> Percussion -> Palpation.
Auscultation: Listen in all four quadrants (starting RLQ).
Normal: .
Hypoactive/Hyperactive (borborygmus).
Absent: Must listen for full before confirming.
Percussion: Tympany predominates; dullness over liver/spleen.
CVA Tenderness: Pain upon percussion of kidneys at the .
Palpation:
Light: depth.
Deep: depth.
Aorta: Note pulsations; lateral expansion may indicate aneurysm.
Musculoskeletal System
Postural Abnormalities (Box 12-11):
Lordosis (Swayback).
Kyphosis (Hunchback).
Scoliosis (Lateral curvature).
Muscle Strength Grading (Table 12-4):
: No movement.
: Trace movement.
: Full ROM but not against gravity.
: Full ROM against gravity but not resistance.
: Full ROM against gravity, some resistance (weak).
: Full ROM against gravity, full resistance.
Neurological System
Level of Consciousness: Stages include alert, confused, delirious, unconscious, stupor, coma. Utilize Glasgow Coma Scale (GCS) for standardized grading.
Coordination:
Rapid Alternating Movements (Hands on knees).
Heel-to-Shin: Straight line down the leg.
Sensory Testing:
Stereognosis: Recognizing objects in hand.
Graphesthesia: Identifying numbers traced on skin.
Two-Point Discrimination.
Kinesthesia: Perceiving passive movement of fingers/toes.
Reflexes:
Deep Tendon Reflex (DTR) Scoring (Box 12-12): (no response), (diminished), (average), (brisker than average), (hyperactive with clonus).
Babinski's Sign: Stroke sole of foot. Normal in adults is plantar flexion (toes curl). Abnormal (positive) is dorsiflexion of great toe/fanning of others in anyone > 2 \, \text{years old}.
Meningeal Irritation:
Brudzinski’s Sign: Passive neck flexion causes hip/knee flexion.
Kernig’s Sign: Pain along vertebral column when leg is extended after flexing hip and knee.
Genitourinary Assessment
Females: Litotomy position; Pap smear for cervical cancer (with/without HPV screening); check for cystocele (bladder prolapse) or rectocele (rectum prolapse).
Males: Inspect for hernia (cough/bear down); Teach Testicular Self-Exam (TSE) to be done monthly after warm shower.
Rectum: Check sphincter tone and prostate. Normal prostate is firm, not boggy or nodular. Hardness/nodules may indicate cancer; bogginess/tenderness may indicate infection.