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PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDENursing Assessment1. Part of Nursing Process2. Nurses use physical assessment skills to:a) Obtain baseline data and expand the data base from which subsequent phases of thenursing process can evolveb) To identify and manage a variety of patient problems (actual and potential)c) Evaluate the effectiveness of nursing cared) Enhance the nurse-patient relationshipe) Make clinical judgmentsGathering DataSubjective data - Said by the client (S)Objective data - Observed by the nurse (O)Document: SOAPIERAssessment Techniques:The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for theabdomen which is Inspect – Auscultation – Percuss – Palpate.A. Inspection – critical observation *always first*1. Take time to “observe” with eyes, ears, nose (all senses)2. Use good lighting3. Look at color, shape, symmetry, position4. Observe for odors from skin, breath, wound5. Develop and use nursing instincts6. Inspection is done alone and in combination with other assessment techniquesB. Palpation – light and deep touch1. Back of hand (dorsal aspect) to assess skin temperature2. Fingers to assess texture, moisture, areas of tenderness3. Assess size, shape, and consistency of lesions and organs4. Deep 5-8 cm (2-3”) deep; Light 1 cm deepC. Percussion – sounds produced by striking body surface1. Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)2. Used to determine size and shape of underlying structures by establishing their borders andindicates if tissue is air-filled, fluid-filled, or solid3. Action is performed in the wrist.D. Auscultation – listening to sounds produced by the body1. Direct auscultation – sounds are audible without stethoscope2. Indirect auscultation – uses stethoscope3. Know how to use stethoscope properly [practice skill]4. Fine-tune your ears to pick up subtle changes [practice skill]5. Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill]6. Flat diaphragm picks up high-pitched respiratory sounds best.7. Bell picks up low pitched sounds such as heart murmurs.8. Practice using BOTH diaphragmsPage 1 of 35Adapted from the Kentucky Public Health Practice Reference, 2008 andJarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012

PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDEGeneral AssessmentA general survey is an overall review or first impression a nurse has of a person’s well being. This isdone head to toe, or cephalo-caudal, lateral to lateral, proximal to distal, and front to back. Generalsurveying is visual observation and encompasses the following.AppearanceBody structure/mobilityBehaviorappears to be reported age;sexual development appropriate;alert & oriented;facial features symmetric;no signs of acute distressweight and height within normal range (refer to Center for Disease Controland Prevention (CDC) Body Mass Index (BMI) [adult] or BMI-for-age andgender forms [children]);body parts equal bilaterally;stands erect,sits comfortably;gait is coordinated;walk is smooth and well balanced;full mobility of jointsmaintains eye contact with appropriate expressions;comfortable and cooperative;speech clear;clothing appropriate to climate;looks clean and fit;appears clean and well-groomedDeviations from what would generally be considered to be normal or expected should be documentedand may require further evaluation or action, including a report and/or referral.Standardized and routine screening such as audiometric screening, scoliosis and vision screeningusing the Snellen Test are usually discussed in General Survey *****Health HistoryA patient history should be done as indicated by the age specific prevention guidelines, usually set forthby Center for Disease Control and Prevention (CDC), American Medical Association, AmericanAssociation of Pediatrics, and National Association of Pediatric Nurse Practitioners. The HealthyPeople website (www.healthypeople.gov) provides an excellent source to determine benchmarks forhealthy living across the life span.A comprehensive history, including chief complaint or reason for the visit, a complete review ofsystems, and a complete past family and/or social history should be obtained on the first encounter witha patient, regardless of setting and by a registered nurse. The history should be age and sexappropriate and include all the necessary questions to enable an adequate delivery of servicesaccording to prevention guidelines, scope of practice, patient need, visit requirement, and/or request.Usually, completing a provider based Health History and Physical Examination Form will assist in theassessment of the patient’s past and current health and behavior risk status. Certain health problems,which may be identified on a health history, are more common in specific age groups and gender.Page 2 of 35Adapted from the Kentucky Public Health Practice Reference, 2008 andJarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012

PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDEAn interval history (including an update of complaints, reason for visit, review of systems and pastfamily and/or social history) should be done. Usually family health histories are completed across threegenerations looking specifically for patterns in genetic issues that negatively impact quality of life.The health history gives picture of the patient’s current health and behavior risk status. Additionalinformation than what is on a form may be required depending on the specialized service(s) to beprovided or if the person presents with special needs or conditions. So a health history maybe may beproblem focused, expanded problem focused, detailed, or comprehensive. Regardless, documentationmust be completed for each visit and/or assessment.Mental status evaluation may be done while doing health history (see neuro ***Physical ExaminationA comprehensive physical examination should be performed according to age specific preventivehealth guidelines. American Medical Association clinical practice guidelines recognize the followingbody areas and organ systems for purpose of the examination: Body Areas: Head (including the face); Neck; Chest (including breasts and axillae); Abdomen;genitalia, groin, buttocks; Back (including spine); and each extremity. Organ Systems: Constitutional (vital signs, general appearance), Eyes, Ear, Nose, Throat;Cardiovascular; Gastrointestinal; Genitourinary; Musculoskeletal; Dermatological; Neurological;Psychiatric; Hematological/lymphatic/immunological Integumentary: Both overall body and organ systems should have skin assessments integratedinto them. Integument includes skin, hair and nails.Normal and abnormal findings should be recorded on a health history and physical examination Body measurements include length or height, weight, and head circumference for children from birth to36 months of age. Thereafter, body measurements include height and weight. The assessment ofhearing, speech and vision are also measurements of an individual’s function in these areas. TheDenver Development Screening Test measures an infant’s and young child’s gross motor, language,fine motor-adaptive and personal-social development milestones. If developmental delay is suspectedbased on an assessment of a parent’s development/behavior concern or if delays are suspected after ascreening of development benchmarks, a written referral is to a physician or pediatric nurse practitioneris imperative.A patient’s measurements can be compared with a standard, expected, or predictable measurement forage and gender. Deviation from standards helps identify significant conditions requiring closemonitoring or referral to a physician or pediatric nurse practitioner.The significance of measurements and actions to take when they deviate from normal expectations areage-specific.Page 3 of 35Adapted from the Kentucky Public Health Practice Reference, 2008 andJarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012