Assessing Health Status

Assessing Health StatusChapter 22

Objectives - Theory

1) Discuss the types of assessment used in various situations.

2) Demonstrate the techniques used during physical examination.

3) Describe how to gather information for a comprehensive database for a

patient.

Objectives – Skills & Steps

Skill 22.1 – Performing a Physical Examination

Skill 22.2 – Performing a basic physical examination on a patient

Steps 22.1 – Weighing the Adult With a Standing Balance Scale

Steps 22.2 – Testing Visual Acuity

Steps 22.3 – Basic Assessment of Heart Sounds

Steps 22.4 – Auscultating the Lungs

Data Collection and Assessment

Assessment is a vitally important nursing function – it is a continual

process for determining the patients’ condition and progress

Expected to:

Assess lung sounds properly

Abnormal heart sounds

Determine when something may be wrong in the abdomen

Monitor circulatory status

Detect neurologic changes

Note skin problems

Recognize signs and symptoms of problems in any body system

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Data Collection and Assessment

When an illness occurs, it is likely to affect more than one

body system

Staff nurse may not have the time to do a thorough physical

examination of each patient assigned, but a quick focused

assessment and a survey of all body systems are performed

for each patient at the beginning of each shift

Strong assessment skills can quickly identify new signs and

symptoms that indicate complications of an illness or adverse

side effects of medical therapy

Important in LTC or home health because the nurse is often the only

health professional who sees the patient at regular intervals

LVN charge nurse in LTC and home health acts as “eyes and ears” of PCP

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Data Collection and Assessment –Psychosocial and Cultural Assessment

An initial assessment is performed when a patient is admitted to the hospital, LTC, home care services, or other agencies

Assessment usually includes gathering a history and demographic data and performing a brief physical examination

In addition to physical examination, you are also expected to obtain some historical data concerning the patient’s past and present state of health

The health history and psychosocial data to provide pertinent information about the patient to assist in administering daily care

To care for the whole patient rather than just tend to an area of physical need, you must be aware of how the illness is affecting the patient’s life

Assess for cultural preferences and health beliefs so that an individualized plan of care can be formulated

Includes asking patient and family about preferences for food, bathing, and personal care; what they think about their illness and treatment; and who should be consulted about decisions – do not assume

Cultural considerations page 378

Page 376

Data Collection and Assessment Think of this data collection as an interview. Phrase questions in a positive,

non threatening way

Include: social data, marital status, occupation, visual/hearing deficits, dentures,

prostheses, allergies (food, medications, other), medications being taken

(including OTC and herbal)

Box 22.1 page 377

If the older adult has difficulty with memory, data may be gathered from a

family member or significant other

When patients are first encountered, observe their behavior and

appearance to begin to form an opinion about their health status

Detecting possible signs of abuse should be included in the assessment (Box 22.3

page 378)

Information gathered from the physical assessment can be used for a variety

of purposes

( Page 376 bullet points on last paragraph )

Page 376

When the patient is seen with a new illness or complaint, obtain a history

of that illness or complaint with the questions in Box 22.4 on page 379

Examination can be performed by physician, nurse, PA, NP, clinical nurse

specialist, or other clinician depending on the type of assessment its

purpose and the policies of the particular agency

In addition to using interviewing and communication skills, information is

obtained by using the senses

Sight – Inspection / Observation

Hearing – Auscultation

Smell – Olfaction

Touch – Palpation / Percussion

The most helpful of these senses is sight, closely followed by touch

Vocabulary Specific to Physical Assessment page 379

Data Collection and Assessment –Physical Examination Techniques

Page 378

Data Collection and Assessment –Physical Examination Techniques :

Inspection and Observation

Through the sense of sight, you are able to inspect the

various parts of the body and observe the patient’s

behavioral responses

When assessing physiological condition, use inspection

to make observations about the patient’s general

appearance, contours of the body, skin tone and color,

rashes, scars, and lesions, deformities or extremity

weakness, characteristics or movements and respirations

Page 378

Data Collection and Assessment –

Physical Examination Techniques :Palpation

The sense of touch can be used to obtain a great deal of clinical

information about patients

Palpation involves using the hands to feel various parts of the body

Can be used to detect the size, shape, and position of parts and

the texture, temperature and moisture of the skin

Used to ascertain:

Muscle spasms or rigidity

Pain, swelling, or a growth

Any restriction in movement of a body part

Skin temperature, turgor, and edema

Page 379



The back of the hands and fingers are used to investigate the

differences in skin temperature over an inflamed joint or a foot

with poor circulation

Skin is thinner in back of hand and more sensitive to changes in

temperature

Pads of the fingers are used to palpate the size, position and

consistency of various structures such as lymph nodes and breast

tissue

Palm of the hand used to detect vibration or tremors (involuntary

fine movement of body or limb)

Thumb and index fingers are used to check the skin turgor, joint

position, and the firmness of muscles and other tissues

Page 380



Palpate the abdomen lightly to identify painful or tender areas

or locate masses or abnormal collection of fluid

Pads of fingers are used in light palpation and pressure exerted

to indent the skin palpation about 1 to 2 cm (figure 22.1 page

380)

Deep palpation depresses skin 4 to 5 cm and can be done using

both hands

ALWAYS watch the patient’s face for signs of discomfort when

palpating and discontinue if pain occurs

Page 380


Physical Examination Techniques :Percussion

Involves light, quick tapping on the body surface to produce sounds

Variations in sounds reflect the characteristics of the organs or structures below the surface

Used primarily over the chest and abdomen to determine the size, location, and density of organs that lie within

Most common type of percussion consists of striking the middle finger of one hand with the index finger of another hand

When tapping, do not move the forearm; all force is generated by a quick snap of the wrist (figure 22.2 page 280)

Different sounds are emitted as the examiner moves from one resonant area to a less or more resonant

Sounds vary in in their intensity, pitch and duration depending on the presence of underlying air, fluid or solid organ

Resonant sound – things that are hollow, or full of gas/air such as bowl or healthy lung

Dull sound – things that are solid like liver tissue

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Page 380

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Physical Examination Techniques :Auscultation

Process if listening with the aid of the stethoscope to sounds produced in the body

Particularly valuable in hearing sounds produced in the heart, lungs, and abdomen

When listening to lungs, use diaphragm of stethoscope, heart valve sounds are best assessed through the bell of stethoscope placed lightly on chest wall

Diaphragm used to detect high pitched sounds; breath, bowel and normal heart sounds

Held firmly against the skin, and may leave a ring on skin when lifted

Bell piece is used to detect low pitched sounds such as abnormal heart sound made by the valves

Held lightly against the skin – pressing harder eliminates low pitched sounds

Page 380


Physical Examination Techniques :Olfaction

Sense of smell – identify characteristic smells associated with

specific problems

Fruity odor to the breath can indicate diabetic acidosis ,

alcohol on the breath can provide a clue to the patient’s

lethargy or irrational behavior

Foul mouth odor can indicate periodontal disease or poor

oral hygiene

Foul or sweet odor coming from under a cast or a wound

indicates infection

Foul odor in genital area may indicate infection

Page 380

Basic Physical Examination

Height and Weight The basics of physical examination are the foundation on which you begin to

build expertise

Basic nursing function is to weigh and measure the patient – the standing scale is most frequently used to weigh adults

Weight is measured consistently with or without shoes

Infants are weighed in infant scale that is covered with clean paper or cleaned each time prior to use – NEVER leave an infant unattended on the scale

Height is measured from the sole of the foot to the crown of the head

Shoes should not be worn

Stand with feet together centered under the rod with the back of the rod and look straight ahead. Lower extension rod while keeping it at a 90 degree angle until it rests level on patient’s head

Infants and children < 3 are measured supine with legs fully extended

Children are weighed and measured frequently to track growth and determine whether there is expected progression

Older adults patients are measured yearly to track decreases in height that might indicate alterations in the spine such as those caused by osteoporosis

Page 381-382

Basic Physical Examination

Vital Signs

Should be measured at the time of the physical examination

Blood pressure should be measured on both arms if abnormal

with patient standing as well

Never take the BP on arm containing a dialysis shunt or IV site or on side of mastectomy and lymph node dissection has occurred

Radial pulse is assessed and if irregular the apical pulse is

counted

Respirations and temperature are also assessed

In the hospital a full set of vital signs is assessed – in office

practice, the temperature is taken if the patient has a

complaint that may alter body temperature. Respirations are

counted if there is a problem in the respiratory system

Page 382

Review of Body Systems

Head and Neck

Assess the patient's general appearance, color, tone if skin and its condition. Assess the appearance of the eyes and condition of hair

Is the patient alert and oriented?

Does thinking seem logical?

