10/8/23, 8:52 PM Hesi- health assessment
30 Health Assessment
LEARNING OUTCOMES
After completing this chapter, you will be able to:
1. Identify the purposes of the physical examination. l. Assessing the heart and central vessels.
2. Explain the four techniques used in physical examination: m. Assessing the peripheral vascular system.
inspection, palpation, percussion, and auscultation. n. Assessing the breasts and axillae.
3. Identify expected findings during health assessment. o. Assessing the abdomen.
p. Assessing the musculoskeletal system.
4. Verbalize the steps used in performing selected examination
q. Assessing the neurologic system.
procedures:
r. Assessing the female genitals and inguinal area.
a. Assessing appearance and mental status.
s. Assessing the male genitals and inguinal area.
b. Assessing the skin.
t. Assessing the anus.
c. Assessing the hair.
d. Assessing the nails. 5. Describe suggested sequencing to conduct a physical health
e. Assessing the skull and face. examination in an orderly fashion.
f. Assessing the eye structures and visual acuity. 6. Discuss variations in examination techniques appropriate for
g. Assessing the ears and hearing. clients of different ages.
h. Assessing the nose and sinuses. 7. Recognize when it is appropriate to delegate assessment
i. Assessing the mouth and oropharynx. skills to unlicensed assistive personnel.
j. Assessing the neck. 8. Demonstrate appropriate documentation and reporting of
k. Assessing the thorax and lungs. health assessment.
KEY TERMS
adventitious breath sounds, 555 external auditory meatus, 539 mydriasis, 534 resting tremor, 577
alopecia, 528 extinction, 582 myopia, 533 S1, 561
angle of Louis, 553 fasciculation, 577 normocephalic, 531 S2, 561
antihelix, 539 flatness, 519 nystagmus, 536 semicircular canals, 540
aphasia, 580 fremitus, 557 one-point discrimination, 582 sensorineural hearing loss, 540
astigmatism, 533 gingivitis, 546 ossicles, 540 sordes, 546
auricle, 539 glaucoma, 533 otoscope, 539 stapes, 540
auscultation, 519 glossitis, 546 pallor, 523 stereognosis, 582
blanch test, 530 goniometer, 579 palpation, 517 sternum, 554
bruit, 562 helix, 539 parotitis, 546 strabismus, 536
caries, 546 hernia, 593 percussion, 518 systole, 561
cataracts, 533 hordeolum (sty), 533 perfusion, 566 tartar, 546
cerumen, 539 hyperopia, 533 periodontal disease, 546 thrill, 562
clubbing, 530 hyperresonance, 519 PERRLA, 537 tragus, 539
cochlea, 540 incus, 540 pinna, 539 tremor, 577
conductive hearing loss, 540 inspection, 517 pitch, 519 triangular fossa, 539
conjunctivitis, 533 intensity, 519 plaque, 546 two-point discrimination, 582
cyanosis, 523 intention tremor, 577 pleximeter, 518 tympanic membrane, 539
dacryocystitis, 533 jaundice, 523 plexor, 518 tympany, 519
diastole, 561 lift, 560 precordium, 560 vestibule, 540
dullness, 519 lobule, 539 presbyopia, 533 visual acuity, 533
duration, 519 malleus, 540 proprioceptors, 581 visual fields, 533
edema, 523 manubrium, 554 pyorrhea, 546 vitiligo, 523
erythema, 523 mastoid, 539 quality, 519
eustachian tube, 540 miosis, 534 reflex, 581
exophthalmos, 532 mixed hearing loss, 540 resonance, 519
514 Unit 7 ● Assessing Health
513
INTRODUCTION the location of the examination, and the agency’s priorities and pro-
Assessing a client’s health status is a major component of nursing cedures. The order of head-to-toe assessment is given in Box 30–1.
care and has two aspects: (1) the nursing health history discussed in Regardless of the procedure used, the client’s energy and time need
Chapter 11 and (2) the physical examination discussed in this to be considered. The health assessment is therefore conducted in
chapter. A physical examination can be any of three types: (1) a a systematic and efficient manner that results in the fewest position
complete assessment (e.g., when a client is admitted to a health care changes for the client.
agency), (2) examination of a body system (e.g., the cardiovascular Frequently, nurses assess a specific body area instead of the entire
system), or (3) examination of a body area (e.g., the lungs, when dif- body. These specific assessments are made in relation to client com-
ficulty with breathing is observed). Note: Some nurses consider as- plaints, the nurse’s own observation of problems, the client’s present-
sessment to be the broad term used in applying the nursing process to ing problem, nursing interventions provided, and medical therapies.
health data and examination to be the physical process used to gather Examples of these situations and assessments are provided in Table 30–1.
