Chapter 22: Health Assessment

What Are the Main Points in This Chapter?

-A physical examination may be conducted to obtain data about the patient, to further investigate an identified health problem, to monitor a client's health status, or to screen for health problems. -A comprehensive physical assessment includes a complete head-to-toe examination of every body system. Data from a comprehensive physical assessment provide guidance for care and determine the need for further assessment. -A focused physical assessment is performed to obtain data about an actual, potential, or possible problem that has been identified. A focused exam adds to the database created from the comprehensive assessment. -An ongoing assessment is appropriate for periodic reassessment of the client and reflects the dynamic state of the client. This is a less detailed examination than a comprehensive assessment. -Before a physical assessment, you will need to gather equipment, prepare the environment, review the skills you will use, familiarize yourself with the patient situation, review the nursing plan of care, and assist the patient to relax by taking the time to develop a rapport. -Inspection is the use of sight to gather data. Inspection begins the moment you meet the client. -Palpation is the use of touch to gather data. Use palpation to assess temperature, skin texture, moisture, anatomical landmarks, and abnormalities such as edema, masses, or areas of tenderness. -Percussion, tapping on the skin with short strokes from your fingers, produces vibrations that allow you to determine the location, size, and density of underlying structures. -Auscultation is the use of hearing to gather data. Direct auscultation is unassisted listening. Indirect auscultation is listening to the sounds produced by the body with the help of a stethoscope.

The Nine Regions of the Abdomen

-Right Hypochondriac (3) Right lobe of liver Gallbladder Duodenum Hepatic flexure Portion of right kidney Suprarenal gland -Epigastric (1) Pylorus Duodenum Head of pancreas Portion of liver -Left Hypochondriac (2) Stomach Spleen Pancreas tail Splenic flexure Upper portion of left kidney Suprarenal gland -Right Lumbar (6) Portion of right kidney Hepatic flexure of colon Ascending colon Duodenum Jejunum -Umbilical (4) Lower duodenum Jejunum Ileum -Left Lumbar (5) Descending colon Lower half of left kidney -Right Inguinal (9) Cecum Appendix Ileum Right ureter Right spermatic cord Right ovary -Hypogastric (7) Ileum Bladder (if distended) Uterus (if enlarged) -Left Inguinal (8) Sigmoid colon Left ureter Left spermatic cord Left ovary

Name one abnormal assessment finding related to the external eye.

Answer: Possible answers include crusting, swelling, pterygium, ectropion, entropion, and ptosis.

Identify the best position for examining the lungs, heart, pulses, and abdomen.

Answer: -The best position for examining the patient's lungs and heart is an upright position—seat the patient in Fowler's or semi-Fowler's position. The lateral recumbent position is also appropriate for assessing heart murmurs. -The best position for assessing the patient's pulses is supine -The best position for assessing the patient's abdomen is supine, or dorsal recumbent if the patient has abdominal pain.

List and describe the location of the horizontal and vertical landmarks of the anterior chest.

Answer: -To locate sounds vertically, use the intercostals spaces (ICS). The first rib is tucked up next to the clavicle. The first ICS is between the first and second rib. The space between the second and third ribs is the second ICS, and so forth. -The left midclavicular line begins at the midpoint of the patient's left clavicle and extends vertically down the length of the chest. The right midclavicular line begins at the midpoint of the right clavicle, and so on. The midsternal line is a vertical line running through the center of the sternum. The anterior axillary lines begin (on the right and on the left) at the anterior axillary folds. They are used to locate sounds both on the anterior and lateral chest.

List and describe the location of the horizontal and vertical landmarks of the posterior chest.

Answer: -To locate sounds vertically, use the vertebrae. The prominent vertebra at the base of the neck is the seventh cervical vertebra (C7). The next one down is T1 (first thoracic). Counting down to about T9 should be adequate. The vertebral line extends vertically down the spine. The right and left scapular lines are vertical lines through the inferior angle of the scapula.

