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COURSE GUIDE
Introduction
Welcome to OAN3156, Fundamentals of Nursing I. This subject introduces the students to the evolution of nursing thus deepening the appreciation and understanding of the profession. Nursing theories is introduced as the foundations to nursing practice. In addition, the subject also deals with the concepts, principles and techniques of health history taking, and physical assessment emphasizing on the importance of assessment as a basic element in providing safe, effective and quality care to individuals in various settings.
In this course guide, I will share the course learning outcomes, the overview of the plan of the course and the assessments. I will also share the expectations of being a student in this course. It is our intent to make this learning experience both convenient and fun while achieving the intended outcomes.
Course Learning Outcomes
A course learning outcome (CLO) is the expectation of what you should be able to do by the end of the course. It provides a guide to both the educator as well as the student to focus on achieving the intended outcomes. For this course, we have three course learning outcomes (CLO) that can be categorized into two domains; cognitive and psychomotor. The CLOs are as follows:
CLO1
Explain the evolution of nursing and the various nursing theories. (C2, PLO1)
CLO2
Apply Gordon’s Functional Health Patterns framework in health history-taking. (C3, PLO2)
CLO3
Perform physical assessment in a systematic and appropriate manner. (P4, PLO3)
Overview of the Teaching and Learning Plan
As an online course, we will use the Learning Management System (LMS) for all our communication, materials and assessments. We will have synchronous meeting via the LMS as well as Self Instructional Materials (SIM) to facilitate your learning and progress through the course. As an ODL learner, you are expected to be self-directed. The SIM will provide you with a complete guide of the course materials and resources. Each topic will have topic learning outcomes followed by the lesson notes. Links to videos and other resources will be provided to support your learning process. You will also be given reading materials out of the SIM. At the end of each topic, there will be self-check questions. Here you can test yourself. Review the notes and resources should you need to. We will also have scheduled online meetings. Here we will have discussions and tutorials. In this course procedures will be reordered and shared in the SIM. You will be required to watch and reflect on your own practice. No of meeting for this subject is six two-hour synchronous online session.
Assessment
The assessments are planned as coursework and well as a final examination. The breakdown of the weightage is as follows:
A. Continuous Assessment
Weightage (%)
Test
10%
Assignment
10%
Recording of Performance
20%
B. Summative Assessment
Final Examination
60%
Total
100%
Test
A test will be given at a set time within the semester to test your knowledge of the content covered as well as your ability to apply the knowledge into scenarios. The test will be given online in Week 5.
Assignment
An assignment which consists of documentation of health assessment findings based on a subject (a roommate / friend / patient / family member) who has a health issue and collect data utilising the Gordon’s Functional Pattern form and Health Assessment form. You will be required to submit a draft of the essay by Week 8 of the semester. I will read your work and provide you with constructive feedback for improvement by Week 9. Final submission will be by Week 12.
Recording of Performance
For the practical test, you will need to perform physical assessment in a systematic and appropriate manner. The purpose is to ensure you will be confident in assessing your patient.
Final Examination
For the summative assessment, a final examination will be given in a form of multiple-choice question and multiple essay question. It is to test your knowledge of the content covered as well as your ability to apply the knowledge into scenarios. The exam will be given online based on the exam schedule.
Your Responsibility as an ODL Student
The concept of ODL is to be flexible and facilitate learning even while working. As an ODL student, you are expected to be self-directed. Utilise the SIM provided and make full use of the resources (recorded lectures, videos, readings) provided. Attend synchronous meetings to facilitate discussion, clarification and guidance. You are expected to attend at least 85% of synchronous meeting. Should you miss the meeting, do refer to the recordings that will be uploaded after the meeting.
Academic Honesty
Cheating, in any form, is a very serious offence which could lead to severe disciplinary action. Cheating includes:
- using unauthorized materials in tests and examinations;
- letting another person take tests or examinations on one’s behalf OR taking tests or examinations on another person’s behalf;
- working jointly, copying or sharing another student’s work and presenting it as one’s own piece of work;
- inventing, copying or altering data, quotations or references;
- plagiarising, i.e. taking or using another person’s work without attributing the source and thus, giving the impression that it is one’s own work.
Any student caught and found guilty in the disciplinary hearing will be deemed to have FAILED in the subject and will be required to REPEAT the said subject. Any repeated offence may result in EXPULSION FROM THE UNIVERSITY
Closing Note
We are glad to have you with us 😃. Let's look forward to a fun, challenging and fruitful semester.
Do contact me should you need any help. I will be gladly assisting you.
Lee Xui Xian
📩 xxlee@nilai.edu.my
TOPIC 1: Development of Nursing
Introduction:
This topic will introduce the evolution of nursing and a better appreciation of nursing profession.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Discuss contemporary factors influencing the development of nursing.
- Define nursing comprehensively.
- Differentiate the TWO (2) recipients of Nursing.
- Identify the FOUR (4) major areas within the scope of nursing practice.
- Discuss each roles and functions of the nurse clearly.
- Plan the trajectory of their future in nursing.
Historical Perspectives
The evolution of nursing influences by first, the women’s roles, such as wife; mother; daughter; sister, which having caring characteristic. Second is religion. The religious values, such as Self-denial; Spiritual calling; Devotion duty; hard work, especially in the Christian value of “love thy neighbor as thy self” and Christian parable of the good Samaritan. Several knights were formed such as:
• Knights of Saint John of Jerusalem (knight of Hospitalers)
• Knights of Saint Lazarus-cared for people with leprosy, syphilis and with chronic skin problems provided nursing care to the sick and injured comrades
• Build hospitals, organisation and management of standards
• Theodore Fliedner: reinstituted the order of deaconess and open a small hospital in and training school in Kaiserswerth, Germany
Third is influence by War. Crimean War (1854-1856)- the inadequacy of care given to soldier led to a public outcry in Great Britain. The role of Florence Nightingale played in addressing this problem is well known. She transformed the hospital setting, setting up sanitation practices like hand washing and washing clothes properly and regularly. Then, the Civil War (1861-1865) several nurses emerged for their contributions, e.g. Harriet Tubman & Sojourner Truth. Both provided care to injured and safety to slaves fleeing to the North on the underground Railroad. Mother Biekerdyke & Clara Barton - gave care to injured and dying soldier. Noted Authors Walt Whitman & Louisa May Alcott volunteered as nurses to give care to injured soldiers in military hospitals. In World War II create shortage of care, so the Cadet Nurse Corps was established in response to a marked shortage of nurses.
Lastly the societal attitudes significantly influenced professional nursing. Before mid-1800’s nursing was without organization, education and social status. Usual public negative attitudes and image toward nurses include: Woman’s place was in the home; No respectable woman should have a career.; Woman is said to be a wife and mother; Pleasant companion for his husband; Responsible mother for her children. However, the Guardian Angel or Angel of Mercy image arose in the latter part of 19th century because of Florence Nightingale during the Crimean War, which are Respect for the nursing profession; Granted women the right to vote and allow nurse to control their profession. Nightingale also raised the status of Nursing through education, where nurses were no longer untrained housekeepers but people educated in the care of the sick.
Definition of Nursing
Florence Nightingale defined nursing as the act of utilizing the environment of the patient to assist him in his recovery (Nightingale, 1860). Next, Virginia Henderson was one of the first modern nurses to define nursing. She defined nursing as the unique function of the nurse is to assist the individual, sick or well in the performance of those activities contributing to the health or its recovery. (or to peaceful death). It means the client would perform unaided if he had the necessary strength, will or knowledge and to do such a way as to help him gain independence as rapidly as possible. In 1966, Henderson described nursing in relation to client and the client’s environment as compared to nightingale, Henderson saw the nurse as concerned with both the healthy and the ill individual
Professional Nursing Associations also developed their definition:
In 1973, American Nurses Association (ANA) described nursing practice as direct, goal oriented and adoptable to the needs of the individual, the family and the community during health and illness (ANA, 1973). Then in 1980, the ANA changed this definition of nursing to this: “Nursing is the diagnosis and treatment of the human responses to actual and potential health problems” (ANA, 1980). In 1995, ANA recognized the influence and contribution of the science of caring to nursing acknowledges four essential features to contemporary nursing practice:
• Attention to the full range of human experiences and responses to health and illness without restriction to a problem focused orientation
• Integration of objective data with knowledge gained from an understanding of the client or group’s subjective experience
• Application of scientific knowledge to the processes of diagnosis and treatment
• Provision of a caring relationship that facilitates health and healing
In 1987, Canadian Nurses Association (CAN) defined nursing as a dynamic, caring, helping relationship which the nurse assists the client to achieve and obtain optimal health.
In the latter 20th century, several nurse theorists developed their own theoretical definitions of nursing. Theoretical definitions are important because they go beyond the simplistic common definitions. They described what nursing is; The relationship among nurses and nursing, the client, the environment and the intended client outcome: health.
Certain themes are common to the definitions of nursing, such as:
• Nursing is caring
• Nursing is an art
• Nursing is a science
• Nursing is client centered
• Nursing is holistic
• Nursing is adoptive
• Nursing is concerned with the health promotion, health maintenance, and health restoration
• Nursing is a helping profession
Recipients of Care
By the end of this topic, you should be able to differentiate the TWO (2) recipients of Nursing.
The recipients of nursing are sometimes called Consumers. Consumers is an individual, group of people, or community that uses a service or commodity. People who use health care products or service are consumers of health care.
Patient is a person who is waiting for or undergoing medical treatment and care. The word patient came from a Latin word meaning “to suffer” or “to bear”. Traditionally the person receiving health care has been called a patient. Usually, people become patients when they seek assistance because of illness or for surgery.
Clients is a person who engages the service or services of another who is qualified to provide this service. The term client presents the receiver of health care as laboratories in the care, as people who are also responsible for their own health. The health status of the client is the responsibility of the individual in collaboration with health professionals
Scope of Nursing Practice
Nurses provides care for three types of clients, which are individuals, families and communities. The nursing practice involves four areas:
- Promoting health and wellness
Wellness is a state of well-being. Engaging in attitudes and behavior that enhance the quality of life and maximize personal potential (Anspaugh, hamrick, & Rosata, 2001). Nurses promote wellness in clients in both healthy and ill by improving nutrition and physical fitness; preventing drug and alcohol misuse; restricting smoking; preventing accidents and injury at home and workplace.
- Preventing illness
The goal of preventing illness is to maintain optimal health by preventing disease. The nursing activities includes, Immunizations; Prenatal and infant care; Prevention of sexually transmitted disease.
- Restoring health
It focuses on the ill client and it extends from early detection of disease through helping the client during the recovery period. The nursing Activities includes, providing direct care to the ill person, such as administering medications, baths and specific procedures and treatment; and Rehabilitating clients to their optimal functional level following physical or mental illness, injury, or chemical addiction.
- Care of the dying
In this area provides comforting and caring for people of all ages who are dying. Includes: Helping clients as comfortably as possible until death and support persons cope with death. Usually, nurses carry these activities at home, hospitals, extended care facilities and some agency, like hospices are specially designed for this purpose.
Roles and Functions of The Nurse
Nurses assume a number of roles when they care to clients. They carry these roles concurrently, not exclusively of one another. Nurses role required at a specific time depends on the needs of the client ad aspects of the particular environment. The following are some roles and function of a nurse:
- Care and assist the client physically and psychologically while preserving the client’s dignity, which encompasses: Physical, Psychosocial, Developmental, Cultural and Spiritual level. Examples of required nursing actions are: Full care of the dependent client; Supportive and educative care to assist client attain their highest possible level of health and wellness. The Nursing process provides the nurse with a framework for providing care. A nurse may provide care directly or delegate it to other caregivers
2. Communication is integral to all nursing roles Nurses communicates with: Client, Support persons, Other health professional and People in the community. The role of the communicator is when the nurse identifies client’s problems and communicates these verbally or in writing to other member of the health team. The nurse must able to communicate clearly and accurately in order for a client’s health care needs are met.
3. Nurse teach clients learn their health and the health care procedures they need to perform, to restore or maintain health. Activities includes: Nurse assesses client’s learning needs and readiness to learn; Sets specific learning goals in conjunction with the client; Enacts teaching strategies. Nurses also teach unlicensed assistive personnel to whom they delegate care and share expertise with other nurses and health professional.
4. Client Advocate. Nurse acts to protect the client. In this role the nurse may represent the client’s needs and wishes for information to the physician, also assist clients in exercising their rights and help them speak up for themselves.
5. Counseling is the process of helping a client to recognize and cope with stressful Psychologic and social problems. The nurse counsel healthy individuals with normal adjustment difficulties and focuses on helping the person develop new attitudes, feelings and behavior and encouraging clients to look at alternatives’ behaviors, recognizing the choices and develop a sense of control.
6. The nurse acts as a change agent when assisting others (clients) to make modifications in their own behavior. Nurses continually deal with change in the health care system such as: Technological change; Change in the age of the client population and Changes in medication.
7. Nurse leader who Influences other to work together to accomplish a specific goal. The leader role can be employed in different level: Individual client; Family; Group of clients; Colleagues; The community.
8. Nurse case manager works with the multidisciplinary healthcare team to measure the effectiveness of the case management plan and to monitor the outcomes. The case manager works with the primary or staff to oversee the care of a specific caseload. For some agencies, the case manager is the primary nurse or provides some level of direct client care and family. Insurance companies also develop a number of roles for nurse case manager, and responsibilities.
9. Research Consumer. Research work of the nurse includes: Have some awareness of the process and language of research; Be sensitive to issues related to protecting the rights of human subjects; Participate in the identification of significant researchable problems; lastly be a discriminating consumer of research findings.
10. Nurse are fulfilling expanded roles, such as: Nurse practitioner; Clinical nurse specialist; Nurse midwife; Nurse educator; Nurse researcher and Nurse anesthetist.
Careers Pathways in Nursing
There are a multitude of career opportunities to choose from including:
• Medical/Surgical - Care for a variety of ill or injured patients and patients who have undergone surgery.
• Critical Care - Care for critically ill or injured patients of all ages.
• Labor and Delivery - Care for mothers and babies before, during, and after delivery.
• Pediatrics - Care for ill or injured children.
• Cardiac Care - Care for patients with issues involving their hearts.
• Geriatrics - Care for elderly ill or injured patients.
• Neurology - Care for patients with illnesses or injuries involving the nervous system.
• Dermatology - Care for patients with skin conditions.
• Orthopedic - Care for patients with illnesses or injuries to muscles and bones.
• Same Day Surgery/Post Anesthesia Care Unit Recovery Room - Care for patients immediately before or after surgery.
•
A nurse with advanced education adds options to the following career opportunities:
• Clinical Nurse Specialist - Provides care to patients with complex illnesses or injuries and often responsible for the continuing education of staff nurses.
• Nurse Practitioner - Diagnoses and treats a wide variety of patients.
• Research - Involved with research studies to increase the knowledge base of the nursing profession.
• Nurse Midwives - Care for women during pregnancy and deliver their babies.
• Nursing Professor - Teaches nursing students in nursing schools.
• Nurse Anesthetist - Provides anesthesia to patients during surgical and non-surgical procedures.
- View
Please do this practice quiz to self-evaluate your understanding of this topic.
TOPIC 2: Nursing Theory I
Introduction:
From Topic 2 to Topic 4 will introduces the nursing theorist as nursing theory is essential concept used in nursing education, research and clinical setting.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Discuss selected nursing theories clearly
· Nightingale’s Environmental Theory
· Virginia Henderson’s Need Theory
· Watson’s Human Caring Theory
· Orem’s General Theory of Nursing
Nightingale’s Environmental Theory
Environmental Theory is the first nursing theorist. “Act of utilizing the environment of the patient to assist him in his recovery” (Nightingale, 1860/1969). Involves five environmental factors: Pure or fresh air; Pure water; Efficient drainage; Cleanliness; and Light, esp. direct sunlight. Deficiency in these factors will lead to lack of health and illness. She stressed the importance keeping the client warm, maintaining noise-free environment; Diet intake of client and Timeliness of food. So, the general concept of health in this theory are, Ventilation, Cleanliness, Quiet environment and Diet. Nightingale’s Environmental Theory remains the integral part of nursing and health care today.