the data. In this text, the terms assessment and examination are some- These are some of the purposes of the physical examination:
times used interchangeably—both referring to a critical investigation • To obtain baseline data about the client’s functional abilities
about:blank 1/89
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514 Unit 7 ● Assessing Health
513
INTRODUCTION the location of the examination, and the agency’s priorities and pro-
Assessing a client’s health status is a major component of nursing cedures. The order of head-to-toe assessment is given in Box 30–1.
care and has two aspects: (1) the nursing health history discussed in Regardless of the procedure used, the client’s energy and time need
Chapter 11 and (2) the physical examination discussed in this to be considered. The health assessment is therefore conducted in
chapter. A physical examination can be any of three types: (1) a a systematic and efficient manner that results in the fewest position
complete assessment (e.g., when a client is admitted to a health care changes for the client.
agency), (2) examination of a body system (e.g., the cardiovascular Frequently, nurses assess a specific body area instead of the entire
system), or (3) examination of a body area (e.g., the lungs, when dif- body. These specific assessments are made in relation to client com-
ficulty with breathing is observed). Note: Some nurses consider as- plaints, the nurse’s own observation of problems, the client’s present-
sessment to be the broad term used in applying the nursing process to ing problem, nursing interventions provided, and medical therapies.
health data and examination to be the physical process used to gather Examples of these situations and assessments are provided in Table 30–1.
the data. In this text, the terms assessment and examination are some- These are some of the purposes of the physical examination:
times used interchangeably—both referring to a critical investigation • To obtain baseline data about the client’s functional abilities.
and evaluation of client status. • To supplement, confirm, or refute data obtained in the nursing
history.
• To obtain data that will help establish nursing diagnoses and plans
PHYSICAL HEALTH ASSESSMENT of care.
A complete health assessment may be conducted starting at the head • To evaluate the physiological outcomes of health care and thus the
and proceeding in a systematic manner downward (head-to-toe as- progress of a client’s health problem.
sessment). However, the procedure can vary according to the age of • To make clinical judgments about a client’s health status.
the individual, the severity of the illness, the preferences of the nurse, • To identify areas for health promotion and disease prevention.
BOX 30–1 Head-to-Toe Framework
• General survey • Chest and back
• Vital signs • Skin
• Head • Thorax shape and size
• Hair, scalp, face • Lungs
• Eyes and vision • Heart
• Ears and hearing • Spinal column
• Nose • Breasts and axillae
• Mouth and oropharynx • Abdomen
• Neck • Skin
• Muscles • Abdominal sounds
• Lymph nodes • Femoral pulses
• Trachea • External genitals
• Thyroid gland • Anus
• Carotid arteries • Lower extremities
• Neck veins • Skin and toenails
• Upper extremities • Gait and balance
• Skin and nails • Joint range of motion
• Muscle strength and tone • Popliteal, posterior tibial, and dorsalis pedis pulses
• Joint range of motion
• Brachial and radial pulses
• Sensation
TABLE 30–1 Nursing Assessments Addressing Selected Client Situations
Situation Physical Assessment
Client complains of abdominal pain. Inspect, auscultate, percuss, and palpate the abdomen; assess vital signs.
Client is admitted with a head injury. Assess level of consciousness using Glasgow Coma Scale (see Table 30–10
later in this chapter); assess pupils for reaction to light and accommodation;
assess vital signs.
The nurse prepares to administer a cardiotonic drug to Assess apical pulse and compare with baseline data.
a client.
The client has just had a cast applied to the lower leg. Assess peripheral perfusion of toes, capillary blanch test, pedal pulse if able,
and vital signs.
The client’s fluid intake is minimal. Assess tissue turgor, fluid intake and output, and vital signs.
Chapter 30 ● Health Assessment 515
BOX 30–2 Cancer Screening Guidelines for Asymptomatic People
COLORECTAL CANCER (MALES AND FEMALES) CERVICAL AND UTERINE CANCER (FEMALES)
• Fecal occult blood test or fecal immunochemical test annually • For women ages 21 to 29, screening every 3 years with Pap tests.
beginning at age 50 or • For women ages 30 to 65, screening every 5 years with both HPV
• Stool DNA test may be done beginning at age 50. test and the Pap test, or every 3 years with the Pap test alone.
• Flexible sigmoidoscopy every 5 years beginning at age 50 or • Women ages 65 and older who have had ≥3 consecutive neg-
• Colonoscopy every 10 years beginning at age 50 or ative Pap tests or ≥2 consecutive negative HPV and Pap tests
• Double contrast barium enema every 5 years beginning at in the last 10 years, the most recent test in the last 5 years, and
age 50. women who have had a total hysterectomy should stop cervical
• Computerized tomography colonography every 5 years begin- cancer screening.
ning at age 50.
PROSTATE CANCER (MALES)
BREAST CANCER (FEMALES) • For men who have at least a 10-year life expectancy, discussion
• Beginning in their early 20s, women should be told about with the primary care provider about the benefits, risks, and un-
the benefits and limitations of breast self-examination (BSE) certainties associated with prostate cancer screening
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and vital signs.