Describe how you would prepare for a physical exam.

Answer: -To prepare for a physical exam, you must prepare the environment, yourself, and the patient. -Prepare the environment by selecting a quiet, private location with good lighting, gathering the equipment needed, and providing drapes for the patient. -Prepare yourself by reviewing any knowledge or technical skills you feel unsure of; securing help, if needed; and reviewing the patient record and care plan. -Prepare the patient by selecting an appropriate time, establishing rapport, explaining all steps of the exam, and properly positioning the patient.

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? 1) Sims' 2) Supine 3) Dorsal recumbent 4) Semi-Fowler's

Answer: 1) Sims' Rationale: Sims' position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery. The patient with a hip replacement can assume the supine, dorsal recumbent, or semi-Fowler's position without causing harm to the joint. Supine position is lying on the back, facing upward. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. In semi-Fowler's position, the patient is supine with the head of the bed elevated and legs slightly elevated.

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? 1) Sitting upright 2) Lying flat on the back with knees flexed 3) Lying flat on the back with arms and legs fully extended 4) Side-lying with the knees flexed

Answer: 1) Sitting upright Rationale: If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. In addition, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on their back) and can have direct eye contact with the examiner. However, other positions can be suitable when the patient's physical condition restricts the comfort or ability of the patient to sit upright.

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding might the nurse expect when assessing the patient's nails? 1) Soft, boggy nails 2) Brittle nails 3) Thickened nails 4) Thick nail with yellowing

Answer: 1) Soft, boggy nails Rationale: Soft, boggy nails are seen with poor oxygenation. Brittle nails are seen with hypothyroidism, malnutrition, calcium, and iron deficiency. Thickened nails may result from poor circulation. A thick nail with yellowing is an indication of fungal infection known as onychomycosis.

The nurse should assess skin temperature by using the: 1) dorsum of the hand. 2) pad of the fingertip. 3) palm of the hand. 4) dorsum of the wrist.

Answer: 1) dorsum of the hand Rationale: The dorsum of the hand should be used to assess skin temperature. The nurse should compare the temperature of the hands with that of the feet and compare the right side of the body with the left.

Match the following assessment findings with the part of the body or organ that is being assessed: Assessment Finding 1. Miosis 2. Otitis media 3. Glossitis 4. Egophony 5. Borborygmi Body Part or Organ A. Tongue B. Pupil C. Lung D. Abdomen E. Ear

Answer: 1, B 2, E 3, A 4, C 5, D

For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques? A. Palpation B. Auscultation C. Inspection D. Percussion 1) D, B, A, C 2) C, A, D, B 3) B, C, D, A 4) A, B, C, D

Answer: 2) C, A, D, B Rationale: Inspection begins immediately when the nurse meets the patient, as she observes the patient's appearance and behavior. Observational data are not intrusive to the patient. When performing assessment techniques involving physical touch, the behavior, posture, demeanor, and responses might be altered. Palpation, percussion, and auscultation should be performed in that order, except when performing an abdominal assessment. During abdominal assessment, auscultation should be performed before palpation and percussion to prevent altering bowel sounds.

How should the nurse modify an examination for a 7-year-old child? 1) Ask the parents to leave the room before the examination. 2) Demonstrate equipment before using it. 3) Allow the child to help with the examination. 4) Perform invasive procedures (e.g., otoscopic) last.

Answer: 2) Demonstrate equipment before using it. Rationale: The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The nurse should make sure parents are not present during the physical examination of an adolescent, but they usually help younger children feel more secure. The nurse should allow a preschooler to help with the examination when possible, but not usually a school-age child. Toddlers are often fearful of invasive procedures, so those should be performed last in this age group. It is best to perform invasive procedures last for all age groups; therefore, this does not represent a modification.