Virginia Henderson’s Need Theory
In 1966, Henderson uniquely defined nursing separating it from medicine and concerned both in healthy and ill individual. She developed the 14 Fundamental needs:
- Breathing normally
- Eating and drinking adequately
- Eliminating body wastes
- Moving and maintaining a desirable position
- Sleeping and resting
- Selecting suitable clothes
- Maintaining body temperature within normal range adjusting and modifying the environment
- Avoiding dangers in the environment and avoiding injuring others
- Keeping the body clean and well-groomed to protect the integument
- Communicating with others in expressing emotions, needs, fears and emotions
- Worshipping according to one’s faith
- Working in such a way that one feels a sense of accomplishment
- Playing or participating in various forms of recreations
- Learning, discovering or satisfying the curiosity that leads to normal development and health and using available facilities
• Besides, Henderson put emphasis on nursing independence, interdependence with other health care discipline. She was one of the first modern nurses to define nursing as “The unique function of the nurse is to assist the individual, sick or well in the performance of those activities contributing to the health or its recovery. (or to peaceful death)”. Means he would perform unaided if he had the necessary strength, will or knowledge and to do such a way as to help him gain independence as rapidly as possible. Therefore, Henderson (1966) described nursing in relation to client and the client’s environment as compared to nightingale, Henderson saw the nurse as concerned with both the healthy and the ill individual.
Watson’s Human Caring Theory
Jean Watson (1979), unifying focus for practice of caring is center in nursing. She highlights that nursing intervention to human care are referred to as Carrative Factors. There are 10 Core of Nursing in her theory:
- Forming a humanistic –altruistic system of values
- Instilling faith and hope
- Cultivating sensitivity to one’s self- and others
- Developing a helping-trust (human care) relationship
- Promoting and accepting the expression of positive and negative feelings
- Systematically using the scientific problem-solving method for decision making
- Promoting interpersonal teaching-learning
- Providing a supportive, protective or corrective mental, physical, sociocultural and spiritual environment
- Assisting with the gratification of human needs
- Allowing for existential-phenomenological spiritual forces
Watson’s theory of human care received worldwide recognition and major force in redefining nursing as a caring healing health care.
Orem’s General Theory of Nursing
Dorothea Orem’s General Theory of Nursing was first published in 1971. Orem believe that” patient wish to care for themselves. Recovery is quick if they are allowed to perform their own self care activities to the best of their ability or at least incorporated in taking care of themselves”. Three related concepts: Self-care, Self-deficit and Nursing system. The explanation is as following:
Ø There are Four concepts in Self-Care theory
- Self-care activities is activities an individual performs independently throughout life to promote and maintain personal well-being
- Self-care agency is individual’s ability to perform self-care activities. There are two agents: Self-care agent (individual who can perform self-care independently) and Dependent care agent (person other than the individual who provides the care).
- Self-care requisites, divided to three categories:
· Universal requisites are common to all people (Maintaining intake and elimination of air, water, and food. balancing rest, social interaction, preventing hazard to life and well-being).
· Developmental requisites (Maturation or as associated with conditions or events like: adjusting to a change in body image or loss of a spouse)
· Health deviation requisites (result from illness, injury or disease or its treatment like: seeking health and carrying our prescribed therapies learning to live with the effects of illness or treatment).
4. Therapeutic self-care demand, refers to all self-care activities required to meet existing self-care requisites.
Ø Self-Care deficit, results when self-care agency is not adequate to meet the known self-care demand. Five methods of helping; Acting or doing for; Guiding; Teaching; Supporting; providing an environment that promotes the individual’s abilities to meet current and future demands.
Ø Orem identified three types of nursing systems: Wholly compensatory system; Partly compensatory; Supportive-educative (developmental).
TOPIC 3: Nursing Theory II
Introduction:
From Topic 2 to Topic 4 will introduces the nursing theorist as nursing theory is essential concept used in nursing education, research and clinical setting.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Discuss selected nursing theories clearly
· Roy’s Adaptation Model
· King’s Goal Attainment Theory
Roy’s Adaptation Model
• Sister Callista Roy defines ADAPTATION as the “process and outcome whereby the thinking and feeling person uses conscious awareness”. She creates human and environmental are integration. The theory focuses on increasing complexity of person and environment; Self-organization; Relationship between and among persons. This theory also focuses on the individual as biopsychosocial adaptive system. Roy believe that creation spirituality- view that “persons and the earth are one and that they are in God and of God” and Universe and supreme being.
• Theory employs feedback cycle of the input (stimuli); Throughout (control processes) and Output (behavioral and adaptive response). Both individual and environment are sources of stimuli requiring modification to promote adaptation and ongoing purposive response. Process she defined as being and becoming integrated is the adaptive responses contribute to health; Ineffective and maladaptive responses do not contribute to health and each person’s adaptation is unique and constantly changing.
• Individual respond to needs (stimuli) are in four modes:
1. Physiologic mode involves the body’s basic physiologic needs and ways of adapting with regards to fluid and electrolytes, activity, rest, circulation, oxygen, nutrition, elimination, protection, senses neurologic and endocrine function. Behaviour pertaining to the physical aspect of the human system; Physical and chemical processes.
2. Self-concept have 2 components, which are physical self-involving sensation and body image and personal self (self-ideal) self-consistency and the moral –ethical self. The composite of beliefs and feelings held about oneself at a given time. It focusses on the psychological and spiritual aspects of the human system.
3. Role of function determined by the need for social integrity and performance of duties based on the given position in the society
4. Interdependence mode is ones relation with significant others and support system that provide help, affection and attention.
• The goal of Callista’s Roy model is enhancing life processes through adaptation in four adaptive modes. Behaviour pertaining to interdependent relationships of individuals and group where each relationship exists for some reason.
King’s Goal Attainment Theory
• King’s conceptual framework for nursing consist of three dynamic interacting system: Relationship of operational systems (individual’s); interpersonal system (groups) and social system (educational or health care system). The theory selected 15 concepts from nursing, which are Self-role; Perception; Communication; Interaction; Transaction; Growth and development; Stress; Time; Personal space; Organization; Status; Power; Authority; Decision making and Essential knowledge for use by nurses.
• In the transaction model design, it describes the nature of and standard of nurse-patient interaction (goal-attainment) where nurse purposely interact and mutually set, explore and agree to means to achieve goals. So, goal-attainment represent outcomes. For examples, recorded information in the patient record, represent evidence-based practice; Provides insights into nurse’s interaction with the individual or groups. It highlights the importance of client’s participation in decisions that influence care and focuses on nurse-client interaction and outcomes of care.
TOPIC 4: Nursing Theory III
Introduction:
From Topic 2 to Topic 4 will introduces the nursing theorist as nursing theory is essential concept used in nursing education, research and clinical setting.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Discuss selected nursing theories clearly
· Peplau’s Interpersonal Relations Model
· Orlando’s Nursing Process
· Leininger’s Cultural Care Diversity
Peplau’s Interpersonal Relations Model
Hildergard Peplau is a psychiatric nurse. Introduced her interpersonal concepts in 1952. She emphasizes on use of therapeutic relationship between the nurse and the client. Nurse-Patient Relationship consists of four phases the following it sequences:
Ø Orientation phase is client seeks help
Ø Identification phase is assuring the person the nurses understanding of the situation
Ø Exploitation phase is deriving full value from the relationship
Ø Resolution phase is older goals are put aside, newer new ones are adopted
This model is essential for nurses because nurse assumes many roles, such as Stranger, Teacher, Resource person, Surrogate, Leader and Counselor.
Orlando’s Nursing Process Theory
• Orlando developed nursing process theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing. From her observations she learned that the patient must be the central character and nursing care needs to be directed at improving outcomes for the patient, and not about nursing goals. Therefore, the nursing process is an essential part of the nursing care plan. There are four steps in nursing process:
• Assessment is deliberative nursing process used to share and validate the nurse’s direct and indirect observation.
• Planning occurs with participation from the nurse and the patient.
• Both direct help and indirect help occur in the implementation phase.
• Evaluation is focus on change in the patient’s behaviour. If no change, nurse continues the process until improvement occur.
Leininger’s Cultural Care Diversity
• Madeleine Leininger is a well-known anthropologist. She develops transcultural nursing in 1970s. In 1991 published her book Culture Care Diversity and Universality: A theory in Nursing. Leininger consider care is essence of nursing and the dominant, distinctive and unifying feature of nursing. She emphasizes on human caring.
Leininger produced the sunrise model to depict her theory of cultural care diversity and universality. The model emphasize health is influenced by elements of social structure, such as Technology; Religious; Philosophical; Kinship and social system; Cultural values; Political and legal factors; Economic factors and Educational factors. Each of the system is part of the social structure of any society in health care expression, patterns and practices. Leininger’s three importance intervention modes are:
Ø Culture care and preservation
Ø Culture care accommodation, negotiation or both
Ø Culture care restructuring and repatterning
TOPIC 5: Introduction to Health Assessment
Introduction:
Health Assessment is the first phase of the nursing process and probably the most vital as nursing assessment directs the rest of the process. It does not matter what nursing outcomes and goals as when the assessment is wrong the entire nursing intervention will be incorrect.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Explain the purpose of health assessment in today’s context.
- Describe the roles of the professional nurse in health assessment.
- Discuss the different levels of preventive care.
Nursing Assessment in Today’s Context
Nursing assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. Assessment identifies a patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing initial assessment, you establish your baseline, identify nursing diagnoses, and develop a plan. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient.
The purpose of assessment is to collect data pertinent to the patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to pinpoint actual problems, and to spot factors that place the patient at risk for health problems. Assessment requires at least these skills; cognitive, problem-solving, psychomotor, affective/interpersonal, and ethical skills. Cognitive skills are needed for critical thinking, creative thinking, and clinical decision making. With experience, you will develop your problem-solving skills. Do not limit yourself to one method; instead, select the method that best suits your patient’s needs. Assessment is “doing.” Psychomotor skills are needed to perform the four techniques of physical assessment: inspection, palpation, percussion, and auscultation. Affective skills are needed to practice the “art” of nursing. Affective skills are essential in developing caring, therapeutic nurse-patient relationships. The data collected through assessment is used to plan the patient’s care, but it is important to remember that the data are the patient’s information. Therefore, you are responsible and accountable for your practice following the code of practice for nurses.
The Role of the Nurse in Assessment
The role of the nurse has changed drastically over the years. The importance of assessment can be traced to the beginning of modern nursing. Florence Nightingale (1859) stressed the importance of observation and experience as essential in maintaining or restoring one’s state of health. The scope of assessment has also expanded from simple observation to a holistic view of the patient that includes biophysical, psychosocial, developmental, and cultural assessments. Therefore, major roles are firstly direct and indirect caregiving, such as restore health for ill patients; assist patient and family to cope with disability and as a designers/coordinators/manager of care. Then advocates for the patient and the profession. For examples, patient’s safety; communicates patient’s needs; identifies side effects of treatment and finds better options; help patients understand their diseases and treatments. Besides, nurse takes responsibility to protect the legal and ethical rights of patients by based on professional values: Altruism (unselfishness); Human dignity; Autonomy; Integrity and Social justice. Lastly, professional nursing practice is grounded in best practice, critical inquiry and skilled questioning that involve research. Knowledge of patient care technologies and information systems is essential in the management of care through health assessment.
Level of Preventive Care
Health promotion and disease prevention are necessary to improve health at both the individual and the population level. Nurses have a vital role in all three levels of health care, and assessment skills are needed at all levels. Preventive healthcare can be classified as primary, secondary, and tertiary.
In Primary Preventive Care, nurses use assessment skills to screen and identify patient education needs about wellness and the risk factors for health problems. Mainly focuses on health promotion and guards against health problems. Examples include: health fairs, immunizations, and nutritional instructions.
In Secondary Preventive Care, accurate assessment is crucial to establish the patient’s baseline and to continually monitor his or her condition and response to treatment. Mainly focuses on early detection prompt intervention, and health maintenance for patients with health problems. Examples include: acute health problems seen with inpatient hospitalization.
In Tertiary Preventive Care, although the patient’s health status is generally more stable than in secondary care, patients usually have a chronic illness. Assessment skills are needed to continually monitor health status. Mainly focuses on rehabilitative or extended care. Examples include: skilled nursing care facilities; rehabilitative hospitals; long-term care facilities; home care; Hospice.
TOPIC 6: Framework for Health Assessment
Introduction:
Gordon’s Functional Health Patterns framework provides a way of looking at your patient and the data. It is useful for organising collected data. This framework has addressed the physical, psychosocial, and spiritual needs of a patient in a holistic approach.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Explain the significance of using Gordon’s functional health patterns.
- Describe the 11 functional health patterns by Marjory Gordon.
- Demonstrate satisfactory skills in gathering data using Gordon’s functional.
Gordon’s Functional Health Patterns
Gordon’s Functional Health Patterns guide in Organizes data into 11 functional groups that contribute to a person’s overall health and well-being, quality of life, and attainment of human potential. A Theory neutral as it’s not aligned or built from any nursing theories), and can be used without conflict alongside other principles, theories or care models including self-assessment. This framework is wide utility in nursing practice because of Covers the entire life-span, does not require a license and Evidence-based.
11 Gordon’s Functional Health Patterns as following:
1. Health perception – health management
2. Nutrition – metabolic
3. Elimination
4. Activity – exercise5. Sleep – rest
6. Cognitive – perceptual
7. Self-perception – self-concept8. Coping – stress tolerance
9. Role – relationship
10. Sexuality – reproduction
11. Value – beliefHowever, NANDA separate the Cognitive – perceptual pattern into 2 pattern which are Cognitive Pattern and Sensory—Perceptual Pattern.
Here, is the explanation and guide of question for each functional health pattern when you want to collect data from a patient.
Health Perception-Health Management Pattern
· Determine how the client perceives and manages his or her health. Compliance with current and past nursing and, medical recommendations. The client's ability to perceive the relationship between activities of daily living and health.
· Client's Perception of Health: Describe your health.
· Client's Perception of Illness: Describe your illness or current health problem.
· Health Management and Habits: Tell me what you do when you have a health problem.
· Compliance with Prescribed Medications and Treatments; Have you been able to take your prescribed medications? If not, what caused your inability to do so?
· Wellness Diagnoses: Effective Management of Therapeutic Regimen
· Risk Diagnoses: Risk for Injury & Risk for Trauma
· Actual Diagnoses: Altered Growth and Development; Ineffective Management of Therapeutic Regimen: Individual; Ineffective Management of Therapeutic Regimen: Family
Nutritional—Metabolic Pattern
• Determine the client's dietary habits and metabolic needs, such as assess the conditions of hair, skin, nails, teeth and mucous membranes.
• Dietary and Fluid Intake:
• Describe the type and amount of food you eat at breakfast, lunch, and supper on an average day.
• Do-you take any vitamin supplements? Describe.
• Do you find it difficult to tolerate certain foods? Specify.
• Do you ever experience nausea and vomiting? Describe.
• Do you ever experience abdominal pains? Describe.
• Condition of Skin
• Describe the condition of your skin.
• How well and how quickly does your skin heal?
• Do you have any skin lesions? Describe.
• Do you have any itching? What do you do for relief?
• Condition of Hair and Nails
• Have you had difficulty with scalp itching or sores?
• Do you use any special hair or scalp care products?
• Have you noticed any changes in your nails? Color Cracking? Shape? Lines?
• Metabolism
• What would you consider to be your "ideal weight"?