The client’s fluid intake is minimal. Assess tissue turgor, fluid intake and output, and vital signs.
Chapter 30 ● Health Assessment 515
BOX 30–2 Cancer Screening Guidelines for Asymptomatic People
COLORECTAL CANCER (MALES AND FEMALES) CERVICAL AND UTERINE CANCER (FEMALES)
• Fecal occult blood test or fecal immunochemical test annually • For women ages 21 to 29, screening every 3 years with Pap tests.
beginning at age 50 or • For women ages 30 to 65, screening every 5 years with both HPV
• Stool DNA test may be done beginning at age 50. test and the Pap test, or every 3 years with the Pap test alone.
• Flexible sigmoidoscopy every 5 years beginning at age 50 or • Women ages 65 and older who have had ≥3 consecutive neg-
• Colonoscopy every 10 years beginning at age 50 or ative Pap tests or ≥2 consecutive negative HPV and Pap tests
• Double contrast barium enema every 5 years beginning at in the last 10 years, the most recent test in the last 5 years, and
age 50. women who have had a total hysterectomy should stop cervical
• Computerized tomography colonography every 5 years begin- cancer screening.
ning at age 50.
PROSTATE CANCER (MALES)
BREAST CANCER (FEMALES) • For men who have at least a 10-year life expectancy, discussion
• Beginning in their early 20s, women should be told about with the primary care provider about the benefits, risks, and un-
the benefits and limitations of breast self-examination (BSE) certainties associated with prostate cancer screening.
and the importance of reporting breast symptoms to a health
HEALTH COUNSELING AND CANCER CHECKUP
professional. Those who choose to perform BSE should re-
(MALES AND FEMALES) OVER AGE 20
ceive instruction and have their technique reviewed regularly. • Examination for cancers of the thyroid, testicles, ovaries, lymph
Women may choose to perform BSE regularly, occasionally, or
nodes, oral region, and skin during the regular health examination
not at all.
• Clinical breast examination every 3 years from ages 20 to 40, From “Cancer Screening in the United States, 2014: A Review of Current American Cancer
Society Guidelines and Current Issues in Cancer Screening” by R. A. Smith, D. Manassaram-
and then annually beginning at age 40. Baptiste, D. Brooks, V. Cokkinides, M. Doroshenk, D. Saslow, . . . O. W. Brawley, 2014, CA: A
• Mammogram annually at age 40 and over. Cancer Journal for Clinicians, 64, pp. 31–51.
Nurses use national guidelines and evidence-based practice to BOX 30–3 Health Assessment of the Adult
focus health assessment on specific conditions. The nurse’s judgment
is key when the evidence is inconclusive or conflicting. For example, • Be aware of normal physiological changes that occur with ag-
when screening for cancer, nurses should keep in mind the American ing (see the Lifespan Considerations later in this chapter).
Cancer Society’s guidelines for early detection (Box 30–2). However, • Be aware of stiffness of muscles and joints from aging or
history of orthopedic surgery. The client may need modifica-
whereas those guidelines call for mammography every year begin- tion of the usual positioning necessary for examination and
ning at age 40, the U.S. Preventive Services Task Force (2009) recom- assessment.
mends breast mammography only every 2 years for women ages 50 • Expose only areas of the body to be examined in order to
to 74 and none thereafter. avoid chilling.
• Permit ample time for the client to answer your questions and
assume the required positions.
Preparing the Client • Be aware of cultural differences. The client may want a family
Most people need an explanation of the physical examination. Often member present during disrobing.
clients are anxious about what the nurse will find. They can be reas- • Arrange for an interpreter if the client’s language differs from
that of the nurse.
sured during the examination by explanations at each step. The nurse • Ask clients how they wish to be addressed, such as “Mrs.” or
should explain when and where the examination will take place, why “Miss.”
it is important, and what will happen. Instruct the client that all in- • Adapt assessment techniques to any sensory impairment; for
formation gathered and documented during the assessment is kept example, make sure eyeglasses or hearing aids are nearby.
confidential in accordance with the Health Insurance Portability and • If clients are older or frail, it is wise to conduct the assessment
in several segments in order to not overtire them.
Accountability Act (HIPAA). This means that only those health care
providers who have a legitimate need to know the client’s information
will have access to it. and neck, heart and lungs, and range of motion can be done early in
Health examinations are usually painless; however, it is im- the process, with the ears, mouth, abdomen, and genitals being left
portant to determine in advance any positions that are contraindi- for the end of the exam.
cated for a particular client. The nurse assists the client as needed
to undress and put on a gown. Clients should empty their bladders Preparing the Environment
before the examination. Doing so helps them feel more relaxed and It is important to prepare the environment before starting the assess-
facilitates palpation of the abdomen and pubic area. If a urinaly- ment. The time for the physical assessment should be convenient
sis is required, the urine should be collected in a container for that to both the client and the nurse. The environment needs to be well
purpose. lighted and the equipment should be organized for efficient use.