The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? 1) Dorsal recumbent 2) Semi-Fowler's 3) Lithotomy 4) Sims'

Answer: 2) Semi-Fowler's Rationale: If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position, except that the patient's legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep patient covered as much as possible. The patient in Sims' position is on left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm is placed comfortably. Sims' position is used to examine the rectal area. In semi-Fowler's position, the patient is supine with the head of the bed elevated and legs slightly elevated.

The nurse should use the diaphragm of the stethoscope to auscultate which of the following? 1) Heart murmurs 2) Jugular venous hums 3) Bowel sounds 4) Carotid bruits

Answer: 3) Bowel sounds Rationale: The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen.

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? 1) Ongoing assessment 2) Comprehensive physical assessment 3) Focused physical assessment 4) Psychosocial assessment

Answer: 3) Focused physical assessment Rationale: The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case, shortness of breath. An ongoing assessment is performed as needed, after the initial data are collected, preferably with each patient contact. A comprehensive physical assessment includes an interview and a complete examination of each body system. A psychosocial assessment examines both psychological and social factors affecting the patient. The nurse conducting a psychosocial assessment would gather information about stressors, lifestyle, emotional health, social influences, coping patterns, communication, and personal responses to health and illness, to name a few aspects.

Where should the nurse assess skin color changes in the dark-skinned patient? 1) Nailbeds 2) Any exposed area 3) Oral mucosa 4) Palms of the hands

Answer: 3) Oral muscosa Rationale: In dark-skinned patients, look for color changes in the conjunctiva or oral mucosa. They should be pink and moist. In dark-skinned patients, skin color changes may not be apparent in nailbeds, palms of the hands, and other exposed areas.

A patient's ankles appear swollen. When the nurse assesses the edema, the skin depresses 6 mm, and the depression lasts 2 minutes. The nurse should document this finding as: 1) trace edema. 2) +1 edema. 3) +2 edema. 4) +3 edema.

Answer: 4) +3 edema Rationale: To assess edema, the nurse presses firmly with her fingertip for 5 seconds over a bony area. Trace appears as a minimal depression; +1 appears as a 2-mm depression with a rapid return of skin to position; +2 reveals a 4-mm depression, which disappears in 10 to 15 seconds; +3 displays a 6-mm depression that lasts 1 to 2 minutes; and +4 demonstrates an 8-mm depression that persists for 2 to 3 minutes. The area is grossly edematous.

While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a sign of: 1) fungal infection. 2) poor circulation. 3) iron deficiency. 4) long-term hypoxia.

Answer: 4) Long-term hypoxia Rationale: Clubbing (when the nail plate angle is 180° or more) is associated with long-term hypoxic states such as chronic lung disease. A thick nail with yellowing indicates a fungal infection. Spoon-shaped nails may result from iron-deficiency anemia. Brittle nails are commonly seen with malnutrition, hyperthyroidism, and malnutrition.

The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered: 1) obese. 2) overweight. 3) average. 4) underweight.

Answer: 4) underweight Rationale: For adults, BMI should range between 20 and 25; BMI less than 20 is considered underweight; BMI 25 to 29.9 is overweight; and BMI greater than 30 is considered obese.

What is the most common hernia occurring in men?

Answer: A hernia is a protrusion of the intestine (or other organ) through the wall that contains it. In men, this is most likely to be a protrusion of the intestine (a) through the abdominal wall (direct hernia), or (b) into the inguinal canal and possibly into the scrotum (indirect), or (c) through the abdominal musculature at the umbilicus for infants.

Identify and describe the components assessed in the neurological exam.

Answer: A neurological exam assesses the following components: -Cerebral function through evaluation of level of consciousness, mental status, and cognitive function -Cranial nerve function through assessment of each of the 12 cranial nerves -Reflex function through assessment of DTRs and superficial reflexes -Sensory function through assessment of light touch, light pain, temperature, vibration, position sense, stereognosis, graphesthesia, two-point discrimination, point localization, and extinction -Motor and cerebellar function through musculoskeletal assessment

What are the purposes of a physical examination?