Assess for JVD – jugular vein distention

Visible protrusion of the jugular veins when the patient is positioned sitting in bed at a 15-35 degree angle; assessed as a sign of heart failure or overhydration

Perform a visual acuity examination as described in Steps 22.2 (figure 22.6) page 383

Hearing can be tested quickly and easily using an audio scope (figure 22.7)

Each ear is tested with 4 frequencies

Page 382


Chest, Heart, Lungs The chest should rise and fall with respiration symmetrically on both sides of the

body

Inspect the spine from the rear and the side

Should be midline with gentle concave and convex curves when viewed laterally

Shoulders should appear to be at equal height

Lordosis – exaggerated lumbar curve

Kyphosis – increased curve in the thoracic area

Scoliosis – pronounced lateral curvature of the spine

Inspect the anterior chest to see if there is a noticeable point of maximal impulse (PMI) of the heart

Located at or close to the 5th intercostal space left midclavicular line

S1 is the “lub” sound

Loudest at apex of heart in the mitral area

S2 is the “dub” sound

Loudest over the aortic area

Figure 22.8 page 384

Page 383


Chest, Heart, Lungs Lung sounds are created by air moving through passageways of varying diameter

and length. Vary in pitch and duration depending on the area of auscultation

(figure 22.9) page 385

Sounds over the trachea are loud and coarse. Equal in length for inspiration and

expiration and have a slight pause between them

Sounds over bronchi are harsh and loud and are shorter on inspiration than

expiration. There is a slight pause between two sounds

Bronchovesicular sounds are those heard over the central chest or back. Normally

equal in length during inspiration and expiration and have no pause between

them. Medium in tonality and loudness

Vesicular sounds are soft, rustling sounds heard in the periphery of the lung fields.

Longer on inspiration than expiration and no pause between them

Adventitious sounds (abnormal lung sounds) page 385 table 22.1

Perform auscultation in a systemic manner according to a set pattern Figure 22.10

page 386 – perform on initial assessment and once per shift for all patients who are

on bed rest, who have respiratory problems, and who are at risk for these problems

Page 384


Skin and Extremities

Inspect skin for any rashes or lesions - the assessment frequently includes

the Braden Scale for Predicting Pressure Sores

There should be no flaking or excessive dryness

Check turgor by gently pinching up a bit of skin on the arm or over the

sternum

if the skin is slow to return to a flat position, the patient is most likely dehydrated

if skin returns to the original position in less than 3 seconds, the turgor is “brisk”

Life Span Considerations page 385

Ask about changes in moles or other lesions

Check nails for discoloration or abnormal appearance – nail fungus may

cause changes. Abnormally shaped fingertips may indicate a cardiopulmonary problem

Page 385


Skin and Extremities Check capillary refill time by observing the color of the nail bed and then

compressing the nail bed with the thumbnail or the distal end of a capped pen

Release the pressure and note how quickly the color returns to the nail bed. If color returns slowly, check again and count the seconds to estimate the number of seconds it takes for the color to return --- this is not a comprehensive assessment of circulation but it can be useful

Normal refill time is < 3 seconds

Compare peripheral pulses bilaterally.

It is most important to check the dorsalis pedis pulse because it is an indication of the quality of circulation in the lower extremities

Assess for generalized edema by checking for weigh gain over a short time

Ask about shoe and ring tightness and sock patterns left on the ankles when socks are removed. Look for eye and hand puffiness and abdominal fullness

To check for dependent edema, press fingers into the tissue over the tibia just above the ankle. If indentation remains pitting edema is present Figure 22.11 page 387

To describe edema you can use terms such as taut, tight, puffy, indented or pitting

Page 385


The Abdomen

Assess bowel sounds on admission and once per shift for all patients

Bowel sounds are produced by the contractions of small and large intestine

Wave like clicks and gurgles that occur from 5 -30 times a minute; particularly active after eating; between meals, it is normal to hear only a few sounds

Hyperactive if they are very frequent

Hypoactive if there long periods of silence

Absent if no sound heard for 2-5 minutes in any of the four quadrants

With a patient in a supine position, lightly place the stethoscope over a quadrant (quarter) of the abdomen and listen; if no sound is heard, progress through the other quadrants until sounds are heard or listen for at least 2 minutes (figure 22.12)

If the patient has a gastrointestinal problem, percuss over each quadrant of the abdomen (figure 22.2) page 380

The sound will be dull over solid tissue and resonant over air filled areas. If several resonant areas are present, a large amount of gas is in the bowel

Page 385- 387


The Abdomen

After auscultating and percussing, gently palpate each

quadrant of the abdomen looking for areas of tenderness,

pain, and abnormal masses

When documenting the findings, note the size of the

abdomen to establish a baseline for future comparison,

Sequence for assessing the abdomen :

Inspection

Auscultation

Percussion (if distended) – measure abdominal girth

Palpation

Page 387


Genitalia, Anus and Rectum

Unless the patient has a specific complaint in these

areas, the nurse does not visually assess them.