When assessing adults it is important to recognize that people A client who is physically relaxed will usually experience little dis-
of the same age differ markedly. Box 30–3 provides special consider- comfort. The room should be warm enough to be comfortable for
ations for assessing adults, especially older adults. the client.
The sequence of the assessment differs with children and adults. Providing privacy is important. Most people are embarrassed if
With children, always proceed from the least invasive or uncomfort- their bodies are exposed or if others can overhear or view them dur-
able aspect of the exam to the more invasive. Examination of the head ing the assessment. Culture, age, and gender of both the client and the
516 Unit 7 ● Assessing Health
nurse influence how comfortable the client will be and what special Draping
arrangements might be needed. For example, if the client and nurse Drapes should be arranged so that the area to be assessed is exposed
are of different genders, the nurse should ask if it is acceptable to and other body areas are covered. Exposure of the body is frequently
perform the physical examination. Family and friends should not be embarrassing to clients. Drapes provide not only a degree of privacy
present unless the client asks for someone. but also warmth. Drapes are made of paper, cloth, or bed linen.
Positioning Instrumentation
Several positions are frequently required during the physical assess-
All equipment required for the health assessment should be clean, in
ment. It is important to consider the client’s ability to assume a posi-
good working order, and readily accessible. Equipment is frequently set
tion. The client’s physical condition, energy level, and age should also
up on trays, ready for use. Various instruments are shown in Table 30–3.
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 Methods of Examining
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The sequence of the assessment differs with children and adults. Providing privacy is important. Most people are embarrassed if
With children, always proceed from the least invasive or uncomfort- their bodies are exposed or if others can overhear or view them dur-
able aspect of the exam to the more invasive. Examination of the head ing the assessment. Culture, age, and gender of both the client and the
516 Unit 7 ● Assessing Health
nurse influence how comfortable the client will be and what special Draping
arrangements might be needed. For example, if the client and nurse Drapes should be arranged so that the area to be assessed is exposed
are of different genders, the nurse should ask if it is acceptable to and other body areas are covered. Exposure of the body is frequently
perform the physical examination. Family and friends should not be embarrassing to clients. Drapes provide not only a degree of privacy
present unless the client asks for someone. but also warmth. Drapes are made of paper, cloth, or bed linen.
Positioning Instrumentation
Several positions are frequently required during the physical assess-
All equipment required for the health assessment should be clean, in
ment. It is important to consider the client’s ability to assume a posi-
good working order, and readily accessible. Equipment is frequently set
tion. The client’s physical condition, energy level, and age should also
up on trays, ready for use. Various instruments are shown in Table 30–3.
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 Methods of Examining
in one position, thus minimizing the number of position changes Four primary techniques are used in the physical examination: in-
needed (Table 30–2). spection, palpation, percussion, and auscultation. These techniques
TABLE 30–2 Client Positions and Body Areas Assessed
Position Description Areas Assessed Cautions
Dorsal recumbent Back-lying position with knees Female genitals, rectum, and May be contraindicated for
flexed and hips externally female reproductive tract clients who have cardiopulmo-
rotated; small pillow under nary problems.
the head; soles of feet on the
surface
Supine (horizontal recumbent) Back-lying position with legs Head, neck, axillae, anterior Tolerated poorly by clients with
extended; with or without thorax, lungs, breasts, heart, cardiovascular and respiratory
pillow under the head vital signs, abdomen, extremi- problems.
ties, peripheral pulses
Sitting A seated position, back un- Head, neck, posterior and Older adults and weak clients
supported and legs hanging anterior thorax, lungs, breasts, may require support.
freely axillae, heart, vital signs, upper
and lower extremities, reflexes
Lithotomy Back-lying position with feet Female genitals, rectum, and May be uncomfortable and
supported in stirrups; the hips female reproductive tract tiring for older adults and often
should be in line with the edge embarrassing.
of the table
Sims’ Side-lying position with low- Rectum, vagina Difficult for older adults and
ermost arm behind the body, people with limited joint
uppermost leg flexed at hip movement.
and knee, upper arm flexed at
shoulder and elbow
Prone Lies on abdomen with head Posterior thorax, hip joint Often not tolerated by older
turned to the side, with or movement adults and people with
without a small pillow cardiovascular and respiratory
problems.
Chapter 30 ● Health Assessment 517
TABLE 30–3 Equipment and Supplies Used for a Health Examination
Supplies Purpose
Flashlight or penlight To assist viewing of the pharynx or to determine the reactions of the
pupils of the eye
Ophthalmoscope A lighted instrument to visualize the interior of the eye
Otoscope A lighted instrument to visualize the eardrum and external auditory canal
(a nasal speculum may be attached to the otoscope to inspect the nasal
cavities)
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30 Health Assessment
LEARNING OUTCOMES
After completing this chapter, you will be able to:
1. Identify the purposes of the physical examination. l. Assessing the heart and central vessels.
2. Explain the four techniques used in physical examination: m. Assessing the peripheral vascular system.
inspection, palpation, percussion, and auscultation. n. Assessing the breasts and axillae.