Answer: A physical examination is conducted for the following purposes: -Obtain baseline data about the patient -Identify nursing diagnoses, collaborative problems, and wellness diagnoses -Further investigate a previously identified health problem -Monitor the status of a previously identified problem Screen for health problems

Assessing a client's nails and hair is often not a critical assessment. But these items are important to include in a complete physical exam for which of the following reason(s)? Select all that apply. A. Abnormal assessment findings may indicate a self-care deficit. B. Changes in the distribution of hair and/or color of nailbeds may indicate the presence of a more serious disease. C. Alterations in assessment findings related to hair and nails may represent underlying malnutrition. D. The presence of a callus formation around the nail may indicate a malignancy.

Answer: A, B, C Rationale: Nails should be clean and free of debris. A change in nail shape may indicate underlying disease or malnutrition. Nail-picking may result in callus formation, but a callus around the nail does not indicate malignancy.

Identify the sequence of assessment for the abdominal exam.

Answer: An abdominal exam is performed in the following sequence: Inspection Auscultation Percussion Palpation

Which of the following data would you likely obtain during a general survey of the client during the physical examination? Select all that apply. A. Bowel sounds present × 4 quadrants B. Blood pressure 130/70 mm Hg C. Speech appropriate to developmental stage D. Gait steady

Answer: B, blood pressure; C, speech appropriate, D, gait steady Rationale: A general survey includes physical appearance, mental status, mobility, client behavior, and vital signs. The general survey provides cues to guide physical assessment. The presence or absence of bowel sounds is determined by auscultating the abdomen, an assessment skill used during a head-to-toe or focused assessment.

Which type of assessment is best suited for use in an emergency or urgent patient situation? A. Ongoing B. Focused C. Psychosocial D. Comprehensive

Answer: B. Focused assessment Rationale: Emergency and urgent situations require the use of a focused assessment, which will allow the nurse to quickly gather system-specific data related to a presenting problem. Both a comprehensive and an ongoing assessment would follow a focused assessment once the critical data are obtained. A psychosocial assessment is not directly relevant to a physical examination, especially in an urgent situation.

In completing a nursing assessment of the skin, the nurse knows to instruct the client to seek medical attention for which of the following? A. Acne on the face and neck B. Crusts that have formed over pustules C. Striae found on a female patient's abdomen D. A mole that has become asymmetrical

Answer: D. A mole that has become asymmetrical Rationale: A change in the size, shape, color, or elevation above the skin surface of a mole could indicate the presence of a malignant lesion.

What are the responsibilities of the nurse during an internal exam of the female genitourinary system?

Answer: During an internal exam of the female genitourinary system, the nurse has the following responsibilities: Gathering equipment Preparing the patient Assisting the client and examiner during the procedure Assisting the client after the procedure Documenting the findings

What are the major components of an eye assessment?

Answer: Eye assessments have the following major components: -Inspection of the external eye and lids -Snellen exam for distance vision -Near vision assessment with newsprint -Color vision check -Visual field examination -Internal eye exam with an ophthalmoscope

Identify the cranial nerves involved with eye movement and function.

Answer: Eye movement and function involve the following cranial nerves: -CN III (oculomotor) -CN IV (trochlear) -CN VI (abducens) -CN II (optic) works together with -CN III to control the pupillary reaction to light

In determining the location, size, and density of the liver, the nurse uses the assessment skills of auscultation. True False

Answer: False Rationale: The assessment skill the nurse uses would be percussion.

Identify five physical assessment skills

Answer: Five physical assessment skills are inspection, palpation, percussion, auscultation, and olfaction.

What assessment techniques are used when examining the male genitourinary system?

Answer: Inspection and palpation are the techniques used when examining the male genitourinary system.

What exam modifications, based on developmental stage, should you consider for the following clients (Meet Your Patient, in Volume 1 of your textbook)? Nam Nguyen

Answer: Nam is a middle adult. He does not require exam modifications based on developmental stage but may require modifications based on his physical condition. For example, Nam has knee pain and may have difficulty getting up and down from the exam table, and he might not be able to assume a knee-chest position.