They may be assessed however, when bathing a

patient, performing perineal care, or assisting with

toileting .

Ask the patient if she has any problems or concerns with

these areas

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Review of Body Systems In many instances, a nursing assessment of the areas of basic need is

more appropriate than a total physical assessment is. A systemic way to

perform such an assessment is to use the acronym RNS HOPE

Rest and activity

Nutrition, fluids, and electrolytes

Safety and security

Hygiene and grooming

Oxygenation and circulation needs

Psychosocial and learning

Elimination

The data to be covered for this assessment of psychosocial and

physiologic functioning are listed in box 22.6 page 389 – this data is gathered and a nursing care plan is prepared using the nursing process

Each patient should also be assessed at the beginning of each shift or

shortly after. This is a quick head to toe assessment to enable the nurse to

establish priorities of care and organize the work for the shift (Box 22.7)

Page 388

Assisting with a Physical Examination

You may be asked to do the initial screening of the patient before

the patient is seen by the examiner.

Obtain a brief history of any complaints, measure vital signs, and

prepare the patient for the examination.

Explain the examination, answer any questions and generally try to

put the patient at ease

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Positioning and Draping Most examiners begin with the patient in a gown, seated at the end of the

examination table with a drape over lap and legs

Patient then assume a supine position and the drape is pulled over the upper body to expose the chest and or abdomen

Lithotomy position – used to examine female genitalia and for the pelvic examination, stirrups hold patient’s feet in an elevated position

To drape, provide a draping sheet or a bath blanket turned so that one corner forms a triangle that falls between the leg. Patient’s buttocks is right at end of table

Knee- Chest position is sometimes used for a rectal examination

Lateral or Sim’s position is used for a flexible sigmoidoscopy examination of the lower colon

Prone position needed for the back examination or back of legs

The primary purpose of draping that patient is to prevent unnecessary exposure of the body during examination

A patient who feels exposed or embarrassed will be tense, restless, and less able to cooperate

Positions page 392 figure 22.13

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Positioning and Draping

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Elements of Physical Examination

Before a pelvic examination, the patient should empty the bladder.

If urine specimen is needed, it is obtained before the patient undresses for the

examination.

Ask patient to disrobe and don the examination gown.

Prepare examination table with fresh paper cover, provide drape and prepare

any equipment

A female nurse may be requested to be present in the room when a male health provider performs a pelvic or breast examination of a patient.

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Special Focused Examinations

At times you will need to perform a neurologic check

It is performed at regular intervals on patients who have

experienced a head injury or who have had brain surgery

It is done for any patient at risk of increasing intracranial

pressure.

A decrease in LOC is an indicator of neurologic deterioration

The pupil size is measured under normal/ dimmed light

conditions.

Pupils are usually round and equal in size.

A flash light is used to make pupils constrict – they should

constrict briskly when stimulated by light.

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Consensual Reflex- Both pupils should get smaller when either eye is stimulated by the light

Accommodation – Pupils constrict when looking at a near object and then dilate when viewing a far object

PERRLA - Pupils Equal, Round, Reactive to Light and Accommodation

Sluggish pupil can indicate increased ICP

Skill 22.2 Performing Neurological Check page 394-395

Page 394


Eye muscles are tested by checking the extraocular

movements (EOMS)

Ask patient to track your finger or an object as it moves to

six different positions.

Eyes usually move in coordinated matter.

Absence of movement or irregular movement may

indicate cranial nerve damage or neurological problem

Page 394


Glasgow Coma Scale is used in most hospitals to score the

neurologic examination for patients with decreased LOC

Provides baseline against which changes can be

evaluated.

Take vital signs at the time of the neurologic check

because diseases that increase intracranial pressure can

affect vital signs, although such changes often do not

occur until late, when circulation to the brain has been

impaired.

Table 22.3 – Glasgow Coma Scale

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Key Points

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Assessing Health Status