3. Identify expected findings during health assessment. o. Assessing the abdomen.
p. Assessing the musculoskeletal system.
4. Verbalize the steps used in performing selected examination
q. Assessing the neurologic system.
procedures:
r. Assessing the female genitals and inguinal area.
a. Assessing appearance and mental status.
s. Assessing the male genitals and inguinal area.
b. Assessing the skin.
t. Assessing the anus.
c. Assessing the hair.
d. Assessing the nails. 5. Describe suggested sequencing to conduct a physical health
e. Assessing the skull and face. examination in an orderly fashion.
f. Assessing the eye structures and visual acuity. 6. Discuss variations in examination techniques appropriate for
g. Assessing the ears and hearing. clients of different ages.
h. Assessing the nose and sinuses. 7. Recognize when it is appropriate to delegate assessment
i. Assessing the mouth and oropharynx. skills to unlicensed assistive personnel.
j. Assessing the neck. 8. Demonstrate appropriate documentation and reporting of
k. Assessing the thorax and lungs. health assessment.
KEY TERMS
adventitious breath sounds, 555 external auditory meatus, 539 mydriasis, 534 resting tremor, 577
alopecia, 528 extinction, 582 myopia, 533 S1, 561
angle of Louis, 553 fasciculation, 577 normocephalic, 531 S2, 561
antihelix, 539 flatness, 519 nystagmus, 536 semicircular canals, 540
aphasia, 580 fremitus, 557 one-point discrimination, 582 sensorineural hearing loss, 540
astigmatism, 533 gingivitis, 546 ossicles, 540 sordes, 546
auricle, 539 glaucoma, 533 otoscope, 539 stapes, 540
auscultation, 519 glossitis, 546 pallor, 523 stereognosis, 582
blanch test, 530 goniometer, 579 palpation, 517 sternum, 554
bruit, 562 helix, 539 parotitis, 546 strabismus, 536
caries, 546 hernia, 593 percussion, 518 systole, 561
cataracts, 533 hordeolum (sty), 533 perfusion, 566 tartar, 546
cerumen, 539 hyperopia, 533 periodontal disease, 546 thrill, 562
clubbing, 530 hyperresonance, 519 PERRLA, 537 tragus, 539
cochlea, 540 incus, 540 pinna, 539 tremor, 577
conductive hearing loss, 540 inspection, 517 pitch, 519 triangular fossa, 539
conjunctivitis, 533 intensity, 519 plaque, 546 two-point discrimination, 582
cyanosis, 523 intention tremor, 577 pleximeter, 518 tympanic membrane, 539
dacryocystitis, 533 jaundice, 523 plexor, 518 tympany, 519
diastole, 561 lift, 560 precordium, 560 vestibule, 540
dullness, 519 lobule, 539 presbyopia, 533 visual acuity, 533
duration, 519 malleus, 540 proprioceptors, 581 visual fields, 533
edema, 523 manubrium, 554 pyorrhea, 546 vitiligo, 523
erythema, 523 mastoid, 539 quality, 519
eustachian tube, 540 miosis, 534 reflex, 581
exophthalmos, 532 mixed hearing loss, 540 resonance, 519
514 Unit 7 ● Assessing Health
513
INTRODUCTION the location of the examination, and the agency’s priorities and pro-
Assessing a client’s health status is a major component of nursing cedures. The order of head-to-toe assessment is given in Box 30–1.
care and has two aspects: (1) the nursing health history discussed in Regardless of the procedure used, the client’s energy and time need
Chapter 11 and (2) the physical examination discussed in this to be considered. The health assessment is therefore conducted in
chapter. A physical examination can be any of three types: (1) a a systematic and efficient manner that results in the fewest position
complete assessment (e.g., when a client is admitted to a health care changes for the client.
agency), (2) examination of a body system (e.g., the cardiovascular Frequently, nurses assess a specific body area instead of the entire
system), or (3) examination of a body area (e.g., the lungs, when dif- body. These specific assessments are made in relation to client com-
ficulty with breathing is observed). Note: Some nurses consider as- plaints, the nurse’s own observation of problems, the client’s present-
sessment to be the broad term used in applying the nursing process to ing problem, nursing interventions provided, and medical therapies.
health data and examination to be the physical process used to gather Examples of these situations and assessments are provided in Table 30–1.
