Basic Nursing Assessment

 

 

TERMINAL LEARNING OBJECTIVE

 

Give the necessary medical equipment in a holding or ward setting.   You are providing casualty care as part of an integrated team in a Minimal Care Ward.

INTRODUCTION

Most patients view a physical examination with some anxiety.  They may feel vulnerable, physically exposed, apprehensive about possible pain and uneasy about what the examiner may find.  Mindful of such feelings, the skillful examiner (91w) is thorough without wasting time, and systematic without being rigid.  Using all the human senses, the soldier medic examines each body system and provides expertise and emotional support for the patient and family.

 

Facts about Physical Assessment

    

a.   The systematic collection and analysis of subjective and objective data (facts).  This information is collected to provide a database.

 

   (1)  Subjective data

 

   (2)  Objective data

 

   (3)  Data Base

 

b.   Assessment is used to establish a database for the patient.  It is the basis on which patient strengths and health problems are identified. 

 

c.   The primary source of patient information is the patient. Other resources include

 

   (1)  Patient's support persons

 

   (2)  Patient record

 

   (3)  Information from other health care professionals

 

d.   The physical assessment is focused primarily on the functional abilities of the patient

 

e.   Purposes of a physical assessment

 

   (1)  To confirm the patient's history or to observe findings not reported in the history

 

   (2)  To obtain a physical and mental database on the patient which can be used for nursing intervention

 

   (3)  To evaluate or measure the quality of the care (intervention) given to the patient

 

f.   Considerations in patient preparation for a physical assessment

 

   (1)  Evaluate all sources of data

 

      (a)  Patient

 

      (b)  Support people

 

      (c)  Patient record

 

      (d)  Other health professionals

 

   (2)  Exam should occur in a quiet, well-lit room with consideration for patient privacy and comfort

 

   (3)  Explain all procedures to patient to avoid alarming or worrying patient and encourage cooperation

 

   (4)  Ask patient to empty bladder prior to exam and assist with gowning/draping as needed

 

   (5)  Discuss confidentiality with patient

 

 Basic Techniques Used in Performing an Assessment

  

a.   The nursing assessment includes two steps

 

   (1)  Collection and verification of data from a primary source (the patient) and secondary source (the family, health care professionals)

 

   (2)  The analysis of that data to establish a baseline

 

b.   Inspection - Observations using visual, auditory, and olfactory senses

 

c.   Palpation - Technique using the sense of touch to gather information about temperature, turgor, texture, moisture, vibrations, and shape

 

d.   Auscultation - The act of listening to sound produced within the body with a stethoscope

 

e.   Percussion - The act of striking one object against another for the purpose of producing sound (tympany, resonance, hyperresonance, dullness, flatness)

 

 

Components of the Patient Assessment

    

a.   The interview includes

 

   (1)  Chief Complaint

 

   (2)  History of Present Illness

 

   (3)  Past Health History

 

   (4)  Family Health History

 

   (5)  Psychosocial History: 

 

      (a)  Age

 

      (b)  Sex/Race

  

      (c)  Marital status

 

      (d)  Number of children

 

      (e)  Occupation

 

      (f)   Education

 

      (g)  Religious affiliation

 

      (h)  Living accommodations

 

b.   General appearance and behavior assessment.  Items to inspect

 

   (1)  Body build (measure height and weight)

 

   (2)  Posture

 

   (3)  Gait - coordination of movements and pattern of gait.

 

   (4)  Hygiene, grooming - note cleanliness, body odors, appropriate dress for age and environment

 

   (5)  Signs of illness - note posture, skin color, respirations, nonverbal communications of pain or distress

 

   (6)  Affect, attitude, mood - note speech, facial expressions, ability to relax, eye contact, behavior

 

   (7)  Cognitive process - note speech content and patterns, appropriate verbal responses

 

   (8)  Cognitive function - an intellectual process by which one becomes aware of, perceives, or comprehends ideas.  It involves all aspects of perception, thinking, reasoning, and remembering.

 

c.   Vital Signs 

 

   (1)  Temperature

 

      (a)  May vary with the time of day

 

      (b)  Oral - 98.6 degrees Fahrenheit is considered normal

 

      (c)  Rectal temperature is most accurate. Temperature of > 100.4 = fever.