• Have you had any recent weight gains or losses?
• Do you have any intolerance to heat or cold?
• Have you noted any changes in your eating or drinking habits? Explain.
• Have you noticed any voice changes?
• Assess the client's temperature, pulse, respirations, and height and weight.
• Wellness Diagnoses
• Opportunity to enhance nutritional metabolic pattern
• Opportunity to enhance effective breastfeeding
• Opportunity to enhance skin integrity
• Risk Diagnoses
• Risk for Altered Body Temperature
• Hypothermia
• Risk for Infection
• Risk for altered nutrition less than body requirements.
• Risk for Aspiration
• Actual Diagnoses
• Fluid Volume Deficit
• Fluid Volume Excess
• Altered Nutrition: Less than body requirements
• Altered Nutrition: More than body requirements
• Ineffective Breastfeeding
• Altered Oral Mucous Membrane
• Impaired Skin Integrity.
Elimination Pattern
• Determine adequacy of the client's bowel and bladder. The client's bowel and urinary habits. Identify Bowel or urinary problems, such as use of urinary or bowel elimination devices.
• Bowel Habits
• How frequent are your bowel movements?
• Do you use laxatives? What kind and how often do you use them?
• Do you use enemas or suppositories? How often and what kind?
• Do you have any discomfort with your bowel movements? Describe.
• Bladder Habits
• How frequently do you urinate?
• What is the amount and color of your urine?
• Do you have any of the following problems with urinating:
• Pain? Blood in urine? Difficulty starting a stream? Incontinence? Voiding frequently at night? Voiding frequently during day? Bladder infections?
• Have you ever had a urinary catheter? Describe. When? How long?
• Wellness Diagnoses
• Opportunity to enhance adequate bowel elimination pattern
• Opportunity to enhance adequate urinary elimination pattern
• Risk Diagnoses
• Risk for constipation
• Risk for altered urinary elimination
• Actual Diagnoses
• Altered Bowel Elimination Constipation
• Diarrhea
• Bowel Incontinence
• Altered Urinary Elimination Patterns of Urinary Retention
• Total Incontinence
• Stress Incontinence
Activity—Exercise Pattern
• An assessment is made of any factors that affect or interfere with the client's routine activities of daily living. Activities of daily living, including routines of exercise, leisure, and recreation. It is necessary for personal hygiene, cooking, shopping, eating, maintaining the home, and working.
· Activities of Daily Living
• Describe your activities on a normal day (Including hygiene activities, eating activities).
• Do you have difficulty with any of these self-care activities? Explain.
• Does anyone help you with these activities? How?
• Do you use any special devices to help you with your activities?
• Does your current physical health affect any of these activities e.g. dyspnea, shortness of breath, palpations, chest pain. pain, stiffness, weakness)? Explain.
· Occupational Activities
• Describe what you do to make a living.
• Do you feel it has affected your health?
• How has your health affected your ability to work?
· Assess client’s Thoracic and Lung; Peripheral Vascular and Musculoskeletal system
Wellness Diagnoses
• Opportunity to enhance effective cardiac output
• Opportunity to enhance effective self-care activities
• Opportunity to enhance adequate tissue perfusion
• Opportunity to enhance effective breathing pattern
Risk Diagnoses
• Risk for Disorganized Infant Behavior
• Risk for Peripheral Neurovascular Dysfunction
• Risk for altered respiratory function
Actual Diagnoses
• Activity Intolerance
• Impaired Gas Exchange
• Ineffective Airway Clearance
• Ineffective Breathing Pattern
• Impaired Physical Mobility
• Inability to Sustain Spontaneous Ventilation
• Altered Tissue Perfusion
Sleep—Rest Pattern
· Determine the sleep and rest quality of a client.
· Sleep Habits:
· How would you rate the quality of your sleep?
· Special Problems
· Do you ever experience difficulty with falling asleep? Remaining asleep?
· Do you ever feel fatigued after a sleep period?
· Sleep Aids
· What helps you to fall asleep? medications? reading? relaxation technique? Watching TV? Listening to music?
· Observe appearance of your client, such as pale and puffy eyes with dark circles.
· Observe behavior of your client, such as yawning, dozing during day, irritability and short attention span.
· Wellness Diagnosis: Opportunity to enhance sleep
· Risk Diagnosis: Risk for sleep pattern disturbance
· Actual Diagnosis: Sleep Pattern Disturbance.
7- Sensory—Perceptual Pattern
• Describe your ability to see, hear, feel, taste, and smell.
• Describe any difficulty you have with your vision, hearing, and ability to feel (e.g., touch, pain, heat, cold), taste (salty, sweet, bitter, sour), or smell.
Pain Assessment: Complete Symptom Analysis on client.
Special Aids:
• What devices (e.g., glasses, contact lenses, hearing aids)
• Describe any medications you take to help you with these problems.
• Perform assessment on Eye Ear Nose and Sinus
• Wellness Diagnosis: Opportunity to enhance comfort level
• Risk Diagnoses: Risk for pain
• Actual Diagnoses: Pain
5- Sexuality—Reproduction Pattern
Menstrual history:
• Last cycle begins?
• Duration?
• Any change or abnormality?
• Describe any mood changes or discomfort before, during, or after your cycle
Obstetric history
• How many times have you been pregnant?
• Describe the outcome of each of your pregnancies.
• If you have children, what are the ages and sex of each?
• Explain any health problems or concerns you had with each pregnancy. If pregnant now.
Contraception
• What do you or your partner do to prevent pregnancy?
• Describe any discomfort or undesirable effects this method produces.
• Have you had any difficulty with fertility? Explain
Special problems
• Do you have or have you ever had a sexually transmitted disease? Describe.
• Describe any pain, burning, or discomfort you have while voiding.
• Perform assessment of Breast, Abdominal, and urinary-Reproductive for your client.
• Wellness Diagnosis: Opportunity to enhance sexuality patterns
• Risk-Diagnosis: Risk for altered sexuality pattern
• Actual Diagnoses: Sexual Dysfunction, Altered Sexuality Patterns
8- Cognitive Pattern
· Ability to Understand: Explain what your doctor has told you about your health.
· Ability to Communicate: Can you tell me how you feel about your current state of health?
· Ability to Remember: Are you able to remember recent events and events of long ago? Explain.
· Ability to Make Decisions: Describe how you feel when faced with a decision.
· Perform Mental Status Assessment for your client.
· Wellness Diagnosis: Opportunity to enhance cognition
· Risk Diagnosis: Risk for altered thought processes
· Actual Diagnoses: Acute / Chronic confusion; Knowledge Deficit (Specify) and Impaired Memory
9- Role—Relationship Pattern
Perception of Major Roles and Responsibilities in Family
• Describe your family.
• Are there any major problems now?
Perception of Major Roles and Responsibilities at Work
• Describe your occupation.
• What is your major responsibility at work?
Perception of Major Social Roles and Responsibilities
• Describe your neighborhood and the community in which you live.
· Outline a family genogram for your client and observe your client's family members.
Wellness Diagnoses:
• Opportunity to enhance effective relationships
• Opportunity to enhance effective communication
Risk Diagnoses:
• High risk for Loneliness
• Risk for Altered Parent/Infant/Child Attachment
Actual Diagnoses:
• Impaired Verbal Communication
• Impaired Social Interaction: Social Isolation
10- Self-Perception-Self-Concept Pattern
• Describe self-concept and perception of self-worth, self-competency, body image and mood state. Example: Body comfort, body image, feeling state, attitudes about self-perception of abilities.
• Observe body posture, eye contact and voice tone of your client.
11- Coping-Stress Tolerance Pattern
Perception of Stress and Problems in Life
• Describe what you believe to be the most stressful situation in your Life.
• How has your illness affected the stress you feel?
Coping Methods and Support Systems:
• What do you usually do first when faced with a problem?
• What helps you to relieve stress and tension?
• Do you use medication, drugs, or alcohol to help relieve stress? Explain.
• Perform Mental Status Assessment for your client.
Wellness Diagnoses
• Opportunity to enhance effective individual coping.
• Opportunity to enhance family coping
Risk Diagnoses:
• Risk for self-harm
• Risk for suicide
Actual Diagnoses:
• Ineffective Individual Coping
• Ineffective Family Coping: Disabling
12- Value—Belief Pattern
Determine client’s Goals, and Philosophical Beliefs.
Religious and Spiritual Beliefs: Are there certain health practices or restrictions that are important for you to follow while you are ill or hospitalized? Explain.
• Observe client’s religious practices, such as Bible
• Observe client's behavior for signs of spiritual distress, such as Anxiety, Anger, Depression, Doubt, Hopelessness and Powerlessness
• Wellness Diagnosis: Potential for Enhanced Spiritual Well-Being
• Risk diagnosis: Risk for spiritual distress
• Actual Diagnosis: Spiritual disturbance (distress of the human spirit).
TOPIC 7: The Health History
Introduction:
The health history provides the subjective database for your assessment, allowing you to interact with your patient. It consists of what the patient tells you, what the patient perceives, and what the patient thinks is important. It provides a holistic, qualitative picture of your patient. Data that you obtain from the health history will direct your physical assessment and are essential in developing a successful plan of care for your patient.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Discuss purpose of the health history.
- Differentiate between a complete and focused health history
- Differentiate a nursing health history from a medical health history
- Identify the components of the complete health history.
- Document health history.
Purpose of the Health History
The purpose of the health history is to identify not only actual or potential health problems but also your patient’s strengths. It should also identify discharge needs. In fact, a successful discharge plan begins on admission with the health history. To create a successful plan of care, you must take a holistic view of your patient and all that affects her or him. Remember: The plan you develop will be successful only if your patient is able to follow through with it after discharge. In summary, the purpose of the health history is to:
· Provide the subjective database.
· Identify patient strengths.
· Identify patient health problems, both actual and potential.
· Identify supports.
· Identify teaching needs.
· Identify discharge needs.
· Identify referral needs.
Types of the Health History
A health history may be either complete or focused. A complete health history includes biographical data, reason for seeking care, current health status, past health status, family history, a detailed review of systems, and a psychosocial profile. A focused health history focuses on an acute problem, so all of your questions will relate to that problem.
Complete Health History
The complete health history begins with biographical data, including the patient’s name, age, gender, birth date, birthplace, marital status, race, religion, address, education, occupation, contact person, and health insurance/social security number. It should also include the source of the health history and his or her reliability, who referred the patient, and whether or not the patient has an advance directive. Once you have obtained this information, you should then identify the reason for seeking healthcare, followed by a description of current health status.
The past health history includes childhood illnesses, surgeries, injuries, hospitalizations, adult medical problems, medications, allergies, immunizations, travel, and military service. The family history will identify familial or genetically linked disorders. The review of systems provides a comprehensive assessment to determine your patient’s physiological status. Past or current problems may be identified and warrant further investigation.
The psychosocial profile gives you a picture of your patient’s health promotion and preventive patterns. It includes a description of health practices and health beliefs, a typical day, nutritional patterns, activity/exercise patterns, recreational patterns, sleep/rest patterns, personal habits, occupational and environmental risk factors, socioeconomic status, developmental level, roles and relationships, self-concept, religious and cultural influences,
supports, sexuality patterns, and finally, the emotional health status of your patient. Once you have completed the health history, summarize any pertinent data.
A complete health history provides a comprehensive, holistic picture of your patient. It screens for actual or potential problems and identifies your patient’s strengths and health promotion patterns. A complete health history may be obtained in a primary setting as a screening tool, in a secondary setting once your patient’s condition stabilizes, or in a tertiary setting to establish a baseline from which to develop your plan of care.
Focused Health History
A focused health history contains necessary biographical data, including the patient’s name, age, birth date, birthplace, gender, marital status, dependents, race, religion, address, education, occupation, contact person, and health insurance/social security number. It also includes the source of the health history and her or his reliability, who referred the patient, and whether or not the patient has an advance directive. You should then identify the reason for seeking care, followed by a complete symptom analysis.
In your past health history, address any areas that relate to the reason for seeking care, including diseases of high incidence in the United States, such as heart disease, hypertension, cancer, diabetes, and alcoholism. In your review of systems, ask questions about every system and how it relates to the presenting health problem. The questions in the psychosocial profile identify the impact of the presenting health problem on your patient’s life.
A focused health history may be indicated when your patient’s condition is unstable or when time constraints are an issue. Focused health histories may also be used for episodic follow-up visits for your patient. In this case, you have already obtained a detailed health history at
an earlier point and have established the subjective database. During the follow-up visits, you need to obtain further subjective data to monitor and evaluate your patient’s progress. Once you have completed the focused health history, remember to document any pertinent findings.
Focused versus Comprehensive History
Deciding which type of health history to do depends on two factors: your patient’s condition and the amount of time you have.
Patient’s Condition:
First, determine the condition of your patient. This condition may prohibit a detailed health history upon admission.
For example, if you are working in the emergency department and Mr. Rahim, a 49-year-old man, presents with acute chest pain, a comprehensive health history is not indicated. Instead, you should obtain a focused history while you perform a physical assessment, draw
laboratory studies, obtain an electrocardiogram, and connect your patient to a cardiac monitor. When a patient is in acute distress, trying to obtain a complete health history
not only is detrimental but also provides little valuable or accurate information. So, ask key questions that focus on the acute problem; once your patient’s condition stabilizes, obtain a more detailed health history.
Amount of Time:
Allot at least 30 minutes to an hour to obtain a complete health history. Be sure to let your patient know why you are asking these questions and that it will take time. If you do not have enough time to complete the history, do not rush. Instead, perform a focused history first, and then complete the history at later sessions.
FORUM:
· Suppose you were caring for Mr. Rahim. What questions would you ask him to assess his chest pain?
· What question(s) would you ask Mr. Rahim related to his past health history, family history, review of systems, and psychosocial profile?
Medical History versus Nursing History
The areas addressed and the questions asked during a medical health history are very similar to those in a nursing health history. However, some important differences exist. These differences are defined by the focus and scope of medical versus nursing practice. Although the history questions are similar, the underlying rationale differs. Remember: Physicians diagnose and treat illness. Nurses diagnose and treat the patient’s response to a health problem.
For example, Janushree, an 81-year-old woman, is admitted to the hospital with a fractured right hip. The focus of the medical history would be to identify what caused the fracture in order to determine the extent of injury. The history would also try to identify any pre-existing medical problems that might make her a poor surgical risk. The physician will use the data that he or she obtains to develop a treatment plan for the fracture.
Although the nursing health history also focuses on the cause of the injury, the purpose is to determine Mary Johnson’s response to the injury, or what effect it has on her. You will look at much more than the fractured hip. You will consider how the injury affects every aspect of her health and life. Your history will provide clues about the impact of the injury on her ability to perform her everyday activities and help you identify strengths she has that can be incorporated into her plan of care. You will also identify supports and begin your discharge plan. Then you will use the data to develop a care plan with Mary Johnson that includes not only her perioperative phase but also her discharge rehabilitative planning.
Setting the Scene
Before you begin your assessment, look at your surroundings. Do you have a quiet environment that is free of interruptions? A private room is preferred, but if one is
not available, provide privacy by using curtains or screens. Prevent interruptions and distractions so that both you and your patient can stay focused on the history. Make sure that the patient is comfortable and that the room is warm and well lit. If the patient uses assistant
devices, such as glasses or a hearing aid, be sure that she or he uses them during the assessment to avoid any misperceptions.
Before you begin asking questions, tell your patient what you will be doing and why. Inform him or her if you will be taking notes, and reassure the patient that what he or she says will be confidential. However, avoid excessive note taking—it sends the message to your patient that the health history form is more important than he or she is. Also, if you are too preoccupied with writing and continually break eye contact, you may miss valuable nonverbal messages. Excessive note taking may also inhibit your patient’s responses, especially when discussing personal and sensitive issues such as sexuality or drug or alcohol use.