the data. In this text, the terms assessment and examination are some- These are some of the purposes of the physical examination:
times used interchangeably—both referring to a critical investigation • To obtain baseline data about the client’s functional abilities
about:blank 1/89
,10/8/23, 8:52 PM Hesi- health assessment
514 Unit 7 ● Assessing Health
513
INTRODUCTION the location of the examination, and the agency’s priorities and pro-
Assessing a client’s health status is a major component of nursing cedures. The order of head-to-toe assessment is given in Box 30–1.
care and has two aspects: (1) the nursing health history discussed in Regardless of the procedure used, the client’s energy and time need
Chapter 11 and (2) the physical examination discussed in this to be considered. The health assessment is therefore conducted in
chapter. A physical examination can be any of three types: (1) a a systematic and efficient manner that results in the fewest position
complete assessment (e.g., when a client is admitted to a health care changes for the client.
agency), (2) examination of a body system (e.g., the cardiovascular Frequently, nurses assess a specific body area instead of the entire
system), or (3) examination of a body area (e.g., the lungs, when dif- body. These specific assessments are made in relation to client com-
ficulty with breathing is observed). Note: Some nurses consider as- plaints, the nurse’s own observation of problems, the client’s present-
sessment to be the broad term used in applying the nursing process to ing problem, nursing interventions provided, and medical therapies.
health data and examination to be the physical process used to gather Examples of these situations and assessments are provided in Table 30–1.
the data. In this text, the terms assessment and examination are some- These are some of the purposes of the physical examination:
times used interchangeably—both referring to a critical investigation • To obtain baseline data about the client’s functional abilities.
and evaluation of client status. • To supplement, confirm, or refute data obtained in the nursing
history.
• To obtain data that will help establish nursing diagnoses and plans
PHYSICAL HEALTH ASSESSMENT of care.
A complete health assessment may be conducted starting at the head • To evaluate the physiological outcomes of health care and thus the
and proceeding in a systematic manner downward (head-to-toe as- progress of a client’s health problem.
sessment). However, the procedure can vary according to the age of • To make clinical judgments about a client’s health status.
the individual, the severity of the illness, the preferences of the nurse, • To identify areas for health promotion and disease prevention.
BOX 30–1 Head-to-Toe Framework
• General survey • Chest and back
• Vital signs • Skin
• Head • Thorax shape and size
• Hair, scalp, face • Lungs
• Eyes and vision • Heart
• Ears and hearing • Spinal column
• Nose • Breasts and axillae
• Mouth and oropharynx • Abdomen
• Neck • Skin
• Muscles • Abdominal sounds
• Lymph nodes • Femoral pulses
• Trachea • External genitals
• Thyroid gland • Anus
• Carotid arteries • Lower extremities
• Neck veins • Skin and toenails
• Upper extremities • Gait and balance
• Skin and nails • Joint range of motion
• Muscle strength and tone • Popliteal, posterior tibial, and dorsalis pedis pulses
• Joint range of motion
• Brachial and radial pulses
• Sensation
TABLE 30–1 Nursing Assessments Addressing Selected Client Situations
Situation Physical Assessment
Client complains of abdominal pain. Inspect, auscultate, percuss, and palpate the abdomen; assess vital signs.
Client is admitted with a head injury. Assess level of consciousness using Glasgow Coma Scale (see Table 30–10
later in this chapter); assess pupils for reaction to light and accommodation;
assess vital signs.
The nurse prepares to administer a cardiotonic drug to Assess apical pulse and compare with baseline data.
a client.
The client has just had a cast applied to the lower leg. Assess peripheral perfusion of toes, capillary blanch test, pedal pulse if able,
and vital signs.
The client’s fluid intake is minimal. Assess tissue turgor, fluid intake and output, and vital signs.
Chapter 30 ● Health Assessment 515
BOX 30–2 Cancer Screening Guidelines for Asymptomatic People
COLORECTAL CANCER (MALES AND FEMALES) CERVICAL AND UTERINE CANCER (FEMALES)
• Fecal occult blood test or fecal immunochemical test annually • For women ages 21 to 29, screening every 3 years with Pap tests.
beginning at age 50 or • For women ages 30 to 65, screening every 5 years with both HPV
• Stool DNA test may be done beginning at age 50. test and the Pap test, or every 3 years with the Pap test alone.
• Flexible sigmoidoscopy every 5 years beginning at age 50 or • Women ages 65 and older who have had ≥3 consecutive neg-
• Colonoscopy every 10 years beginning at age 50 or ative Pap tests or ≥2 consecutive negative HPV and Pap tests
• Double contrast barium enema every 5 years beginning at in the last 10 years, the most recent test in the last 5 years, and
age 50. women who have had a total hysterectomy should stop cervical
• Computerized tomography colonography every 5 years begin- cancer screening.
ning at age 50.
PROSTATE CANCER (MALES)
BREAST CANCER (FEMALES) • For men who have at least a 10-year life expectancy, discussion
• Beginning in their early 20s, women should be told about with the primary care provider about the benefits, risks, and un-
the benefits and limitations of breast self-examination (BSE) certainties associated with prostate cancer screening
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and vital signs.
