HA Book

• Physical examination


  A critical investigation and evaluation of client status
• Types of physical examination

  • Complete assessment
  • Examination of a body system
  • Examination of a body area
• Purposes of the physical examination

  • - To obtain baseline data about the client's functional abilities
  • To supplement, confirm, or refute data obtained in the nursing history
  • To obtain data that will help establish nursing diagnoses and plans of care
  • To evaluate the physiological outcomes of health care and thus the progress of a client's health problem
  • To make clinical judgments about a client's health status
  • To identify areas for health promotion and disease prevention
• Nurses use national guidelines and evidence-based practice to focus health assessment on specific conditions
• Preparing the client


  • Most people need an explanation of the physical examination
  • Clients can be reassured during the examination by explanations at each step
  • Instruct the client that all information gathered and documented during the assessment is kept confidential in accordance with HIPAA
  • Determine in advance any positions that are contraindicated for a particular client
  • Assist the client as needed to undress and put on a gown
  • Clients should empty their bladders before the examination
• Preparing the environment


  • - The time for the physical assessment should be convenient to both the client and the nurse
  • The environment needs to be well lighted and the equipment should be organized for efficient use
  • The room should be warm enough to be comfortable for the client
  • Providing privacy is important
• Positions used in physical examination

  • Dorsal recumbent

  Supine (horizontal recumbent)

  Sitting
• Positioning


  • - Consider the client's ability to assume a position
  • Consider the client's physical condition, energy level, and age
  • Organize the assessment so that several body areas can be assessed in one position, minimizing the number of position changes needed
• Client positions


  • Dorsal recumbent
  • Supine (horizontal recumbent)
  • Sitting
  • Lithotomy
  • Sims'
  • Prone
• Dorsal recumbent


  Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface
• Supine (horizontal recumbent)


  Back-lying position with legs extended; with or without pillow under the head
• Sitting


  A seated position, back unsupported and legs hanging freely
• Lithotomy


  Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table
• Sims'


  Side-lying position with lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow
• Prone


  Lies on abdomen with head turned to the side, with or without a small pillow
• Draping


  Drapes should be arranged so that the area to be assessed is exposed and other body areas are covered
• Equipment and supplies used for a health examination

  • Flashlight or penlight
  • Ophthalmoscope
  • Otoscope
  • Percussion (reflex) hammer
  • Tuning fork
  • Cotton applicators
  • Gloves
  • Tongue blades (depressors)
• Inspection


  • Visual examination, assessing by using the sense of sight
  • Should be deliberate, purposeful, and systematic
  • Uses the naked eye and lighted instruments
  • Observes moisture, color, texture, shape, position, size, color, and symmetry
• Palpation


  • Examination of the body using the sense of touch
  • Uses the pads of the fingers
  • Determines texture, temperature, vibration, position, size, consistency, mobility, distention, pulsation, tenderness or pain
  • Light palpation precedes deep palpation
• Percussion


  • Striking the body surface to elicit sounds and vibrations
  • Direct percussion - striking the area directly
  • Indirect percussion - striking an object held against the body
  • Determines size and shape of internal organs, whether tissue is fluid filled, air filled, or solid
• Auscultation


  • Listening to sounds produced within the body
  • Direct auscultation - using the unaided ear
  • Indirect auscultation - using a stethoscope
  • Describes sounds by pitch, intensity, duration, and quality
• General survey


  • Observes general appearance, level of comfort, and mental status
  • Measures vital signs, height, and weight
• Many components of the general survey are assessed while taking the client's health history
• The nurse must know where to locate documentation from other health care providers in the client's medical record
• Perform hand hygiene and observe other appropriate infection prevention procedures

  1. Perform hand hygiene

  2. Observe other appropriate infection prevention procedures
• Prior to performing the procedure, introduce self and verify the client's identity using agency protocol

  1. Introduce self

  2. Verify the client's identity using agency protocol
• Explain to the client what you are going to do, why it is necessary, and how he or she can participate

  1. Explain what you are going to do

  2. Explain why it is necessary

  3. Explain how the client can participate
• Erosion


  Superficial depression in the epidermis, does not extend into the dermis, heals without scarring
• Erosions


  • Scratch marks
  • Ruptured vesicles
• Fissure


  Linear crack with sharp edges, extending into the dermis
• Fissures


  • Cracks at the corners of the mouth or in the hands
  • Athlete's foot
• Lichenification


  Rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing
• Lichenification


  • Chronic dermatitis
• Scar


  Flat, irregular area of connective tissue left after a lesion or wound has healed. New scars may be red or purple; older scars may be silvery or white.
• Scales


  Shedding flakes of greasy, keratinized skin tissue. Color may be white, gray, or silver. Texture may vary from fine to thick.
• Scales


  • Dry skin
  • Dandruff
  • Psoriasis
  • Eczema
• Keloid


  Elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. Extends beyond the site of the original injury. Higher incidence in people of African descent.
• Keloids


  • Keloid from ear piercing
  • Keloid from surgery
• Crust


  Dry blood, serum, or pus left on the skin surface when vesicles or pustules burst. Can be red-brown, orange, or yellow. Large crusts that adhere to the skin surface are called scabs.
• Crusts


  • Eczema
  • Impetigo
  • Herpes
  • Scabs following abrasion