Health Assessment

Kozier & Erb's Fundamentals of Nursing, 8eBerman, Snyder, Kozier, ErbCopyright 2008 by Pearson Education, Inc.

Chapter 30

Health Assessment

Copyright 2008 by Pearson Education, Inc.

Learning Outcomes

1. Identify the purposes of the physical examination.

2. Explain the four methods used in physical examination.

3. Explain the significance of selected physical findings.

4. Identify expected outcomes of health assessment.


Learning Outcomes

5. Identify the steps in selected examination procedures.

6. Describe suggested sequencing to conduct a physical health examination in an orderly fashion.

7. Discuss variations in examination techniques appropriate for clients of different ages.


Pretest

• Use your clickers to complete the following pretest.


Question 1

Which of the following indicates a normal finding on auscultation of the lungs?

1. Tympany over the right upper lobe2. Resonance over the left upper lobe3. Hyperresonance over the left lower lobe4. Dullness above the left 10th intercostal

space


Rationales 1

1. Tympany would be heard over the stomach (air filled).

2. Correct. Resonance is a normal sound over the lung.

3. Hyperresonance is never a normal finding

4. Dullness would be heard below (not above) the 10th intercostal space.


Question 2

After auscultating the abdomen, the nurse should report which of the following to the primary care provider?

1. Bruit over the aorta2. Absence of bowel sounds for 60 seconds3. Continuous bowel sounds over the

ileocecal valve4. A completely irregular pattern of bowel

sounds


Rationales 2

1. Correct. A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified.

2. In order for absence of bowel sounds to be considered abnormal, they must be silent for 3 to 5 minutes.

3. Continuous bowel sounds are normally heard over the ileocecal valve following meals.

4. Bowel sounds are more commonly irregular than they are regular.


Question 3

If unable to locate the client’s popliteal pulse during a routine examination, the nurse should perform which of the following next?

1. Check for a pedal pulse.2. Check for a femoral pulse.3. Take the client’s blood pressure on that

thigh.4. Ask another nurse to try to locate the pulse.


Rationales 3

1. Correct. If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located.

2. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point.

3. Taking a thigh BP requires locating the popliteal pulse.

4. Since the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate.


Question 4

Which of the following is an expected finding during assessment of the older adult?

1. Facial hair becomes finer and softer.2. Decreased peripheral, color, and night

vision.3. Increased sensitivity to odors.4. Respiratory rate and rhythm are irregular

at rest.


Rationales 4

1. Facial hair is likely to become coarser, not finer.

2. Correct. Visual acuity often lessens with age.

3. The sense of smell becomes less, rather than more acute.

4. The respiratory rate and rhythm is regular at rest. However, both may change quickly with activity and be slow to return to the resting level.


Question 5If the client reports loss of short-term memory, the nurse would assess this using which one of the following?

1. Have the client repeat a series of three numbers, increasing to eight if possible.

2. Have the client describe his or her childhood illnesses.

3. Ask the client to describe how he or she arrived at this

4. location.5. Ask the client to count backwards from 100

subtracting seven each time.


Rationales 5

1. Recalling a series of numbers tests immediate recall.

2. Recalling childhood events tests remote (long-term) memory.

3. Correct. Recent memory includes events of the current day.

4. Subtracting backwards from 100 tests attention span and calculation skills.


Purposes of the Physical Examination

• Obtain baseline data • Supplement, confirm, or refute data from

the history• Help establish nursing diagnoses and plans

of care• Evaluate physiologic outcomes and progress• Make clinical judgments • Identify areas for health promotion and

disease prevention


Methods Used in Physical Examination

• Inspection• Palpation• Percussion• Auscultation


Inspection

• Deliberate, purposeful, and systematic visual examination

• Moisture, color, texture of body surfaces

• Shape, position, size, symmetry of the body


Palpation

• Examination using sense of touch– Texture– Temperature– Vibration– Position, size, consistency, mobility of organs

or masses– Distention– Pulsation– Presence of pain upon pressure

• Light and deep• Flatness, dullness, resonance,

hyperresonance, tympany


Palpation

Light palpation

Deep palpation


Percussion

• Striking body surface to elicit sounds or vibrations– Direct—striking body directly– Indirect—striking of an object held

against the body

• Determine size, shape, borders of internal organs


Percussion

Direct percussion

Indirect percussion


Auscultation

• Listening to sounds produced within the body– Direct—use of unaided ear– Indirect—use of stethoscope

• Pitch, intensity, duration, quality

Go to the DVD-Rom that accompanies your textbook to listen to different lung sounds


Physical Assessment

• Helps the nurse establish:– Nursing diagnoses– Plan the client’s care– Evaluate the outcomes of nursing care


Normal Findings on Physical Examination






























Steps in Examination Procedures

• Planning• Obtaining appropriate equipment• Preparing the client• Implementation of the procedures• Evaluation of findings


Suggested Sequencing for Physical Exam

• General survey• Vital signs• Head to Toe


Assessment of Head

• Hair, scalp, cranium, face• Eyes and vision• Ears and hearing• Nose and sinuses• Mouth and oropharynx• Cranial nerves


Assessment of Neck

• Muscles• Lymph nodes• Trachea• Thyroid gland• Carotid arteries• Neck veins


Assessment of Upper Extremities

• Skin and nails• Muscle strength and tone• Range of motion• Brachial and radial pulses• Biceps and triceps reflexes• Sensation