The client’s fluid intake is minimal. Assess tissue turgor, fluid intake and output, and vital signs.
Chapter 30 ● Health Assessment 515
BOX 30–2 Cancer Screening Guidelines for Asymptomatic People
COLORECTAL CANCER (MALES AND FEMALES) CERVICAL AND UTERINE CANCER (FEMALES)
• Fecal occult blood test or fecal immunochemical test annually • For women ages 21 to 29, screening every 3 years with Pap tests.
beginning at age 50 or • For women ages 30 to 65, screening every 5 years with both HPV
• Stool DNA test may be done beginning at age 50. test and the Pap test, or every 3 years with the Pap test alone.
• Flexible sigmoidoscopy every 5 years beginning at age 50 or • Women ages 65 and older who have had ≥3 consecutive neg-
• Colonoscopy every 10 years beginning at age 50 or ative Pap tests or ≥2 consecutive negative HPV and Pap tests
• Double contrast barium enema every 5 years beginning at in the last 10 years, the most recent test in the last 5 years, and
age 50. women who have had a total hysterectomy should stop cervical
• Computerized tomography colonography every 5 years begin- cancer screening.
ning at age 50.
PROSTATE CANCER (MALES)
BREAST CANCER (FEMALES) • For men who have at least a 10-year life expectancy, discussion
• Beginning in their early 20s, women should be told about with the primary care provider about the benefits, risks, and un-
the benefits and limitations of breast self-examination (BSE) certainties associated with prostate cancer screening.
and the importance of reporting breast symptoms to a health
HEALTH COUNSELING AND CANCER CHECKUP
professional. Those who choose to perform BSE should re-
(MALES AND FEMALES) OVER AGE 20
ceive instruction and have their technique reviewed regularly. • Examination for cancers of the thyroid, testicles, ovaries, lymph
Women may choose to perform BSE regularly, occasionally, or
nodes, oral region, and skin during the regular health examination
not at all.
• Clinical breast examination every 3 years from ages 20 to 40, From “Cancer Screening in the United States, 2014: A Review of Current American Cancer
Society Guidelines and Current Issues in Cancer Screening” by R. A. Smith, D. Manassaram-
and then annually beginning at age 40. Baptiste, D. Brooks, V. Cokkinides, M. Doroshenk, D. Saslow, . . . O. W. Brawley, 2014, CA: A
• Mammogram annually at age 40 and over. Cancer Journal for Clinicians, 64, pp. 31–51.
Nurses use national guidelines and evidence-based practice to BOX 30–3 Health Assessment of the Adult
focus health assessment on specific conditions. The nurse’s judgment
is key when the evidence is inconclusive or conflicting. For example, • Be aware of normal physiological changes that occur with ag-
when screening for cancer, nurses should keep in mind the American ing (see the Lifespan Considerations later in this chapter).
Cancer Society’s guidelines for early detection (Box 30–2). However, • Be aware of stiffness of muscles and joints from aging or
history of orthopedic surgery. The client may need modifica-
whereas those guidelines call for mammography every year begin- tion of the usual positioning necessary for examination and
ning at age 40, the U.S. Preventive Services Task Force (2009) recom- assessment.
mends breast mammography only every 2 years for women ages 50 • Expose only areas of the body to be examined in order to
to 74 and none thereafter. avoid chilling.
• Permit ample time for the client to answer your questions and
assume the required positions.
Preparing the Client • Be aware of cultural differences. The client may want a family
Most people need an explanation of the physical examination. Often member present during disrobing.
clients are anxious about what the nurse will find. They can be reas- • Arrange for an interpreter if the client’s language differs from
that of the nurse.
sured during the examination by explanations at each step. The nurse • Ask clients how they wish to be addressed, such as “Mrs.” or
should explain when and where the examination will take place, why “Miss.”
it is important, and what will happen. Instruct the client that all in- • Adapt assessment techniques to any sensory impairment; for
formation gathered and documented during the assessment is kept example, make sure eyeglasses or hearing aids are nearby.
confidential in accordance with the Health Insurance Portability and • If clients are older or frail, it is wise to conduct the assessment
in several segments in order to not overtire them.
Accountability Act (HIPAA). This means that only those health care
providers who have a legitimate need to know the client’s information
will have access to it. and neck, heart and lungs, and range of motion can be done early in
Health examinations are usually painless; however, it is im- the process, with the ears, mouth, abdomen, and genitals being left
portant to determine in advance any positions that are contraindi- for the end of the exam.
cated for a particular client. The nurse assists the client as needed
to undress and put on a gown. Clients should empty their bladders Preparing the Environment
before the examination. Doing so helps them feel more relaxed and It is important to prepare the environment before starting the assess-
facilitates palpation of the abdomen and pubic area. If a urinaly- ment. The time for the physical assessment should be convenient
sis is required, the urine should be collected in a container for that to both the client and the nurse. The environment needs to be well
purpose. lighted and the equipment should be organized for efficient use.