Nam's 3-year-old grandson, Kim Phan

Answer: Nam's 3-year-old grandson, Kim, is a toddler. Because he is being raised by his grandparents, Nam or Yen should be present during the exam. Have Kim help with the exam (e.g., holding items) and provide reassurance throughout the exam.

Nam's elderly mother, Mai Nguyen

Answer: Nam's mother, Mai, is an older adult. You will need to assess her energy and provide rest periods as needed. If she tires easily, arrange the exam sequence to limit position changes. As part of the exam, you will want to assess her support system and ability to perform activities of daily living.

Your client has a negative Weber test. What further testing is required?

Answer: No further testing is required. This is a normal result.

Your client is hospitalized for a documented cerebrovascular accident?

Answer: Perform a comprehensive exam, and compare your findings with findings from previous exams.

Your client has been admitted with an acute head injury and the extent of neurological injury is unknown?

Answer: Perform a comprehensive exam, and compare your findings with findings from previous exams. Use well-defined screening tools whenever possible so that serial assessments can be made.

What approach to assessment should you take if: Your client has no neurological problems but you are performing a comprehensive exam?

Answer: Perform a focused exam that looks at each of the areas in the neurological exam.

List and describe the location of the vertical landmarks of the lateral chest.

Answer: The anterior axillary lines begin (on the right and on the left) at the anterior axillary folds. They are used to locate sounds both on the anterior and lateral chest. The posterior axillary lines are vertical lines through the posterior axillary fold. The midaxillary line is a vertical line from the middle of the axilla.

What aspects of the skin should you assess?

Answer: The following aspects of the skin should be assessed: color, odor, temperature, texture, turgor, edema, and any visible lesions.

In what order are these skills performed?

Answer: The physical skills are performed for all assessments except abdominal assessment in the following order: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation For an abdominal exam, the skills are ordered as follows: 1. Inspection 2. Auscultation 3. Percussion 4. Palpation Olfaction is not formally incorporated into assessment but provides additional data with some assessments.

What warning signs lead you to suspect a malignant lesion?

Answer: The warning signs of malignant lesions are as follows: A—for asymmetry B—for border irregularity C—for color variation D—for diameter greater than 0.5 cm E—for elevation above the skin surface

If a 3-year-old child becomes fearful and cries during a physical assessment, it would be helpful to continue the assessment while the child sits in the lap of a parent. True False

Answer: True

Identify the precautions to take when evaluating the carotid arteries.

Answer: When evaluating the carotid arteries, take the following precautions: Never palpate both carotid arteries at the same time because bilateral pressure may impair cerebral blood flow. Avoid massaging the carotid artery as you palpate. Increased pressure on the carotids will lead to a drop in the pulse rate. Do not routinely palpate the carotids; palpate only if indicated by patient's health status or prescribed by a physician.

What strategies can you use to make the client more comfortable during an abdominal assessment?

Answer: You can make the client more comfortable during an abdominal assessment by using the following strategies: -Have the client empty his bladder prior to his abdominal exam. -Use a supine position with flexed knees, which relaxes his abdominal muscles. -If the client has a painful area, examine that area last to minimize his discomfort. -Use light palpation to assess for tenderness and guarding before proceeding to deep palpation.

What assessments should you perform if you find a lesion?

Answer: You should assess the lesion for size, shape, color, distribution, texture, surface relationship, exudate, and presence of pain or tenderness.

Classification of Heart Murmurs

Grade Description Grade 1/6 Very faint, comes and goes Grade 2/6 Quiet, but heard immediately Grade 3/6 Moderately loud Grade 4/6 Loud, associated with a thrill Grade 5/6 Heard with stethoscope half off the chest wall, associated with a thrill Grade 6/6 Heard with stethoscope entirely off chest wall, associated with a thrill