Role of the RN & Physical Assessment Techniques

Purposes of Physical Examination

• Gather baseline data about patient’s health.

• Compare data to nursing history.

• Identify and confirm nursing problems using the Clinical Judgment Model.

• Make clinical decisions.

• Evaluate the outcomes of care.

• Triage.

• Routine screening.

• To determine eligibility for:

  • Health insurance

  • Military service

  • A new job

• Admitting a patient

Nursing Assessment Characteristics

• Purposeful: The assessment has a specific aim or goal.

• Relevant: The assessment focuses on information pertinent to the patient's condition.

• Prioritized: The assessment addresses the most important issues first.

• Complete: The assessment is thorough and covers all necessary aspects.

• Systematic: The assessment follows a logical and organized approach.

• Factual and Accurate: The assessment records objective and truthful information.

• Recorded in a Standard Manner: The assessment is documented using consistent and recognized methods.

Cultural Sensitivity and Competence

• Stereotyping: Avoid making generalizations about individuals based on their cultural background.

• Implicit bias: Be aware of unconscious biases that may affect interactions and assessments.

• Physiologic variations: Recognize that physiological norms may differ among cultural groups.

• Assigned sex roles: Understand and respect the diversity in gender roles across cultures.

• Family support: Acknowledge the importance of family support systems in different cultures.

• Socioeconomic factors: Consider how socioeconomic factors can influence health and access to care.

• Personal space: Respect cultural differences in personal space preferences.

• Preferred language: Communicate in the patient's preferred language or use a qualified interpreter.

• Nutritional habits: Be aware of cultural variations in dietary practices.

Sexual Orientation and Gender Identity

• Sexual orientation: Includes heterosexual, LGBTQIA+.

• Gender identity: Includes man, woman, nonbinary.

• Create an inclusive environment.

• Educate yourself about different sexual orientations and gender identities.

• Avoid misgendering (using incorrect pronouns).

• Respect preferred pronouns.

• Use the patient's preferred name.

• Be aware of personal biases.

Preparation for Examination

• Establish assessment priorities.

• Environment: Ensure a comfortable and private setting.

• Infection control: Follow proper hygiene and infection control practices.

• Equipment: Gather necessary equipment.

• Physical preparation of patient:

  • Positioning: standing, supine, sims, lithotomy, sitting, dorsal recumbent, prone, knee-chest.

• Psychological preparation of client.

• Assessment of age groups: Consider developmental stages.

Organization of the Examination

• Head-to-toe sequence or system sequence.

• Systematic and organized approach.

• Assessment of each body system.

• Follows the nursing history.

Physical Assessment Techniques

• Inspection

• Palpation

• Percussion

• Auscultation

Inspection

• Observing visually; involves using other senses as well.

• Begins with patient contact and continues throughout the assessment.

• Need adequate lighting.

• Assess various aspects, including:

  • Skin color

  • Lesions

  • Swelling

  • Deformities

  • Hygiene

  • Behavior

Palpation

• Uses the sense of touch.

• Use palmar and dorsal surface of hand and fingers.

• Assess:

  • Skin temperature

  • Turgor

  • Texture

  • Moisture

  • Vibrations

  • Shapes or structures

  • Firmness

  • Contour

  • Shape

  • Tenderness

  • Consistency

• Light versus deep palpation.

Percussion

• Fingertips are used to tap the body over body tissues to produce vibrations and sound waves.

• Assesses tissues:

  • Location

  • Shape

  • Size

  • Density

Auscultation

• Listening with stethoscope to sounds produced within the body.

• Diaphragm versus bell:

  • Diaphragm: high frequency sounds.

  • Bell: low frequency sounds.

• Assessing:

  • Pitch

  • Loudness

  • Quality

  • Duration

Documentation

• Written or electronic legal record of all pertinent interactions with the patient.

• Content is important with physical assessments.

  • Observations.

  • No generalizations.

  • Document objectively.

Appropriate Terminology

• Avoid words such as “good,” “average,” “normal,” or “sufficient."

• Box 20-3 page 523: Abbreviations commonly used.

• Table 20-2 page 524 and table 20-3 page 527: Error prone abbreviations.

Formats of Documenting an Assessment

• Initial nursing assessment.

• Flowsheets.

• Patient care summaries.

• Progress notes.