When assessing adults it is important to recognize that people A client who is physically relaxed will usually experience little dis-
of the same age differ markedly. Box 30–3 provides special consider- comfort. The room should be warm enough to be comfortable for
ations for assessing adults, especially older adults. the client.
The sequence of the assessment differs with children and adults. Providing privacy is important. Most people are embarrassed if
With children, always proceed from the least invasive or uncomfort- their bodies are exposed or if others can overhear or view them dur-
able aspect of the exam to the more invasive. Examination of the head ing the assessment. Culture, age, and gender of both the client and the
516 Unit 7 ● Assessing Health
nurse influence how comfortable the client will be and what special Draping
arrangements might be needed. For example, if the client and nurse Drapes should be arranged so that the area to be assessed is exposed
are of different genders, the nurse should ask if it is acceptable to and other body areas are covered. Exposure of the body is frequently
perform the physical examination. Family and friends should not be embarrassing to clients. Drapes provide not only a degree of privacy
present unless the client asks for someone. but also warmth. Drapes are made of paper, cloth, or bed linen.
Positioning Instrumentation
Several positions are frequently required during the physical assess-
All equipment required for the health assessment should be clean, in
ment. It is important to consider the client’s ability to assume a posi-
good working order, and readily accessible. Equipment is frequently set
tion. The client’s physical condition, energy level, and age should also
up on trays, ready for use. Various instruments are shown in Table 30–3.
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 Methods of Examining
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The sequence of the assessment differs with children and adults. Providing privacy is important. Most people are embarrassed if
With children, always proceed from the least invasive or uncomfort- their bodies are exposed or if others can overhear or view them dur-
able aspect of the exam to the more invasive. Examination of the head ing the assessment. Culture, age, and gender of both the client and the
516 Unit 7 ● Assessing Health
nurse influence how comfortable the client will be and what special Draping
arrangements might be needed. For example, if the client and nurse Drapes should be arranged so that the area to be assessed is exposed
are of different genders, the nurse should ask if it is acceptable to and other body areas are covered. Exposure of the body is frequently
perform the physical examination. Family and friends should not be embarrassing to clients. Drapes provide not only a degree of privacy
present unless the client asks for someone. but also warmth. Drapes are made of paper, cloth, or bed linen.
Positioning Instrumentation
Several positions are frequently required during the physical assess-
All equipment required for the health assessment should be clean, in
ment. It is important to consider the client’s ability to assume a posi-
good working order, and readily accessible. Equipment is frequently set
tion. The client’s physical condition, energy level, and age should also
up on trays, ready for use. Various instruments are shown in Table 30–3.
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 Methods of Examining
in one position, thus minimizing the number of position changes Four primary techniques are used in the physical examination: in-
needed (Table 30–2). spection, palpation, percussion, and auscultation. These techniques
TABLE 30–2 Client Positions and Body Areas Assessed
Position Description Areas Assessed Cautions
Dorsal recumbent Back-lying position with knees Female genitals, rectum, and May be contraindicated for
flexed and hips externally female reproductive tract clients who have cardiopulmo-
rotated; small pillow under nary problems.
the head; soles of feet on the
surface
Supine (horizontal recumbent) Back-lying position with legs Head, neck, axillae, anterior Tolerated poorly by clients with
extended; with or without thorax, lungs, breasts, heart, cardiovascular and respiratory
pillow under the head vital signs, abdomen, extremi- problems.
ties, peripheral pulses
Sitting A seated position, back un- Head, neck, posterior and Older adults and weak clients
supported and legs hanging anterior thorax, lungs, breasts, may require support.
freely axillae, heart, vital signs, upper
and lower extremities, reflexes
Lithotomy Back-lying position with feet Female genitals, rectum, and May be uncomfortable and
supported in stirrups; the hips female reproductive tract tiring for older adults and often
should be in line with the edge embarrassing.
of the table
Sims’ Side-lying position with low- Rectum, vagina Difficult for older adults and
ermost arm behind the body, people with limited joint
uppermost leg flexed at hip movement.
and knee, upper arm flexed at
shoulder and elbow
Prone Lies on abdomen with head Posterior thorax, hip joint Often not tolerated by older
turned to the side, with or movement adults and people with
without a small pillow cardiovascular and respiratory
problems.
Chapter 30 ● Health Assessment 517
TABLE 30–3 Equipment and Supplies Used for a Health Examination
Supplies Purpose
Flashlight or penlight To assist viewing of the pharynx or to determine the reactions of the
pupils of the eye
Ophthalmoscope A lighted instrument to visualize the interior of the eye
Otoscope A lighted instrument to visualize the eardrum and external auditory canal
(a nasal speculum may be attached to the otoscope to inspect the nasal
cavities)
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