 

   (2)  Blood Pressure

 

      (a)  Measure the blood pressure in both arms

 

      (b)  Use the correct sized cuff

 

         1)  To determine cuff size, the length of the cuff should be 80% of the upper arm circumference and be two thirds the width of the upper arm. 

 

         2)  An improper size will give an inaccurate reading.  A higher inaccurate reading will be obtained if too small a cuff is used. conversely, a lower inaccurate reading will be obtained if too large a cuff is used.

 

      (c)  Normal range 95-140 mmHg systolic, 60-90 mmHg diastolic

 

   (3)  Pulse

 

      (a)  Palpate pulses for at least 30 seconds

 

      (b)  Normal adult pulse 60-80 beats/minute

 

      (c)  Note the number of irregular beats per minute

 

      (d)  Peripheral pulses are graded on a scale of 0-4 by the following system 

 

            1)  0 = Absent, no pulse

 

            2)  +1 = Not easily felt, thready, weak

 

            3)  = Difficult to palpate, stronger than +1

  

            4)  +3 = Normal.  Easily felt, not easily obliterated with pressure

 

            5)  +4 = Strong, bounding, unable to obliterate with moderate pressure

 

   (4)  Respiration

 

      (a)  Count number of respirations taken in 15 seconds and multiply by 4

 

      (b)  Normally 12-20 resp/min

 

   (5)  Measure pulse oxygen saturation (See LP C191W059, Cardiac Monitoring)

 

d.   Head-to-toe assessment

 

   (1)  Integumentary System

 

      (a)  Ask if patient has been exposed to harmful environmental materials or increased sun exposure, has recent skin changes, or is currently taking medications

 

      (b)  Normal skin color

 

         1)  Varies among races and individuals

 

         2)  Ranges from pinkish white to various shades of brown

 

         3)  Exposed areas may vary in color with unexposed areas

 

         4)  Healthy dark skin has a reddish undertone; buccal mucosa, tongue, lips, nails, normally appear pink 

 

     (c)  Skin color assessment

 

         1)  Cyanosis - dusky bluish color

 

            a)  Inspect ears, lips, inside of mouth, hands, nailbeds

 

            b)  Caused by respiratory or cardiac diseases, or cold environment (decreased oxygenation)

 

         2)  Jaundice - yellowish color

 

            a)  Inspect skin, mucous membranes, sclera

 

            b)  Caused by liver disease (increased bilirubin)

 

         3)  Pallor - paleness

 

            a)  Inspect face, lips, conjunctival, mucous membranes

 

            b)  Caused by anemia (decreased hemoglobin) or inadequate blood circulation

 

         4)  Erythema - redness

 

            a)  Inspect facial area, localized areas

 

            b)  Caused by blushing, alcohol intake, fever, injury, infection

 

      (d)  Vascularity - bleeding or bruising

 

         1)  Ecchymosis - collection of blood in subcutaneous tissues causing purple discoloration

 

         2)  Petechiae - small hemorrhagic spots caused by capillary bleeding

 

NOTE:  Note location, color, size of vascular findings.

 

      (e)  Lesions - note presence of wounds, scars, rash, etc.

 

      (f)   Note skin temperature and moisture - normally warm and dry

 

      (g)  Skin turgor - fullness or elasticity of skin

 

      (h)  Edema - excess fluid in tissues characterized by swelling with shiny skin

 

      (i)   Edema scale

 

            0 = None

            +1 = Trace

            +2 = Moderate

            +3 = Deep

            +4 = Very deep

 

   (2)  HEENT - Head, eyes, ears, nose, throat (inspection and palpation) 

 

      (a)  Head - size, shape, symmetry, tenderness

 

      (b)  Eyes

 

         1)  Symmetry, alignment and movement of eyes, eyelashes, eyebrows, eyelids, pupils

 

         2)  Visual acuity and peripheral vision

 

         3)  Pupils are normally black, equal in size, round, smooth

 

      (c)  Ears

 

         1)  Hearing; shape, size, symmetry of external ear

 

         2)  Palpate external ear for pain, edema, lesions

 

         3)  Ear canal should be smooth and pinkish - examine for wax, discharge, foreign bodies