Be sure to work at the same level as your patient. Sit across or next to her or him. Avoid anything that may break the flow of the interview. If the interview is being recorded or videotaped, be sure to get your patient’s permission before starting. Position the equipment as unobtrusively as possible so that it does not distract you or your patient.
Your approach to your patient depends on his or her cultural background, age, and developmental level.
FORUM:
· Ask yourself, “Are there any cultural considerations that might influence our interaction with patient?”
· “What approach is best, considering my patient’s age?”
Let COMPARE the following TWO video clip (VIDEO 1 & VIDEO 2) of Nurse-patient Interview:
Video:1
Video: 2
Nurse-Patient Interview
Reflection questions:
1. Describe your observations of the interview as seen in the above video.
2. What will you do differently to improve the nurse -patient interview?
3. Name one lesson learned that you will apply in patient care?
QUIZ:
The nurse will obtain a health history of a patient who is admitted to a care unit. Which patient condition will require the nurse to consider secondary source of data?
- patient is currently confused
- patient is alert but mute
- patient's partner offers to provide information
Components of the Health History
A complete health history addresses health and illness patterns, health promotion and protective patterns, and roles and relationships. The parts of the health history that focus on health and illness patterns include the biographical data, reason for seeking healthcare, current health status, past health history, family history, and review of systems. You identify not only current health problems but also past health problems and any familial factors that place your patient at risk for health problems. Your patient’s health promotion activities, protective patterns, and role and relationship patterns are assessed through the psychosocial component of the health history. Here, you assess for risk factors that pose a threat to your patient’s health in every aspect of her or his life. Also, you need to consider your patient’s cultural and developmental status as it affects her or his health status. Here are the components in nursing health history:
- Biographical data:
The biographical data provide you with direct information related to a current health problem, alert you to risk factors for health problems, and point out the need for referrals. Your patient’s ability to provide biographical data accurately reflects his or her mental status.
Biographical data include the patient’s name, address, phone number, contact person, age/birth date, place of birth, gender, race, religion, marital status, educational level, occupation, and social security number/ health insurance. They also include the person who provided the history and her or his reliability as well as the person who referred the patient. Information on advance directives may also be obtained for hospital admissions. Also note any special considerations, such as the use of an interpreter.
II. Reason for Seeking Healthcare
Ask your patient why he or she is seeking healthcare; then document his or her direct quote. The patient’s reason for seeking care is usually related to the level of preventive healthcare —primary, secondary, or tertiary. If the setting is a primary level of healthcare, there is usually no acute problem. The reason generally relates to health maintenance or promotion. For example, the patient states, “I am here for my annual physical examination.”
If there is an acute problem, ask the patient to state what the problem is and how long it has been going on. For example, “I have had chest pain for the last hour.” If your patient identifies more than one problem, she or he may be confusing associated symptoms with the primary problem. Help her or him clarify and prioritize the problems by asking questions such as, “Which problems are giving you the most difficulty?”
Usually, patients identify problems that affect their ability to do what they usually do. In an acute-care setting, the reason for seeking care is called the chief complaint. The chief complaint gives you the patient’s perspective on the problem, a view of the problem through his or her eyes.
At the tertiary level, the problem may be well defined, a chronic problem, or an acute problem that is resolving. In this case, the problem does not have the acuity or life-threatening urgency of an acute problem.
- Description of Current Health Status / Present Health History
Assess her or his current health status. At a primary level of healthcare (no acute problem), the current health status should include the following:
· Usual state of health.
· Any major health problems.
· Usual patterns of healthcare.
· Any health concerns.
For example: Patient is Mary, age 42, married, mother of three, full-time teacher. Usual state of health good. Has yearly physical with pelvic examination and dental examination. Last eye examination 1 year ago. Expresses concern regarding family history of hypertension and ovarian cancer.
Patients in secondary or tertiary healthcare settings have an existing problem. So, you will need to perform a symptom analysis to assess your patient’s presenting symptoms thoroughly. Although many questions come to mind, your patient’s condition and time constraints may preclude you from going into too much detail. If so, you’ll need to zero in on several key areas to evaluate your patient’s symptoms. As you perform the symptom analysis, try to determine how disabling this problem is for your patient. Also ask if he or she has any medical problems related to the current problems and if he or she is taking any medications for this current problem.
The helpful mnemonic PQRST provides key questions that will give you a good overview of any symptom. Although you can ask additional questions, the following ones provide a thorough analysis of any presenting symptom:
P- Precipitating/Palliative Factors
Ask:
What were you doing when the problem started?
Does anything make it better, such as medications or certain positions?
Does anything make it worse, such as movement or breathing?
Q- Quality/Quantity
Ask:
Can you describe the symptom?
What does it feel like, look like, or sound like?
How often are you experiencing it?
To what degree does this problem affect your ability to perform your usual daily activities?
R- Region/Radiation/Related Symptoms
Ask:
Can you point to where the problem is?
Does it occur or spread anywhere else? (Take care not to lead your patient.)
Do you have any other symptoms? (Depending on the chief complaint, ask about related
symptoms. For example, if the patient has chest pain, ask if she or he has breathing problems or nausea.)
S- Severity
Ask:
Is the symptom mild, moderate, or severe?
Grade it on a pain scale of 0 to 10, with 0 being no symptom and 10 being the most severe. (Grading on a scale helps objectify the symptom.)
T- Timing
Ask:
When did the symptom start?
How often does it occur?
How long does it last?
IV. Past health history
The past health history assesses childhood illnesses, hospitalizations, surgeries, serious injuries, adult medical problems (including serious or chronic illnesses), immunizations, allergies, medications, recent travel, and military service. The purpose is to identify any health factors from the past that may have a direct relationship to your patient’s current health status. For example, a history of rheumatic fever as a child may explain mitral valve disease as an adult.
The past health history also identifies any chronic pre-existing health problems, such as diabetes or hypertension, which may directly affect the current health problem. For example, patients with diabetes often have poor wound healing. Also, even though the chronic disease
may be well controlled, the current health problem may cause an exacerbation. For instance, a patient with well-controlled diabetes may need to adjust his or her medication when scheduled for surgery, because the stress of surgery can elevate blood glucose. In addition, the past health history can identify additional health risks caused by pre-existing conditions.
The past health history may also explain your patient’s response to illness, healthcare, and healthcare workers. If she or he has a history of multiple medical problems requiring frequent hospitalizations, these experiences may affect her or his perception of healthcare either positively or negatively.
When obtaining the past health history, be sure to ask for dates, physicians’ names, names of hospitals, and reasons for hospitalizations or surgeries. This information is important if past records are needed. Also avoid using terms such as “usual,” general,” or “routine.” For example, “usual” childhood illnesses vary depending on the age of your patient and available immunizations.
V. Family History
The family history provides clues to genetically linked or familial diseases that may be risk factors for your patient. Ask about the health status and ages of your patient’s family members. Family members include the patient, spouse, children, parents, siblings, aunts and uncles, and grandparents. Ask about genetically linked or common diseases, such as heart disease, high blood pressure, stroke, diabetes, cancer, obesity, bleeding disorders, tuberculosis, renal disease, seizures, or mental disease. If the patient’s family members are deceased, record the age and cause of death.
The family history may be recorded in one of two ways. You can list family members along with their age and health status, or you can use a genogram (family tree). A genogram allows you to identify familial risk factors at a glance. When developing a genogram, use symbols to represent family members, and include a key to explain the symbols and abbreviations.
FORUM:
· After studying the boxed family history on page 35, what familial health risks would you identify for this patient?
VI. Review of Systems
The review of systems (ROS) is a litany of questions specific to each body system. The questions are usually about the most frequently occurring symptoms related to a specific system. The ROS is used to obtain the current and past health status of each system and to identify health problems that your patient may have failed to mention previously. Remember, if your patient has an acute problem in one area, every other body system will be affected, so look for correlations as you proceed with the ROS. Then perform a symptom analysis for every positive finding and determine the effect of, and the patient’s response to, this symptom. The ROS also provides clues to health promotion activities for each particular system. Identify health promotion activities and provide instruction as needed.
VII. Psychosocial Profile
The psychosocial profile is the last section of the health history. This section focuses on health promotion, protective patterns, and roles and relationships. It includes questions
about healthcare practices and beliefs, a description of a typical day, a nutritional assessment, activity and exercise patterns, recreational activities, sleep/rest patterns, personal habits, occupational risks, environmental risks, family roles and relationships and stress and coping mechanisms.
In a primary healthcare setting, the psychosocial assessment enables you to identify how your patient incorporates health practices into every aspect of her or his life. You can then teach and reinforce health promotion activities that your patient can incorporate into her or his everyday life. If she or he has an acute problem, the psychosocial assessment helps you determine the impact of this illness on every facet of the patient’s life and assists you in determining discharge planning needs. For your plan of care to be successful, the patient must be able to follow through with it after discharge. Help ensure success by identifying clues as you perform the assessment and then making appropriate referrals.
- Developmental considerations
A person’s development crosses the life span. Developmental assessments are often performed on children because the developmental changes that occur at this age are very observable and measurable. Yet adults also go through developmental changes that you need to consider during the assessment. Illness and hospitalization can have a major impact on a child’s growth and development, by either halting its progression or regressing it to an earlier stage.
For example, when Johnny, age 4, is admitted to the hospital for a hernia repair, he begins
wetting the bed during the night, even though his mother assures you that he has been “potty trained” since age 3.
Documenting Your Findings
Once you have completed the health history, summarize pertinent findings and share them with your patient to confirm their accuracy. Then document your findings and begin to formulate a plan of care.
Documentation of history findings varies from one healthcare facility to another. Many acute-care facilities use computerized programs that enable you to enter the history directly into the computer. Standardized nursing admission assessment forms that combine both history and physical assessments are also commonly used.
Regardless of the system, here are some helpful hints for documenting a health history:
· Be accurate and objective. Avoid stating opinions that
· might bias the reader.
· Do not write in complete sentences. Be brief and to
· the point.
· Use standard medical abbreviations.
· Don’t use the word “normal.” It leaves too much room
· for interpretation.
· Record pertinent negatives.
· Be sure to date and sign your documentation.
For further understanding, let watch the following Video clip on “Charting for Nurses | How to Understand a Patient's Chart as a Nursing Student or New Nurse”:
QUIZ:
1. The nurse is completing documentation via the DAR notes. What does each initial of DAR stand for?
A. A is for all nursing actions
B. A is for assessment findings
C. R is for the nurse’s reaction to the assessment findings
D. R is for patient’s response to nursing interventions
D is for deficient knowledge2. The nurse is using the documentation style whereby only abnormal findings are documented. What is this style of documentation called?
A. Discharge teaching note.
B. Narrative note.
C. SOAPIE note.
D. By exemption note
Summary:
The health history provides the subjective database for your patient’s assessment. It is usually your first major interaction with your patient and often provides the foundation of your nurse-patient relationship.
Here I would like to end this topic with a Video clip “Master clinical history taking (with patient example)”:
TOPIC 8: Physical Assessment I
Introduction:
Physical assessment provides another perspective. Whereas the health history allows you to see your patient subjectively through hers or his eyes, the physical examination now allows you to see your patient objectively through your senses. The objective data complete the patient’s health picture. You will need all of the skills of assessment—cognitive, psychomotor, interpersonal, affective, and ethical/legal—to perform an accurate, thorough physical assessment. You also need to know normal findings before you can begin to distinguish abnormal ones. The best way to perfect your physical assessment skills is through practice.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Discuss purpose of physical assessment.
- Differentiate complete from focused physical assessment.
- Identify tools used during the physical examination.
- Demonstrate physical assessment techniques.
Purpose of the Physical Assessment
Like the health history, the goal of physical assessment is not only to identify actual or potential health problems but also to discover your patient’s strengths. Data from the physical assessment can be used to validate the health history. For example, you can use the physical examination to assess clues you obtained from the history. Combined with the history data, your physical assessment findings are essential in formulating nursing diagnoses and developing a plan of care for your patient.
Types of Physical Assessment Components
Also like the health history, physical assessment may be either complete or focused. A complete physical assessment includes a general survey; vital sign measurements; assessment of height and weight; and physical examination of all structures, organs, and body systems. Perform it when you are examining a patient for the first time and need to establish a baseline.
On the other hand, a focused physical assessment zero in on the acute problem. You assess only the parts of the body that relate to that problem. It is usually performed when your patient’s condition is unstable, as a follow-up to a complete assessment, or when you are pressed for time.
Complete Physical Assessment
The complete physical examination begins with a general survey. A general survey includes your initial observations of the patient’s general appearance and behaviour, vital signs, and anthropometric measurements. Vital signs include temperature, pulse, respirations, blood pressure, and pulse oximetry, if available. Anthropometric measurements include height and weight.
Next, perform a head-to-toe systematic physical assessment. As you proceed from one area to another, remember that all systems are related, so a problem in one area eventually will affect or be affected by every other system. Therefore, look for the relationships between the systems as you proceed. For example, a skin lesion or a sore that is not healing may be the first sign of an underlying vascular problem or endocrine problem such as diabetes.
This assessment can be performed at any level of healthcare prevention—primary, secondary, or tertiary. In a primary setting, a complete physical examination is often performed to establish or monitor health status. For example, it may be required for school, camp, or a job. In an acute-care setting, a complete physical examination is often performed shortly after admission to establish a baseline and detect any other actual or potential problems. In a long-term–care setting, a complete physical examination is also helpful in establishing a baseline from which the patient’s condition can then be monitored and evaluated.
Because a complete physical assessment takes from 30 minutes to an hour, save time by asking some of the history questions (especially the review of systems) as you perform parts of the physical examination. Perform the assessment as soon as possible because the findings help to establish a baseline.
Focused Physical Assessment
The focused physical assessment consists of a general survey, vital sign measurements, and assessment of the specific area or system of concern. It also includes a quick head-to-toe scan of the patient, checking for changes in every system as they relate to the problem at hand. This scan may reveal associated problems and help you determine the severity of the problem. For example, if your patient is having breathing problems, do not limit your focused assessment to the respiratory system alone, because detecting confusion or cyanotic skin color changes may reflect severe hypoxia. The extent of the head-to-toe and focused examinations will depend on your patient’s condition and your findings.
A focused physical examination is indicated when your patient’s condition is unstable, when time constraints exist, or for episodic follow-up visits. In the last case, you have already performed a complete physical examination, and so now you perform focused physical assessments to monitor or evaluate your patient’s health status.
Focused physical assessments also can be performed at any level of healthcare prevention. In a primary setting, they may be used to monitor your patient’s health status, for example, performing a breast examination and teaching breast self-examination. In a secondary setting, after you have performed the initial physical assessment, focused assessments are often used to monitor and evaluate your patient’s health problem. For example, you might take vital signs and then auscultate the lungs of a patient who was admitted with pneumonia. In a long-term–care setting, a focused assessment is often used to monitor and evaluate your patient’s progress. For instance, if your patient is recovering from a total hip replacement, you will probably assess his or her musculoskeletal system, including gait, muscle strength, and prescribed range of motion (ROM) of joints.
Tools of Physical Assessment
The most important tools that you have for physical assessment are your senses. You will use your eyes to inspect, looking for both physical changes and nonverbal clues from your patient. You will use your ears to listen, hearing both sounds produced by various body structures and also what your patient is saying. You will use your nose to detect any unusual odors that may indicate an underlying problem.
You will use your hands to feel for physical changes and also to convey a sense of caring to your patient. You will also use a variety of equipment to perform the physical assessment and enhance your assessment abilities. As with any equipment, assessment equipment, especially equipment that is used for measurement, needs to be periodically checked and calibrated for accuracy.
Techniques of Physical Assessment
The four techniques of physical assessment are inspection, palpation, percussion, and auscultation. They are performed in this order, with the exception of the abdominal assessment. In this case, auscultation precedes palpation and percussion so as not to alter the bowel sounds.