Assessment of Chest and Back

• Skin• Chest shape and size• Lungs• Heart• Spinal column• Breasts and axilla


Assessment of Abdomen and Genitals

• Abdomen– Skin– Abdominal sounds– Specific organs– Femoral pulses

• Genitals– Testicles– Vagina– Urethra


Assessment

• Anus and Rectum• Lower Extremities

– Skin and toenails– Gait and balance– Range of motion– Popliteal, posterior tibial, and pedal

pulses– Tendon and plantar reflexes


Variations in Examination Techniques: Adult

• Be aware of normal physiologic changes• Be aware of stiffness of muscles and joints

from aging changes or history of orthopedic surgery

• Expose only areas to be examined• Permit ample time to answer questions and

assume desired positions• Be aware of cultural differences• Arrange for an interpreter if needed• Ask clients how wish to be addressed• Adapt techniques to any sensory

impairment


Variations in Examination Techniques

• Elderly– Plan several assessment times in order

not to overtire • Children

– Proceed from the least invasive or uncomfortable to the more invasive

– Examination of the head and neck, heart and lungs, and range of motion can be done early

– Ears, mouth, abdomen, and genitals should be left for the end


Post Test

• Use your clickers to complete the following post test.


Question 1

Which of the following indicates a normal finding on auscultation of the lungs?

1. Tympany over the right upper lobe2. Resonance over the left upper lobe3. Hyperresonance over the left lower lobe4. Dullness above the left 10th intercostal

space


Rationales 1

1. Tympany would be heard over the stomach (air filled).

2. Correct. Resonance is a normal sound over the lung.

3. Hyperresonance is never a normal finding

4. Dullness would be heard below (not above) the 10th intercostal space.


Question 2

After auscultating the abdomen, the nurse should report which of the following to the primary care provider?

1. Bruit over the aorta2. Absence of bowel sounds for 60 seconds3. Continuous bowel sounds over the

ileocecal valve4. A completely irregular pattern of bowel

sounds


Rationales 2

1. Correct. A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified.

2. In order for absence of bowel sounds to be considered abnormal, they must be silent for 3 to 5 minutes.

3. Continuous bowel sounds are normally heard over the ileocecal valve following meals.

4. Bowel sounds are more commonly irregular than they are regular.


Question 3

If unable to locate the client’s popliteal pulse during a routine examination, the nurse should perform which of the following next?

1. Check for a pedal pulse.2. Check for a femoral pulse.3. Take the client’s blood pressure on that

thigh.4. Ask another nurse to try to locate the pulse.


Rationales 3

1. Correct. If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located.

2. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point.

3. Taking a thigh BP requires locating the popliteal pulse.

4. Since the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate.


Question 4

Which of the following is an expected finding during assessment of the older adult?

1. Facial hair becomes finer and softer.2. Decreased peripheral, color, and night

vision.3. Increased sensitivity to odors.4. Respiratory rate and rhythm are irregular

at rest.


Rationales 4

1. Facial hair is likely to become coarser, not finer.

2. Correct. Visual acuity often lessens with age.

3. The sense of smell becomes less, rather than more acute.

4. The respiratory rate and rhythm is regular at rest. However, both may change quickly with activity and be slow to return to the resting level.


Question 5If the client reports loss of short-term memory, the nurse would assess this using which one of the following?

1. Have the client repeat a series of three numbers, increasing to eight if possible.

2. Have the client describe his or her childhood illnesses.

3. Ask the client to describe how he or she arrived at this

4. location.5. Ask the client to count backwards from 100

subtracting seven each time.


Rationales 5

1. Recalling a series of numbers tests immediate recall.

2. Recalling childhood events tests remote (long-term) memory.

3. Correct. Recent memory includes events of the current day.

4. Subtracting backwards from 100 tests attention span and calculation skills.


Resources

• Audio Glossary• McGill University Virtual Stethoscope

Provides text, images, and sound for a cardiac and lung exam

• Auscultation AssistantProvides heart tones, heart murmurs, and lung sounds

• MVS Cardiac AuscultationExplains how to perform a cardiac assessment and evaluation of murmurs

http://wps.prenhall.com/chet_kozier_fundamentals_8/0,13044,4013737-content,00.html

http://sprojects.mmi.mcgill.ca/mvs/

http://www.wilkes.med.ucla.edu/intro.html

http://sprojects.mmi.mcgill.ca/mvs/CARDIO01.HTM#anchor340119


Resources• Loyola University Chicago--Stritch School of Medicine

Provides an overview of a screening physical exam. Very comprehensive and easy to follow.

• Medical Multimedia LaboratoriesHeart sounds tutorial

• University of California, San DiegoA practical guide to clinical medicine. Provides a comprehensive physical exam with procedures and pictures. Very informative.

• Auditory Finding for Lung SoundsProvides audio to learn lung sounds

• R.A.L.E. Lung SoundsProvides a variety of lung sounds

http://www.lumen.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/PD/Contents.htm



http://www.blaufuss.org/

http://medicine.ucsd.edu/clinicalmed/introduction.htm

http://www.lumen.luc.edu/lumen/MedEd/medicine/pulmonar/pd/auditory.htm

http://www.rale.ca/Repository.htm

Documents

Health Assessment