Inspection
Inspection is the most frequently used assessment technique, but its value is often overlooked. With inspection, you use not only your sense of sight but also your senses of hearing and smell to inspect your patient critically. Do not rush the process; take your time and really look at your patient. Perform inspection at every encounter with your patient.
Inspection
Palpation
During palpation, you are using your sense of touch to collect data. Palpation is used to assess every system. It usually follows inspection, but both techniques are often performed simultaneously. Palpation allows you to assess surface characteristics, such as texture, consistency, and temperature, and allows you to assess for masses, organs, pulsations, muscle rigidity, and chest excursion. It also lets you differentiate areas of tenderness from areas of pain.
Types of Palpation
Two types of palpation may be performed—light and deep. Always begin with light palpation, if for no other reason than to put your patient at ease and convey a message of caring. Light palpation is applying very gentle pressure with the tips and pads of your fingers to a body area and then gently moving them over the area, pressing about 1⁄2 inch. Light palpation is best for assessing surface characteristics, such as temperature, texture, mobility, shape, and size. It is also useful in assessing pulses, areas of edema, and areas of tenderness. Closing your eyes while palpating may help you concentrate better on what you are feeling.
Deep palpation is applying harder pressure with your fingertips or pads over an area to a depth greater than 1⁄2 inch. Deep palpation can be single-handed or bimanual. When using the bimanual technique, feel with your dominant hand. You can place your other hand on top to help control your movements or to stabilize an organ with one hand while you palpate it with the other.
Palpating temperature changes with dorsal part of hand.
Palpating vibratory sensations and tactile fremitus with balls of hands.
Palpating with fingertips to assess pulsations.
Deep palpation, single hand.
Deep palpation, bimanual.
Palpating hands using patient’s hands.
Percussion
Percussion is used to assess density of underlying structures, areas of tenderness, and deep tendon reflexes (DTRs). It entails striking a body surface with quick, light blows and eliciting vibrations and sounds. The sound determines the density of the underlying tissue and whether it is solid tissue or filled with air or fluid. By determining the density, you can also “outline” the underlying structure, allowing you to determine the size and shape of the underlying structure.
Two factors influence the sound produced during percussion—the thickness of the surface being percussed and your technique. The more tissue you have to percuss through, the duller the sound. Percussion is a skill that usually requires practice to perfect. You also need to develop skill at identifying and differentiating the percussion sounds.
Direct percussion
Indirect percussion
Percussing for costovertebral angle tenderness.
Using a percussion hammer.
Auscultation
Auscultation involves using your sense of hearing to collect data. You will listen to sounds produced by the body, such as heart sounds, lung sounds, bowel sounds, and vascular
sounds. Auscultation can be both direct and indirect. Direct auscultation is listening for sounds without a stethoscope, but only a few sounds can be heard this way. Two examples are respiratory congestion in a patient who requires suctioning and the loud audible murmur of mitral valve replacement. For most of the sounds produced by the body, you will need to perform indirect auscultation with a stethoscope. Your ability to hear is affected by the quality of the stethoscope. The stethoscope should have the ability to detect both high- and low-pitched sounds.
Auscultation is also a skill that requires practice. You need to know what constitutes normal sounds before you can begin to identify abnormal sounds. Listen for the characteristics
of sound—the pitch, intensity, duration, and quality. Pitch may be high, medium, or low. Ask yourself, “Which part of the stethoscope was I using when I heard the sound best?” Intensity can range from soft to loud or can be graded on a scale. Ask yourself, “Could I hear the sound easily, or did I have to listen closely?” Duration may be short or long. Ask yourself, “How long was the sound?” Quality describes the sound. Ask yourself, “What did it sound like? Was it harsh, blowing, etc.?”
Listening with diaphragm of stethoscope.
Listening with bell of stethoscope.
You can watch the video clip on the FOUR techniques of physical assessment: "Inspection Palpation Percussion Auscultation for Nursing"
During the examination, you will use all four techniques of physical assessment: inspection, palpation, percussion, and auscultation. If your patient has identified an area of concern, begin there; otherwise, proceed from head to toe. Usually, the more private areas of the examination, such as the pelvic and rectal examination, are performed last. Do not rush. Pay attention to your patient’s responses, both verbal and nonverbal, and respond accordingly. For example, if you see that your patient is tiring, you may need to provide a short rest period. If you have identified any health teaching needs, the physical examination is an ideal opportunity for health teaching.
TOPIC 9: Physical Assessment II
Introduction:
Positioning and effective communication skills are essential to establishing the trust needed to proceed with the examination. You need to remember your ethical and professional responsibility to your patient in respecting his or her right to privacy and confidentiality.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
1. Describes the positions needed for physical assessment
2. Define components of physical assessment
Positions for Physical Assessment
In order to perform a thorough physical assessment, you must ask the patient to assume various positions. Several positions are frequently required during the physical assessment. It is important to consider the client’s ability to assume a position. The client’s physical condition, energy level, and age should also be taken into consideration. Some positions are embarrassing and uncomfortable and therefore should not be maintained for long. The assessment is organized so that several body areas can be assessed in one position, thus minimizing the number of position changes needed. The table Examination Positions describes the positions needed to assess each area.
Components of the Physical Assessment
Before you focus on a particular system or area, perform a general survey and measure vital signs, height, and weight. During the health history, you performed a review of systems
to detect possible problems in other systems. This provided you with a subjective look at the relationship of these systems. Now take an objective look at each system as it affects each other before you focus on a specific system or area.
General Survey
Always begin the physical assessment with the general survey. This “first impression” of your patient begins as soon as you meet him or her. Use your senses and your observational skills to look, listen, and take note of any unusual odors. First, look for the obvious: apparent age, gender, and race. Then look closer for clues that might signal a problem. Also consider your patient’s developmental stage and cultural background; these may influence your findings and interpretation. Make a mental note of any clues detected on the general survey that you may need to follow up during the physical examination. When looking for clues, watch for signs of distress and check facial characteristics, body size and type, posture, movements, speech, grooming, dress, and hygiene.
Signs of Distress
Ask yourself, “Are there any obvious signs of distress (e.g., breathing problems)?” If signs of acute distress are apparent, do a focused physical assessment and address the acute problem.
FORUM: What other signs would indicate acute distress?
Facial Characteristics
Ask yourself, “What is the patient’s face telling me?” Do you see pain, fear, or anxiety? Does the patient maintain eye contact? Is her or his facial expression happy or sad? Facial expression may signal an underlying problem, such as masklike expression in Parkinson’s disease. Look at the patient’s facial features. Are they symmetrical? Ptosis of the eyelid may indicate a neurological problem; drooping on one side of the face may indicate a transient ischemic attack (TIA) or stroke; and exophthalmos suggests hyperthyroidism. Also look at the condition of your patient’s skin. It may reflect your patient’s age, but excessive wrinkling
from excessive sun exposure or illness may make the patient appear older than her or his stated age.
Body Type, Posture, and Gait
View your patient’s body size and build with respect to his or her age and gender. Is he or she stocky, slender, or of average build? Obese or cachectic? Proportional? Does your patient have abnormal fat distribution, such as the truncal obesity and buffalo hump seen with Cushing’s syndrome? Greet your patient with a handshake. The handshake will convey that you care but also allow you to assess muscle strength, hydration, skin temperature, and texture. Then take a close look at your patient’s hands. Do you see clubbing, edema, or deformities? Clubbing and edema may reflect a cardiopulmonary problem; deformities may reflect arthritic changes.
Watch how your patient enters the room. Are her or his movements smooth and coordinated, or does she or he have an obvious gait problem? Does she or he walk with an assistive device such as a cane or walker? Do you see a wide base of support with short stride length? Gait problems may suggest a musculoskeletal or neurological problem. Spastic movements or unsteady gaits may be seen in patients with cerebral palsy or multiple sclerosis. A shuffling gait is seen with Parkinson’s disease. Patients with a wide base of support and short stride length may have a balance or cerebellar problem.
If your patient is bedridden, observe his or her ability to move from side to side, sit up in bed, and change positions. Determine how much assistance he or she needs with moving. Any problem detected during the general survey should be further evaluated during the physical examination.
The patient’s posture may also reveal clues about her or his overall health status. Is she or he sitting upright or slumped? Can she or he assume a supine position? Is there a position that she or he prefers? A slumped position may indicate fatigue or depression. Patients with cardiopulmonary disease often cannot assume a supine position. They prefer a sitting or tripod position because it eases breathing. Patients with abdominal pain also may find it difficult to assume a supine position. Sitting hunched over or in a side-lying position with legs flexed often eases the pain.
Speech
Listen to your patient’s speech pattern and pace. Speech reflects the mental state, thought process, and affect. Are your patient’s responses appropriate? Speech patterns and appropriateness of responses reflect his or her thought process. Pressured speech, inappropriate responses, and illogical or incoherent speech may be associated with psychiatric disorders. Pressured, hurried speech may also be seen in patients with hyperthyroidism. Note the tone and quality of his or her voice. Do you hear anger? Sadness?
Changes in voice quality may indicate a neurological problem, specifically, a problem with cranial nerve (CN) IX (glossopharyngeal) or CN X (vagus). Notice whether his or her speech is clear or garbled.Aphasia can be expressive (motor/Broca’s), receptive (sensory/Wernicke’s), or global, a combination of these. Aphasia of any type is often associated with a TIA or stroke.
The patient’s vocabulary and sentence structure offer clues to her or his educational level, which you will need to consider when developing teaching plans. Also, be alert for foreign accents. You need to determine if there is a language barrier and solicit an interpreter, if needed.
Dress, Grooming, and Hygiene
The way your patient is dressed and groomed tells a great deal about his or her physical and psychological wellbeing. Is he or she neatly dressed and well-groomed or is he or she untidy? Disinterest in appearance may reflect depression or low self-esteem. Poor hygiene and a untidy appearance may also reflect the patient’s inability to care for himself or herself.
Also take note of the appropriateness of dress for the season and situation. Inappropriate dress may be a sign of hyperthyroidism, which causes heat intolerance. Worn clothing may indicate financial problems. Be sure to take note of any unusual odors, such as alcohol or urine, that may indicate a problem and warrant further investigation.
Mental State
Determine if your patient is awake, alert, and oriented to time, place, and person. Are her or his responses appropriate? Bizarre responses suggest a psychiatric problem. Is your patient lethargic? Many conditions can affect the level of consciousness. Determine if this is a change in your patient’s mental status. If so, investigate further. Also take note of your patient’s medications, because they may be contributing to the change in mental status.
Cultural Considerations
Note any cultural influences that may affect your patient’s physical characteristics, response to pain, dress, grooming, and hygiene. Patterns of verbal and nonverbal communication may also be culturally influenced. Keeping these factors in mind will help you avoid making hasty, inaccurate interpretations. Here are a few examples of cultural differences:
■ Asian Americans are often shorter than Westerners.
■ European Americans and African Americans tend to speak loudly, whereas Chinese Americans speak softly.
■ Asians may avoid eye contact with anyone considered a superior.
■ Japanese and Korean individuals maintain a tense posture to convey confidence and competence, whereas Americans assume a relaxed posture to convey the same message.
Developmental Considerations
Consider the developmental stage of your patient. Here are some points to keep in mind when performing the general survey:
Children
■ Behavior should correspond with the child’s developmental level.
■ Children tend to regress when ill.
■ Take note of the relationship between child and parent.
Pregnant Patients
■ General appearance should reflect gestational age.
■ Look for normal changes that occur with pregnancy, such as wide base of support and lordosis.
■ Look for swelling.
■ Note patient’s affect and response to pregnancy.
Older Adults
■ Look for normal changes that occur with aging.
■ Look for clues of decreasing ability to function, especially dress and grooming problems.
■ Pay attention to your patient’s affect, especially signs of depression.
■ Note changes in mental status such as confusion, and then consider medications, hydration, and nutritional status or an underlying infection as a possible cause.
Documenting the General Survey
Documentation of the general survey records your first overall impression of your patient. It should include age (actual and apparent), gender, race, level of consciousness, dress, posture, speech, affect, and any obvious abnormalities or signs of distress. Here is an example of documentation:
Mr. Bato, 56-year-old Malaysian-Indian male, looks younger than stated age; alert and oriented to time, place, and person. Neatly dressed, well groomed. Well-developed physic. Speech clear, responds appropriately, affect pleasant. No signs of acute distress.
The following is the Step in Assessing Appearance and Mental Status of a patient:
For better understanding, you may watch the video clip on “General Survey and Vital Signs"
Video:
Vital Signs
Vital signs include measurements of temperature, pulse, respirations, and blood pressure. They are the most frequent assessments performed, reflecting cardiopulmonary function and the overall functioning of the body.
The purpose of taking vital signs is to:
■ Establish a baseline.
■ Monitor the patient’s condition.
■ Evaluate the patient’s response to treatments.
■ Identify problems.
Documenting Vital Signs
Vital signs are often documented on graphic charts, which allow you to monitor or plot the patterns of the vital signs. This is very helpful in evaluating the effectiveness of treatment. Vital signs may also be documented in narrative form. For example: T 36.8° C; P 88 bpm, regular; R 16 per min, unlaboured, regular and deep; BP 120/80mmHg, lying,118/80mmHg, sitting, and 118/80mmHg standing.
Height and Weight
Anthropometric measurements provide valuable data about your patient’s growth and development, nutritional status, and overall general health. Be sure to document the measurements in centimetres or inches, kilograms or pounds. Because children have frequent changes in growth and development, their measurements are often documented on growth charts for easy monitoring.
Head-to-Toe Scan
Whether you are doing a complete or a focused physical assessment, remember that all body systems are interrelated. A problem in one system will eventually affect or be affected by every other system. When performing a complete physical assessment, perform a thorough assessment of each system, looking for relationships. When you perform a focused physical assessment, an in-depth assessment of one system begin by scanning the other systems, looking for changes as they relate to the system being assessed.
For example, suppose you were performing a focused assessment of the cardiovascular system. Here are some of the affects you should look for:
■ Integumentary: Look for color changes, pallor, edema, and changes in skin and hair texture and growth. Patients with cardiovascular problems may have edema and thin, shiny, hairless skin.
■ Head, eyes, ears, nose, and throat (HEENT): Look for periorbital edema. Funduscopic examination may
reveal vascular changes.
■ Respiratory: Look for cyanosis and breathing difficulty. Auscultate for adventitious sounds such as crackles
that are associated with congestive heart failure (CHF).
■ Breast: Assess for male breast enlargement that may occur with cardiac medications such as digoxin.
■ Abdominal: Assess for ascites and hepatomegaly, which may be associated with CHF.
■ Musculoskeletal: Assess for muscle weakness and atrophy associated with disuse.
■ Neurological: Assess level of consciousness. Confusion, fatigue, and lethargy may be associated with decreased CO and hypoxia.
Documenting Your Physical Assessment Findings
Once you have completed the physical assessment, document your findings. Because writing should be kept to a minimum during the examination, document your findings as soon as possible, while they are foremost in your mind. Document accurately, objectively, and concisely. Avoid general terms such as “normal. “Record your findings system by system, being sure to chart pertinent negative findings. Once you have completed your objective database, combine it with your subjective database, cluster your data, identify pertinent nursing diagnoses, and develop a plan of care for your patient.
TOPIC 10: Systems Physical Assessment I
Introduction:
The integumentary system, consisting of the skin, hair, and nails, is the largest organ of the body and the easiest of all systems to assess. The skin, hair, and nails provide clues about general health, reflect changes in environment, and signal internal ailments stemming from other organs. Therefore, a thorough assessment of this system may help you detect actual or potential problems, not only in the skin but also in underlying systems.
The head, face, and neck form a large portion of what is often referred to as the skull, face, eyes, ears, nose, sinuses, mouth, and pharynx. These components are complex in their actions and are involved in expression, communication, nourishment, respiration, and sensation, among other functions.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Demonstrate an integumentary physical assessment.
- Document integumentary findings.
- Demonstrate a physical assessment of the skull, face, eyes, ears, nose, sinuses, mouth, and pharynx.
- Document skull, face, eyes, ears, nose, sinuses, mouth, and pharynx findings.
Structures and Functions of the Integumentary System
The structures of the integumentary system are the skin, hair, nails, sweat glands, and sebaceous glands. Their functions are described in the following table.
Performing an Integumentary Physical Assessment
Skin
Assessment of the skin involves inspection and palpation. The entire skin surface may be assessed at one time or as each aspect of the body is assessed. In some instances, the nurse may also use the olfactory sense to detect unusual skin odors; these are usually most evident in the skinfolds or in the axillae. Pungent body odor is frequently related to poor hygiene, hyperhidrosis (excessive perspiration), or bromhidrosis (foul-smelling perspiration).
Pallor is the result of inadequate circulating blood or haemoglobin and subsequent reduction in tissue oxygenation. In clients with dark skin, it is usually characterized by the absence of underlying red tones in the skin and may be most readily seen in the buccal mucosa. In brown-skinned clients, pallor may appear as a yellowish-brown tinge; in black-skinned clients, the skin may appear ashen gray. Pallor in all people is usually most evident in areas with the least pigmentation such as the conjunctiva, oral mucous membranes, nail beds, palms of the hand, and soles of the feet.Cyanosis (a bluish tinge) is most evident in the nail beds, lips, and buccal mucosa. In dark-skinned clients, close inspection of the palpebral conjunctiva (the lining of the eyelids) and palms and soles may also show evidence of cyanosis. Jaundice (a yellowish tinge) may first be evident in the sclera of the eyes and then in the mucous membranes and the skin. Nurses should take care not to confuse jaundice with the normal yellow pigmentation in the sclera of a dark-skinned client. If jaundice is suspected, the posterior part of the hard palate should also be inspected for a yellowish color tone. Erythema is skin redness associated with a variety of rashes and other conditions.
Localized areas of hyperpigmentation (increased pigmentation) and hypopigmentation (decreased pigmentation) may occur as a result of changes in the distribution of melanin (the dark pigment) or in the function of the melanocytes in the epidermis. An example of hyperpigmentation in a defined area is a birthmark; an example of hypopigmentation is vitiligo. Vitiligo, seen as patches of hypopigmented skin, is caused by the destruction of melanocytes in the area. Albinism is the complete or partial lack of melanin in the skin, hair, and eyes. Other localized color changes may indicate a problem such as edema or a localized infection. Dark-skinned clients normally have areas of lighter pigmentation, such as the palms, lips, and nail beds.
Edema is the presence of excess interstitial fluid. An area of edema appears swollen, shiny, and taut and tends to blanch the skin color or, if accompanied by inflammation, may redden the skin. Generalized edema is most often an indication of impaired venous circulation and in some cases reflects cardiac dysfunction or venous abnormalities.
A skin lesion is an alteration in a client’s normal skin appearance. Primary skin lesions are those that appear initially in response to some change in the external or internal environment of the skin as in table below.
Secondary skin lesions are those that do not appear initially but result from modifications such as chronicity, trauma, or infection of the primary lesion. For example, a vesicle or blister (primary lesion) may rupture and cause an erosion (secondary lesion). Table below illustrates secondary lesions.
Nurses are responsible for describing skin lesions accurately in terms of location (e.g., face), distribution (i.e., body regions involved), and configuration (the arrangement or position of several lesions) as well as color, shape, size, firmness, texture, and characteristics of individual lesions. The following table describes how to assess the skin.
Hair
Assessing a client’s hair includes inspecting the hair, considering developmental changes and ethnic differences, and determining the individual’s hair care practices and factors influencing them. Much of the information about hair can be obtained by questioning the client.
Normal hair is resilient and evenly distributed. In people with severe protein deficiency (kwashiorkor), the hair color is faded and appears reddish or bleached, and the texture is coarse and dry. Some therapies cause alopecia (hair loss), and some disease conditions and medications affect the coarseness of hair. For example, hypothyroidism can cause very thin and brittle hair. The table below describes how to assess the hair.
Nails
Nails are inspected for nail plate shape, angle between the fingernail and the nail bed, nail texture, nail bed color, and the intactness of the tissues around the nails. The parts of the nail are shown in Figure below.
The nail plate is normally colorless and has a convex curve. The angle between the fingernail and the nail bed is normally 160 degrees. One nail abnormality is the spoon shape, in which the nail curves upward from the nail bed. This condition, called koilonychia, may be seen in clients with iron deficiency anemia. Clubbing is a condition in which the angle between the nail and the nail bed is 180 degrees, or greater. Clubbing may be caused by a long-term lack of oxygen.
Nail texture is normally smooth. Excessively thick nails can appear in older adults, in the presence of poor circulation, or in relation to a chronic fungal infection. Excessively thin nails or the presence of grooves or furrows can reflect prolonged iron deficiency anemia. Beau’s lines are horizontal depressions in the nail that can result from injury or severe illness. The nail bed is highly vascular, a characteristic that accounts for its color. A bluish or purplish tint to the nail bed may reflect cyanosis, and pallor may reflect poor arterial circulation. Should the client report a history of nail fungus (onychomycosis), a referral to a podiatrist or dermatologist for treatment of nail fungus may be appropriate. Symptoms of nail fungus includes brittleness, discoloration, thickening, distortion of nail shape, crumbling of the nail, and loosening (detaching) of the nail.
The tissue surrounding the nails is normally intact epidermis. Paronychia is an inflammation of the tissues surrounding a nail. The tissues appear inflamed and swollen, and tenderness is usually present.
A blanch test can be carried out to test the capillary refill, that is, peripheral circulation. Normal nail bed capillaries blanch when pressed, but quickly turn pink or their usual color when pressure is released. A slow rate of capillary refill may indicate circulatory problems.
The table below describes how to assess the nails.
Documentation
Skin is expected color for ethnicity without lesions or rashes. Skin is warm and dry with no
edema. Capillary refill is less than 3 seconds. Normal skin turgor with no tenting.
For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Skin”
Video:HEAD
During assessment of the head, the nurse inspects and palpates simultaneously and also auscultates. The nurse examines the skull, face, eyes, ears, nose, sinuses, mouth, and pharynx.
Structures of the Skull and Face
Skull and Face
There is a large range of normal shapes of skulls. A normal head size is referred to as normocephalic. If head size appears to be outside of the normal range, the circumference can be compared to standard size tables. Measurements more than two standard deviations from the norm for the age, sex, and race of the client are abnormal and should be reported to the primary care provider. Names of areas of the head are derived from names of the underlying bones: frontal, parietal, occipital, mastoid process, mandible, maxilla, and zygomatic. The following diagram shown the structure of skull and face.
Many disorders cause a change in facial shape or condition. Kidney or cardiac disease can cause edema of the eyelids. Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression. Hypothyroidism, or myxedema, can cause a dry, puffy face with dry skin and coarse features and thinning of scalp hair and eyebrows.
Increased adrenal hormone production or administration of steroids can cause a round face with reddened cheeks, referred to as moon face, and excessive hair growth on the upper lips, chin, and sideburn areas. Prolonged illness, starvation, and dehydration can result in sunken eyes, cheeks, and temples.
Performing The Skull and Face Physical Assessment
Table below describes how to assess the skull and face.
Documentation
Skull
§ Generally round, with prominences in the frontal and occipital area. (Normocephalic).
§ No tenderness noted upon palpation.Scalp
§ Lighter in color than the complexion.
§ Can be moist or oily.
§ No scars noted.
§ Free from lice, nits and dandruff.
§ No lesions should be noted.
§ No tenderness or masses on palpation.Hair
§ Can be black, brown or burgundy depending on the race.
§ Evenly distributed covers the whole scalp (No evidences of Alopecia)
§ Maybe thick or thin, coarse or smooth.
§ Neither brittle nor dry.Face
§ Shape maybe oval or rounded.
§ Face is symmetrical.
§ No involuntary muscle movements.
§ Can move facial muscles at will.
§ Intact cranial nerve V and VII.Structures of the Eyes
Eyes
Examination of the eyes includes assessment of the external structures, visual acuity (the degree of detail the eye can discern in an image), ocular movement, and visual fields (the area an individual can see when looking straight ahead). Most eye assessment procedures involve inspection. Consideration is also given to developmental changes and to individual hygienic practices, if the client wears contact lenses or has an artificial eye. For the anatomic structures of the eye, see the below diagram.
Many people wear eyeglasses or contact lenses to correct common refractive errors of the lens of the eye. These errors include myopia (nearsightedness), hyperopia (farsightedness), and presbyopia (loss of elasticity of the lens and thus loss of ability to see close objects). Presbyopia begins at about 45 years of age. People notice that they have difficulty reading newsprint. When both far and near vision require correction, two lenses (bifocals) are required. Astigmatism, an uneven curvature of the cornea that prevents horizontal and vertical rays from focusing on the retina, is a common problem that may occur in conjunction with myopia and hyperopia. Astigmatism may be corrected with glasses or surgery.
Common inflammatory visual problems that nurses may encounter in clients include conjunctivitis, dacryocystitis, hordeolum, iritis, and contusions or hematomas of the eyelids and surrounding structures. Conjunctivitis (inflammation of the bulbar and palpebral conjunctiva) may result from foreign bodies, chemicals, allergenic agents, bacteria, or viruses. Redness, itching, tearing, and mucopurulent discharge occurs. During sleep, the eyelids may become encrusted and matted together. Dacryocystitis (inflammation of the lacrimal sac) is manifested by tearing and a discharge from the nasolacrimal duct. Hordeolum (sty) is a redness, swelling, and tenderness of the hair follicle and glands that empty at the edge of the eyelids. Iritis (inflammation of the iris) may be caused by local or systemic infections and results in pain, tearing, and photophobia (sensitivity to light). Contusions or hematomas are “black eyes” resulting from injury.
Cataracts tend to occur in individuals over 65 years old although they may be present at any age. This opacity of the lens or its capsule, which blocks light rays, is frequently removed and replaced by a lens implant. Cataracts may also occur in infants due to a malformation of the lens if the mother contracted rubella in the first trimester of pregnancy. Glaucoma (a disturbance in the circulation of aqueous fluid, which causes an increase in intraocular pressure) is the most frequent cause of blindness in people over age 40 although it can occur at younger ages. It can be controlled if diagnosed early. Danger signs of glaucoma include blurred or foggy vision, loss of peripheral vision, difficulty focusing on close objects, difficulty adjusting to dark rooms, and seeing rainbow-colored rings around lights.
Upper eyelids that lie at or below the pupil margin are referred to as ptosis and are usually associated with aging, edema from drug allergy or systemic disease (e.g., kidney disease), congenital lid muscle dysfunction, neuromuscular disease (e.g., myasthenia gravis), and third cranial nerve impairment. Eversion, an outturning of the eyelid, is called ectropion; inversion, an inturning of the lid, is called entropion. These abnormalities are often associated with scarring injuries or the aging process.
Pupils are normally black, are equal in size (about 3 to 7 mm in diameter), and have round, smooth borders. Cloudy pupils are often indicative of cataracts. Mydriasis (enlarged pupils) may indicate injury or glaucoma, or result from certain drugs (e.g., atropine, cocaine, amphetamines). Miosis (constricted pupils) may indicate an inflammation of the iris or result from such drugs as morphine/heroin and other narcotics, barbiturates, or pilocarpine. It is also an age-related change in older adults. Anisocoria (unequal pupils) may result from a central nervous system disorder; however, slight variations may be normal. The iris is normally flat and round. A bulging toward the cornea can indicate increased intraocular pressure.
Performing Eyes Physical Assessment
The following table describes how to assess a client’s eye structures and visual acuity.
Documentation
Eyebrows
§ Symmetrical and in line with each other.
§ Maybe black, brown or blond depending on race.
§ Evenly distributed.Eyes
§ Evenly placed and in line with each other.
§ None protruding.
§ Equal palpebral fissure.Eyelashes
§ Color dependent on race.
§ Evenly distributed.
§ Turned outward.Eyelids
§ Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open.
§ No PTOSIS noted. (Drooping of upper eyelids).
§ Meets completely when eyes are closed.
§ Symmetrical.Lacrimal Apparatus
§ Lacrimal gland is normally non-palpable.
§ No tenderness on palpation.
§ No regurgitation from the nasolacrimal duct.Conjunctivae
§ Both conjunctivae are pinkish or red in color.
§ With presence of many minutes capillaries.
§ Moist
§ No ulcers
§ No foreign objectsSclerae
§ Sclerae is white in color (anicteric sclera)
§ No yellowish discoloration (icteric sclera).
§ Some capillaries maybe visible.
§ Some people may have pigmented positions.Cornea
§ There should be no irregularities on the surface.
§ Looks smooth.
§ The cornea is clear or transparent. The features of the iris should be fully visible through the cornea.
§ There is a positive corneal reflex.Anterior Chamber and Iris
§ The anterior chamber is transparent.
§ No noted any visible materials.
§ Color of the iris depends on the person’s race (black, blue, brown or green).
§ From the side view, the iris should appear flat and should not be bulging forward. There should be NO crescent shadow casted on the other side when illuminated from one side.Pupils
§ Pupillary size ranges from 3 – 7 mm, and are equal in size.
§ Equally round.
§ Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual.
§ Pupils dilate when looking at distant objects, and constrict when looking at nearer objects.
§ If all of which are met, we document the findings using the notation PERRLA, pupils equally round, reactive to light, and accommodateVisual Acuity (Cranial Nerve II – Optic Nerve)
§ The normal vision at a set distance at 20/20.
§ Peripheral Vision or visual fields - The normal visual field is 180 degrees.Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
§ The client can hold the position and there should be no nystagmus.
Structures of the Ears
Ears
Assessment of the ear includes direct inspection and palpation of the external ear, inspection of the internal parts of the ear by an otoscope (instrument for examining the interior of the ear, especially the eardrum, consisting essentially of a magnifying lens and a light), and determination of auditory acuity.
The ear is divided into three parts: external ear, middle ear, and inner ear. Many of the structures discussed next are illustrated in diagram below.
Sound transmission and hearing are complex processes. In brief, sound can be transmitted by air conduction or bone conduction. Air conducted transmission occurs by this process:
1. A sound stimulus enters the external canal and reaches the tympanic membrane.
2. The sound waves vibrate the tympanic membrane and reach the ossicles.
3. The sound waves travel from the ossicles to the opening in the inner ear (oval window).
4. The cochlea receives the sound vibrations.
5. The stimulus travels to the auditory nerve (the eighth cranial nerve) and the cerebral cortex.
Bone-conducted sound transmission occurs when skull bones transport the sound directly to the auditory nerve. Conductive hearing loss is the result of interrupted transmission of sound waves through the outer and middle ear structures. Possible causes are a tear in the tympanic membrane or an obstruction, due to swelling or other causes, in the auditory canal. Sensorineural hearing loss is the result of damage to the inner ear, the auditory nerve, or the hearing center in the brain. Mixed hearing loss is a combination of conduction and sensorineural loss.
Performing Ears Physical Assessment
The table below describes how to assess the ears and hearing.
Documentation
§ The ear lobes are bean shaped, parallel, and symmetrical.
§ The upper connection of the ear lobe is parallel with the outer canthus of the eye.
§ Skin is same in color as in the complexion.
§ No lesions noted on inspection.
§ The auricles are have a firm cartilage on palpation.
§ The pinna recoils when folded.
§ There is no pain or tenderness on the palpation of the auricles and mastoid process.
§ The ear canal has normally some cerumen of inspection.
§ No discharges or lesions noted at the ear canal.
§ On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in color.For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Head, Eyes and”
Video: https://youtu.be/O1MnyQMy6dI?list=PLBdcS7ILKLhRP4w0R6CjLXpWC4-BX_ABv&t=446
Nose and Sinuses
Structures and Functions of the Nose and Sinuses
A nurse can inspect the nasal passages very simply with a flashlight. However, a nasal speculum and a penlight or an otoscope with a nasal attachment facilitates examination of the nasal cavity. Assessment of the nose includes inspection and palpation of the external nose (the upper third of the nose is bone; the remainder is cartilage); patency of the nasal cavities; and inspection of the nasal cavities.
If the client reports difficulty or abnormality in smell, the nurse may test the client’s olfactory sense by asking the client to identify common odors such as coffee or mint. This is done by asking the client to close the eyes and placing vials containing the scent under the client’s nose. The nurse also inspects and palpates the facial sinuses as in the diagram below.
Performing the Nose and Sinuses Physical Assessment
The table below describes how to assess the nose and sinuses.
Documentation
§ Nose in the midline
§ No Discharges.
§ No flaring alae nasi.
§ Both nares are patent.
§ No bone and cartilage deviation noted on palpation.
§ No tenderness noted on palpation.
§ Nasal septum in the mid line and not perforated.
§ The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of allergy).
§ No tenderness noted on palpation of the paranasal sinuses.
§ Cranial Nerve I (Olfactory Nerve) – The client was able to differentiate two given substances.Mouth and Oropharynx
Structures and Functions of the Mouth and Oropharynx
The mouth and oropharynx are composed of a number of structures: lips, oral mucosa, the tongue and floor of the mouth, teeth and gums, hard and soft palate, uvula, salivary glands, tonsillar pillars, and tonsils. Anatomic structures of the mouth are shown in diagram below.
Normally, three pairs of salivary glands empty into the oral cavity: the parotid, submandibular, and sublingual glands. The parotid gland is the largest and empties through Stensen’s duct opposite the second molar. The submandibular gland empties through Wharton’s duct, which is situated on either side of the frenulum on the floor of the mouth. The sublingual salivary gland lies in the floor of the mouth and has numerous openings.
Dental caries (cavities) and periodontal disease (or pyorrhea) are the two problems that most frequently affect the teeth. Both problems are commonly associated with plaque and tartar deposits. Plaque is an invisible soft film that adheres to the enamel surface of teeth; it consists of bacteria, molecules of saliva, and remnants of epithelial cells and leukocytes. When plaque is unchecked, tartar (dental calculus) forms. Tartar is a visible, hard deposit of plaque and dead bacteria that forms at the gum lines. Tartar buildup can alter the fibers that attach the teeth to the gum and eventually disrupt bone tissue. Periodontal disease is characterized by gingivitis (red, swollen gingiva [gum]), bleeding, receding gum lines, and the formation of pockets between the teeth and gums. In advanced periodontal disease, the teeth are loose and pus is evident when the gums are pressed.
Other problems nurses may see are glossitis (inflammation of the tongue), stomatitis (inflammation of the oral mucosa), and parotitis (inflammation of the parotid salivary gland). The accumulation of foul matter (food, microorganisms, and epithelial elements) on the teeth and gums is referred to as sores.
Performing the Mouth and Oropharynx Physical AssessmentThe table below describes how to assess the mouth and oropharynx.
Documentation
Mouth and Oropharynx Lips
1. With visible margin
2. Symmetrical in appearance and movement
3. Pinkish in color
4. No edemaTemporomandibular
1. Moves smoothly no crepitous.
2. No deviations noted
3. No pain or tenderness on palpation and jaw movement.Gums
1. Pinkish in color
2. No gum bleeding
3. No receding gumsTeeth
1. 28 for children and 32 for adults.
2. White to yellowish in color
3. With or without dental carries and/or dental fillings.
4. With or without malocclusions.
5. No halitosis.Tongue
1. Pinkish with white taste buds on the surface.
2. No lesions noted.
3. No varicosities on ventral surface.
4. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue.
5. Gag reflex is present.
6. Able to move the tongue freely and with strength.
7. Surface of the tongue is rough.Uvula
1. Positioned in the mid line.
2. Pinkish to red in color.
3. No swelling or lesion noted.
4. Moves upward and backwards when asked to say “ah”Tonsils
1. No swelling or inflammation noted.
Neck
Structures and Functions of the Neck
Examination of the neck includes the muscles, lymph nodes, trachea, thyroid gland, carotid arteries, and jugular veins. Areas of the neck are defined by the sternocleidomastoid muscles, which divide each side of the neck into two triangles: the anterior and posterior as shown in the following diagram.
The trachea, thyroid gland, anterior cervical nodes, and carotid artery lie within the anterior triangle; the carotid artery runs parallel and anterior to the sternocleidomastoid muscle as shown in the following diagram.
Each sternocleidomastoid muscle extends from the upper sternum and the medial third of the clavicle to the mastoid process of the temporal bone behind the ear. These muscles turn and laterally flex the head. Each trapezius muscle extends from the occipital bone of the skull to the lateral third of the clavicle. These muscles draw the head to the side and back, elevate the chin, and elevate the shoulders to shrug them. The posterior lymph nodes lie within the posterior triangle as in the following diagram.
Lymph nodes in the neck that collect lymph from the head and neck structures are grouped serially and referred to as chains. Table below shown the lymph nodes and its location.
Performing the Neck Physical Assessment
The table below describes how to assess the neck.
Documentation
Neck
§ Non-tender if palpable.
§ The neck is straight.
§ No visible mass or lumps.
§ Symmetrical
§ No jugular venous distension (suggestive of cardiac congestion).
§ The trachea is palpable - It is positioned in the line and straight.Lymph nodes
§ May not be palpable. Maybe normally palpable in thin clients.
§ Non-tender if palpable.
§ Firm with smooth rounded surface.
§ Slightly movable.
§ About less than 1 cm in size.Thyroid
§ Normally the thyroid is non-palpable.
§ Isthmus maybe visible in a thin neck.
§ No nodules are palpable.
§ No bruits sound heard on auscultation.For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Nose, Mouth and Neck”
Video:TOPIC 11: Systems Physical Assessment II
Introduction:
Respiration and cardiovascular system are a vital function in our body. An ineffectively functioning of both systems causes disruption throughout the body, just as changes in other body systems have a significant impact on the respiratory and cardiovascular system. On other hand, peripheral-vascular (PV) system is a branching network of vessels that transports oxygenated blood to all body organs and tissues and then returns it to the heart for reoxygenation in the lungs. A disruption in the PV system can cause significant pain, loss of limb, or even death. The lymphatic system helps the heart and peripheral vasculature maintain adequate circulation. Therefore, a thorough, accurate physical assessment will allow you to develop a plan of care that addresses not only treatment measures but also health promotion and disease prevention on your patient.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Demonstrate a respiratory physical assessment.
- Document respiratory findings.
- Demonstrate a cardiovascular physical assessment
- Document cardiovascular findings.
- Demonstrate a peripheral-vascular and lymphatic physical assessment
- Document peripheral-vascular and lymphatic findings.
Respiratory System
Structures and Functions of the respiratory system
Assessing the thorax and lungs is frequently critical to assessing the client’s oxygenation status. Changes in the respiratory system can occur slowly or quickly. In clients with chronic obstructive pulmonary disease (COPD), such as chronic bronchitis, emphysema, and asthma, changes are frequently gradual.
Chest Landmarks
Before beginning the assessment, the nurse must be familiar with a series of imaginary lines on the chest wall and be able to locate the position of each rib and some spinous processes. These landmarks help the nurse to identify the position of underlying organs (e.g., lobes of the lung) and to record abnormal assessment findings.
The diagram above shows the anterior, lateral, and posterior series of lines. The midsternal line is a vertical line running through the center of the sternum. The midclavicular lines (right and left) are vertical lines from the midpoints of the clavicles. The anterior axillary lines (right and left) are vertical lines from the anterior axillary folds. The posterior axillary line is a vertical line from the posterior axillary fold. The midaxillary line is a vertical line from the apex of the axilla. The vertebral line is a vertical line along the spinous processes. The scapular lines (right and left) are vertical lines from the inferior angles of the scapulae.
These specific landmarks (i.e., T3 and the fourth, fifth, and sixth ribs) are located as follows. The starting point for locating the ribs anteriorly is the angle of Louis, the junction between the body of the sternum (breastbone) and the manubrium (the handle-like superior part of the sternum that joins with the clavicles). The superior border of the second rib attaches to the sternum at this manubriosternal Junction, as shown in the following diagram.
The nurse can identify the manubrium by first palpating the clavicle and following its course to its attachment at the manubrium. The nurse then palpates and counts distal ribs and intercostal spaces (ICSs) from the second rib. It is important to note that an ICS is numbered according to the number of the rib immediately above the space. When palpating for rib identification, the nurse should palpate along the midclavicular line rather than the sternal border because the rib cartilages are very close at the sternum. Only the first seven ribs attach directly to the sternum.
The counting of ribs is more difficult on the posterior than on the anterior thorax. For identifying underlying lung lobes, the pertinent landmark is T3. The starting point for locating T3 is the spinous process of the seventh cervical vertebra (C7), as in the following diagram.
When the client flexes the neck anteriorly, a prominent process can be observed and palpated. This is the spinous process of the seventh cervical vertebra. If two spinous processes are observed, the superior one is C7, and the inferior one is the spinous process of the first thoracic vertebra (T1). The nurse then palpates and counts the spinous processes from C7 to T3. Each spinous process up to T4 is adjacent to the corresponding rib number; for example, T3 is adjacent to the third rib. After T4, however, the spinous processes project obliquely, causing the spinous process of the vertebra to lie, not over its correspondingly numbered rib, but over the rib below. Thus, the spinous process of T5 lies over the body of T6 and is adjacent to the sixth rib.
Chest Shape and Size
In healthy adults, the thorax is oval. Its anteroposterior diameter is half its transverse diameter as shown in the diagram.
The overall shape of the thorax is elliptical; that is, its transverse diameter is smaller at the top than at the base. In older adults, kyphosis and osteoporosis alter the size of the chest cavity as the ribs move downward and forward.
There are several deformities of the chest as in the above diagram. Pigeon chest (pectus carinatum), a permanent deformity, may be caused by rickets (abnormal bone formation due to lack of dietary calcium). A narrow transverse diameter, an increased anteroposterior diameter, and a protruding sternum characterize pigeon chest. A funnel chest (pectus excavatum), a congenital defect, is the opposite of pigeon chest in that the sternum is depressed, narrowing the anteroposterior diameter. Because the sternum points posteriorly in clients with a funnel chest, abnormal pressure on the heart may result in altered function. A barrel chest, in which the ratio of the anteroposterior to transverse diameter is 1 to 1, is seen in clients with thoracic kyphosis (excessive convex curvature of the thoracic spine) and emphysema (chronic pulmonary condition in which the air sacs, or alveoli, are dilated and distended). Scoliosis is a lateral deviation of the spine.
Breath Sounds
Abnormal breath sounds, called adventitious breath sounds, occur when air passes through narrowed airways or airways filled with fluid or mucus, or when pleural linings are inflamed. Table below describes normal breath sounds.
Adventitious sounds are often superimposed over normal sounds, as in following table.
Performing the Respiratory System Physical Assessment
Assessment of the lungs and thorax includes all methods of examination: inspection, palpation, percussion, and auscultation. The table below describes how to assess the thorax and lungs.
Documentation
The chest wall is symmetric, without deformity, and is atraumatic in appearance. No tenderness is appreciated upon palpation of the chest wall. The patient does not exhibit signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, rhonchi, or wheezes. Resonance is normal upon percussion of all lung fields.
For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Thorax and Lungs”
Video:CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEMS
The cardiovascular system consists of the heart and the central blood vessels (primarily the pulmonary, coronary, and neck arteries and veins). The peripheral vascular system includes those arteries and veins distal to the central vessels, extending all the way to the brain and to the extremities.
Heart
Nurses assess the heart through inspection, palpation, and auscultation, in that sequence. Auscultation is more meaningful when other data are obtained first. The heart is usually assessed during an initial physical assessment; periodic reassessments may be necessary for long-term or at-risk clients or those with cardiac problems.
Heart sounds can be heard by auscultation. The normal first two heart sounds are produced by closure of the valves of the heart. The first heart sound, S1, occurs when the atrioventricular (AV) valves close. These valves close when the ventricles have been sufficiently filled. Although the AV valves do not close simultaneously, the closure occurs closely enough to be heard as one sound. S1 is a dull, low pitched sound described as “lub.” After the ventricles empty the blood into the aorta and pulmonary arteries, the semilunar valves close, producing the second heart sound, S2, described as “dub.” S2 has a higher pitch than S1 and is shorter in duration. These two sounds, S1 and S2 (“lub-dub”), occur within 1 second or less, depending on the heart rate.
The two heart sounds are audible anywhere on the precordial area, but they are best heard over the aortic, pulmonic, tricuspid, and mitral areas, as in following diagram.
Each area is associated with the closure of heart valves: the aortic area with the aortic valve (inside the aorta as it arises from the left ventricle); the pulmonic area with the pulmonic valve (inside the pulmonary artery as it arises from the right ventricle); the tricuspid area with the tricuspid valve (between the right atrium and ventricle); and the mitral area (sometimes referred to as the apical area) with the mitral valve (between the left atrium and ventricle).
Associated with these sounds are systole and diastole. Systole is the period in which the ventricles contract. It begins with S1 and ends at S2. Systole is normally shorter than diastole. Diastole is the period in which the ventricles relax. It starts with S2 and ends at the subsequent S1. Normally no sounds are audible during these periods, let look at the following diagram for a better understanding.
The experienced nurse, however, may perceive extra heart sounds (S3 and S4) during diastole. Both sounds are low in pitch and heard best at the apex, with the bell of the stethoscope, and with the client lying on the left side. S3 occurs early in diastole right after S2 and sounds like “lub-dub-ee” (S1, S2, S3) or “Kentuc-ky.” It often disappears when the client sits up. S3 is normal in children and young adults. In older adults, it may indicate heart failure. The S4 sound (ventricular gallop) occurs near the very end of diastole just before S1 and creates the sound of “dee-lub-dub” (S4, S1, S2) or “Ten-nessee.” S4 may be heard in older clients and can be a sign of hypertension. Normal heart sounds are summarized in the below Table.
The nurse may also hear abnormal heart sounds, such as clicks, rubs, and murmurs. These are caused by valve disorders or impaired blood flow within the heart and require advanced training to diagnose.
Central Vessels
The carotid arteries supply oxygenated blood to the head and neck as shown in the following diagram.
Because they are the only source of blood to the brain, prolonged occlusion of these arteries can result in serious brain damage. The carotid pulses correlate with central aortic pressure, thus reflecting cardiac function better than the peripheral pulses. When cardiac output is diminished, the peripheral pulses may be difficult or impossible to feel, but the carotid pulse should be felt easily.
The carotid is also auscultated for a bruit. A bruit (a blowing or swishing sound) is created by turbulence of blood flow due either to a narrowed arterial lumen (a common development in older people) or to a condition, such as anemia or hyperthyroidism, that elevates cardiac output. If a bruit is found, the carotid artery is then palpated for a thrill. A thrill, which frequently accompanies a bruit, is a vibrating sensation like the purring of a cat or water running through a hose. It, too, indicates turbulent blood flow due to arterial obstruction.
The jugular veins drain blood from the head and neck directly into the superior vena cava and right side of the heart. The external jugular veins are superficial and may be visible above the clavicle. The internal jugular veins lie deeper along the carotid artery and may transmit pulsations onto the skin of the neck. Normally, external neck veins are distended and visible when a person lies down; they are flat and not as visible when a person stands up, because gravity encourages venous drainage. By inspecting the jugular veins for pulsations and distention, the nurse can assess the adequacy of function of the right side of the heart and venous pressure. Bilateral jugular venous distention (JVD) may indicate right-sided heart failure.
Performing the Heart and Central Vessels Physical Assessment
The table below describes how to assess the heart and central vessels.
Documentation
Inspection of the Heart
- No pulsation of the apical impulse.
- Chest is symmetrical expansion with respiration, no scars.
- No lift or heaves.
Palpation of the Heart
- No, palpable pulsation over the aortic, pulmonic, and mitral valves.
- Apical pulsation can be felt on palpation.
- No noted abnormal cardiac lift or heaves, and thrills felt over the apex.
Auscultation of the Heart
- PMI noted at fifth intercostal space and midclavicular line.
- Normal S1 & S2 can be heard at all anatomic site.
- No abnormal heart sounds are heard (e.g. Murmurs, S3 & S4).
- Cardiac rate ranges from 60 – 100 bpm, regular.
For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Cardiovascular system”
Video:Peripheral Vascular System
Assessing the peripheral vascular system includes measuring the blood pressure, palpating peripheral pulses, and inspecting the skin and tissues to determine perfusion (blood supply to an area) to the extremities. Certain aspects of peripheral vascular assessment are often incorporated into other parts of the assessment procedure. For example, blood pressure is usually measured at the beginning of the physical examination.
Performing the Peripheral Vascular System Physical Assessment
The table below describes how to assess the peripheral vascular system.
Documentation
No rashes, swelling, color change, or cyanosis in arms or legs. No clubbing in fingernails. Capillary refill is < 2 sec. Hands and feet pink and warm to touch. No pitting edema in feet.
For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Peripheral Vascular system”
Video:TOPIC 12: Systems Physical Assessment III
Introduction:
The assessment of the genitourinary (GU) system and breast are essential to obtaining a picture of a woman’s overall health status. Because most breast masses are detected by self-examination, teaching your patients how to examine their breasts is just as critical and the female reproductive systems undergo cyclical changes in response to hormonal levels throughout the life cycle.
The stomach, small and large intestines, liver, gallbladder, pancreas, spleen, kidneys, ureters, bladder, aortic vasculature, spine, uterus and ovaries, or spermatic cord are all located in the abdomen. So, abdominal assessment provides information about a variety of systems can also provide vital information about the health status of every other system.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Demonstrate a physical assessment of the breast.
- Document breast findings.
- Demonstrate an abdominal physical assessment.
- Document abdominal assessment findings.
- Demonstrate a physical assessment of the female genitourinary system.
- Document female genitourinary findings
BREASTS AND AXILLAE
The breasts of men and women need to be inspected and palpated. Men have some glandular tissue beneath each nipple, a potential site for malignancy, whereas mature women have glandular tissue throughout the breast. In females, the largest portion of glandular breast tissue is located in the upper outer quadrant of each breast. A projection of breast tissue from this quadrant extends into the axilla, called the axillary tail of Spence, as shown in the following diagram.
The majority of breast tumors are located in this upper outer breast quadrant including the tail of Spence. During assessment, the nurse can localize specific findings by dividing the breast into quadrants and the axillary tail.
Performing the Breast and Axillae Physical Assessment
The table below describes how to assess the breast and axillae.
Documentation
Inspection of the Breast
- The overlying the breast should be even.
- May or may not be completely symmetrical at rest.
- The areola is rounded or oval, with same color.
- Nipples are rounded, everted, same size and equal in color.
- No “orange peel” skin is noted which is present in edema.
- The veins maybe visible but not engorge and prominent.
- No obvious mass noted.
- Not fixated and moves bilaterally when hands are abducted over the head, or is learning forward.
- No retractions or dimpling.
Palpation of the Breast
- No lumps or masses are palpable.
- No tenderness upon palpation.
- No discharges from the nipples.
For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Breast and Axillae”
Video:
ABDOMEN
The nurse locates and describes abdominal findings using two common methods of subdividing the abdomen: quadrants and regions. To divide the abdomen into quadrants, the nurse imagines two lines: a vertical line from the xiphoid process to the pubic symphysis, and a horizontal line across the umbilicus, as following diagram.
Using the second method, division into nine regions, the nurse imagines two vertical lines that extend superiorly from the midpoints of the inguinal ligaments, and two horizontal lines, one at the level of the edge of the lower ribs and the other at the level of the iliac crests, as shown in the following diagram.
In addition, practitioners often use certain landmarks to locate abdominal signs and symptoms. These are the xiphoid process of the sternum, the costal margins, the anterosuperior iliac spine, the umbilicus, the inguinal ligaments, and the superior margin of the pubic symphysis, as in the following diagram.
Performing the Abdomen Physical Assessment
Assessment of the abdomen involves all four methods of examination (inspection, auscultation, palpation, and percussion). When assessing the abdomen, the nurse performs inspection first, followed by auscultation, percussion, and/or palpation. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.
The table below describes how to assess the abdomen.
Documentation
The abdomen is the same color as the rest of the body with sparse hair distribution close to the perineum. The abdomen is rounded, symmetrical with straie around the waist. The umbilicus is midline and no odor or discharge noted. The abdomen is soft, non-distended, non-tender with positive bowel sounds to all four quadrants and no guarding noted during the assessment. No distention to the suprapubic area and no edema to face, hand, or lower extremities noted.
For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Abdomen”
Video:FEMALE GENO-URINARY
The system consists of external and internal genitalia, which develop and function according to the hormonal influences that affect fertility and childbearing. It also consists of urinary structures. External genitalia include the mons pubis, clitoris, vestibule, labia majora, labia minora, vaginal introitus, hymen, Bartholin’s glands, Skene’s glands, and the urethral meatus. Internal genitalia include the vagina, cervix, uterus, adjacent structures (adnexa), ovaries, and fallopian tubes. Internal urinary structures include the ureters, bladder, and urethra, as in the following diagram.
Performing the Female Genitals and Inguinal Physical Assessment
The examination of the genitals and reproductive tract of women includes assessment of the inguinal lymph nodes and inspection and palpation of the external genitals. Completeness of the assessment of the genitals and reproductive tract depend on the needs and problems of the individual client. In most practice settings, generalist nurses perform only inspection of the external genitals and palpation of the inguinal lymph nodes. Examination of the genitals usually creates uncertainty and apprehension in women, and the lithotomy position required for an internal examination can cause embarrassment.
The table below describes how to assess the female genitals and inguinal area.
Documentation
External genitalia without erythema, exudate or discharge. Vaginal vault is without discharge. Cervix is of normal color without lesion. The os is closed. There is no bleeding noted. Uterus is noted to be of normal size and nontender. No cervical motion tenderness is seen. No masses are palpated. The adnexa are without masses or tenderness.
For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Female Genitalia, Anus and Rectum”
Video:TOPIC 13: Systems Physical Assessment IV
Introduction:
The male reproductive system is anatomically divided into external and internal genital organs. The penis and scrotum are external organs and are easily inspected and palpated, whereas the internal structures have limited accessibility. So, the assessment includes both the male reproductive system and the urinary system.
The musculoskeletal system provides shape and support to the body, allows movement, protects the internal organs, produces red blood cells in the bone marrow and stores calcium and phosphorus in the bones. This chapter also presents the sensory-neurologic assessment, including information on assessing cerebral function, cranial nerves (CNs), sensation, and reflexes. The neuromuscular function, just one aspect of the highly complex neurologic system. The goal of overall physical assessment is to detect risk factors, potential problems, or any dysfunction early and then to plan appropriate interventions, including teaching health promotion and disease prevention and implementing treatment measures.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Demonstrate a physical assessment of the male genitourinary system
- Document male genitourinary findings
- Demonstrate a physical assessment of the motor-musculoskeletal system
- Document motor-musculoskeletal findings
- Demonstrate a physical assessment of the sensory-neurologic system
- Document sensory-neurologic system findings
MALE GENITO-URINARY
In adult men, a complete examination includes assessment of the external genitals and prostate gland, and for the presence of any hernias. Nurses in some practice settings performing routine assessment of clients may assess only the external genitals. The male reproductive and urinary systems share the urethra, which is the passageway for both urine and semen. Therefore, in physical assessment of the male these two systems are frequently assessed together.
Performing the Male Genitals and Inguinal Physical Assessment
The techniques of inspection and palpation are used to examine the male genitals. The table below describes how the nurse can assess the male genitals and inguinal area.
Performing the Anus Physical Assessment
For the anal examination, an essential part of every comprehensive physical examination, involves only inspection. The table below describes how to assess the rectum and anus.
Documentation
Penis normal shape without lesions. Testicles normal shape and contour without tenderness. Epididymides normal shape and contour without tenderness. No discharge or hernias. Rectum normal tone to sphincter. Prostate normal shape and contour without nodules. Stool hemoccult negative. No external hemorrhoids. No skin lesions.
For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Male Genitalia, Hernias, Anus, and Rectum”
Video:MUSCULOSKELETAL SYSTEM
Before beginning your assessment, you need to understand how the musculoskeletal system works. It consists of three major components: bones, muscles, and joints. Tendons, ligaments, cartilage, and bursae serve as connecting structures and complete the system. Diagram below illustrates the musculoskeletal system, anterior and posterior view.
The nurse usually assesses the musculoskeletal system for muscle strength, tone, size, and symmetry of muscle development, and for tremors. A tremor is an involuntary trembling of a limb or body part. Tremors may involve large groups of muscle fibers or small bundles of muscle fibers. An intention tremor becomes more apparent when an individual attempts a voluntary movement, such as holding a cup of coffee. A resting tremor is more apparent when the client is relaxed and diminishes with activity. A fasciculation is an abnormal contraction of a bundle of muscle fibers that appears as a twitch.
Bones are assessed for normal form. Joints are assessed for tenderness, swelling, thickening, crepitation (a crackling, grating sound), and range of motion. Body posture is assessed for normal standing and sitting positions.
Performing the Musculoskeletal Physical Assessment
The table below describes how to assess the musculoskeletal system.
Documentation
· Both extremities are equal in size.
· Have the same contour with prominences of joints.
· No involuntary movements.
· No edema
· Color is even.
· Temperature is warm and even.
· Has equal contraction and even.
· Can perform complete range of motion.
· No crepitus must be noted on joints.
· Can counter act gravity and resistance on ROM.For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Musculoskeletal System”
Video:Sensory-Neurologic System
Sensory impulses are transmitted to the brain through afferent, or ascending, pathways. Motor impulses are transmitted from the brain to muscles through the efferent, or descending, pathways as shown in the following diagram.
The brain is composed of gray matter, made up of neuronal cell bodies, and white matter, composed of axons and dendrites. The brain consists of four major structures: the cerebrum, diencephalon, cerebellum, and brainstem. These and other components of the brain are shown in the below diagram.
There are 12 pairs of cranial nerves originate from the brain and are called the peripheral nerves of the brain. As shown in the following diagram.
Branching from the spinal cord are 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal as shown in the following diagram.
The autonomic nervous system is divided into the sympathetic and parasympathetic, with efferent fibers to muscle, organs, or glands. Usually, the two systems work opposite each other. The sympathetic allows the body to respond to stressful situations. The parasympathetic functions when all is normal. The sympathetic nerves exit the spinal cord between the level of the first thoracic and the second lumbar vertebrae. The preganglionic nerves descend the cord and exit, and then enter a relay station known as the sympathetic chain. The impulse is then transmitted to a postganglionic neuron that goes to the target organ to stimulate a response. The following diagram illustrates the autonomic nervous system.
Performing the Neurologic Assessment
The table below describes how to assess the neurologic system.
Documentation
Alert and oriented to situation, person, place, and time. Behavior appropriate to situation and developmental age. Clear speech and follow verbal commands. Cranial nerves II to XII grossly intact. Pupils Equal, Round, React to Light and Accommodation (PERRLA). Active range of motion all extremities with symmetry strength. Peripheral sensation intact.
For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Nervous System: Sensory System and Reflexes”
Video:TOPIC 14: Adapting Assessment to Special Population
Introduction:
Obtaining an accurate and useful history and physical assessment is a vital skill. This topic will help you effectively assess paediatric and older adult by familiarizing you with the physical, psychosocial, and cognitive developmental changes that occur.
Topic Learning Outcome (TLOs):
By the end of this topic, you should be able to:
- Describe the adapting assessment to paediatric.
- Describe the adapting assessment to older adult.
Adapting Assessment for Paediatric
At this age, the assessment is performed with the parent or guardian present. Even so, you need to explain what you are doing and why. Because the toddler thinks in a very concrete way, keep your explanations very simple. Toys, such as hand puppets, or games can be helpful when examining the toddler or pre-schooler. If some procedures might cause discomfort—such as the otoscopic examination if the child has an earache—leave them until the end.
As you perform the exam, keep in mind the normal developmental changes affecting this age group. As with all assessments, the process involves subjective and objective data collection, nursing diagnoses, planning, interventions, and evaluation.
When physical assessment the paediatric, keep in mind the specific variations that are unique to this developmental period.
Begin with a general survey, obtaining height, weight, and vital signs such as temperature and blood pressure (BP). Keep track of the child’s growth and development by plotting height and weight on growth charts. The toddler usually gains 4 to 6 pounds and grows 3 inches a year. Head and chest circumferences are usually equal by age 2. The preschooler gains 5 pounds and grows 21⁄2 to 3 inches a year. Changes in vital signs include a slight, gradual increase in BP and a slight decrease in temperature, pulse, and respirations.
Once you have completed your assessment, document your findings, identify any nursing diagnoses, and formulate a plan of care.
Let watch this video clip “Head-to-Toe Assessment: Child"
Video:
FORUM:
1. How does assessment of the paediatric differ from assessment of other patients?
2. What health concerns should you keep in mind as you proceed with the assessment?
Adapting Assessment for Older Adult
A complete history and physical exam are essential to providing comprehensive, holistic care for the older adult. If the patient has a long and complicated medical history, you may need to do the history and physical exam on separate visits and schedule an hour for each
visit. You may also need to allow more time to help your patient into the exam room and with dressing and undressing. When obtaining a history, ask one question at a time and allow enough time for your patient to respond. You may also need to repeat questions and confirm answers.
Remember that older adults may not present in the same way as younger people when they are ill. When performing your assessment, keep these three factors in mind:
■ Older adults may minimize or ignore symptoms.
■ They often have several concurrent medical problems.
■ They often present with atypical signs and symptoms of disease.
Once you have completed the health history, collect objective data through your physical exam.
Approach
When examining the older patient, make sure the environment is as safe and appropriate as possible. To ensure a senior-friendly environment, do the following:
■ Keep examination rooms warm
■ Use bright but no glaring lights.
■ Keep background noise to a minimum.
■ Provide higher than standard seating (because patients might have trouble getting up, and if they have had joint replacement, they shouldn’t flex the joint more than 90 degrees) with arm rests on all chairs.
■ Use exam tables that mechanically elevate the patient from lying to sitting and vice versa and a broad-based step stool to help patients get onto the table.
■ Use a private exam room, if possible, or at least pull the privacy curtain if there is a roommate.
■ Minimize position changes to keep the patient from getting tired.
■ Uncover only the area being assessed, making sure that patient is warm and covered with blankets or drapes.
■ Provide reading materials with large print.
■ Allow more time than usual for the exam. The complete exam may need to be scheduled over several meetings.
■ Make safety a priority. If your patient can’t tolerate or perform what is expected for the exam, then adapt the exam to meet her or his needs.
■ Take the time to explain everything you are doing to your patient.
Let watch this video clip on "Head-to-Toe Assessment: Older Adult"
Video:
The history and physical exam of the paediatric and older adult should take into consideration the normal changes associated with aging and focus strongly on function.