 

      (d)  Nose/sinuses

 

      (e)  Throat - inspect lips, gums, teeth, tongue, hard and soft palates

 

         1)  Uvula normally centered and freely movable

 

         2)  Tonsils normally small, pink, symmetrical in size

 

   (3)  Nervous System / Neurological Assessment 

 

      (a)  Mental Status

 

         1)  Orientation level - person, place, time

 

         2)  Observe patients' appearance, general behavior, response to questions, ability to speak clearly

 

         3)  Note memory recall - short and long term

 

      (b)  Pupillary reaction to light, accommodation, convergence

 

      (c)  Motor ability - note abnormal balance, gait, or coordination

 

      (d)  Sensory function - response to pain, light touch

 

   (4)  Thorax and lungs (respiratory) 

 

      (a)  Inspection

 

         1)  Shape of chest

 

         2)  Breathing patterns

 

         3)  Rate of respirations

 

            a)  Bradypnea - Rate less than 12 respirations per minute

 

            b)  Tachypnea - Rate greater than 20 respirations per minute

 

            c)  Dyspnea - Breathlessness or difficult breathing

 

            d)  Orthopnea - Shortness of breath when lying down

 

            e)  Kussmaul - Faster and deeper respirations than normal without pauses

 

            f)   Cheyne-Stokes - Cyclic pattern which progresses from slow and shallow to fast and deep with a gradual return to slow and shallow respirations, followed by a period of apnea

 

      (b)  Palpation - detect areas of sensitivity, chest expansion during respiration

 

      (c)  Auscultation - auscultate anterior and posterior fields (upper, middle, and lower lobes)

 

         1)  Rales (crackles) - fizzing sound produced by moisture in airways

 

         2)  Rhonchi - Coarse, gurgling sound in bronchial tubes - low pitched - resulting from air flow across passages which are narrowed by fluids, tumors, swelling

 

         3)  Wheezes - Type of rhonchi - squeaky sound - high pitched

 

         4)  Cough - Note whether the cough is productive or non-productive and character of secretions

 

   (5)  Cardiovascular System 

 

         (a) Inspect the neck and epigastric areas for visible pulsations

 

         (b) Palpate 

 

            1)  Pulses

 

            2)  Edema

 

            3)  Capillary refill

 

              a) Acceptable - < 3 seconds

 

              b) Abnormal or sluggish - > 3 seconds 

 

      (c)  Auscultate - Heart sounds

 

         1)  Rate - per minute

 

         2)  Rhythm - regular or irregular

 

   (6)  Gastrointestinal

 

NOTE:  Be sure the patient has an empty bladder and that he/she is lying flat with knees slightly flexed.

 

      (a)  Flat

 

      (b)  Protuberant - (A part that is prominent beyond a surface).

 

         3)  Concave

 

         4)  Note local bulges/scars, note color of scars

 

NOTE:  Inspect the general contour of abdomen

 

      (b)  Auscultate

 

NOTE:  This is done before palpation because the latter may alter the character of bowel sounds.

 

            a)  Auscultate each of four quadrants in a clockwise systematic manner

 

            b)  Normal frequency ranges from 5-34 bowel sounds per minute, described as audible, hyperactive, hypoactive, or inaudible

 

NOTE:  Character of bowel sounds (clicks and gurgles produced by movement of air and flatus in GI tract)

 

NOTE:  Listen for 5 minutes in order to distinguish inaudible from audible bowel sounds.

 

      (c)  Palpate all four quadrants and note: 

 

         1)  Muscular resistance

 

         2)  Tenderness

 

         3)  Enlargement of organs

 

         4)  Masses

 

NOTE:  Appetite, usual elimination patterns, character of stool, recent changes, artificial orifices, and use of laxatives should be assessed during the interview. 

 

   (7)  Genitourinary 

 

      (a)  History of urinary elimination

 

         1)  Unusual patterns of elimination

 

         2)  Recent changes

 

         3)  Aids to elimination

 

         4)  Present or past voiding difficulties

 

      (b)  Inspection

 

         1)  Urine

 

            a)  Color

 

            b)  Clarity

 

            c)  Odor

 

         2)  Urethral orifice for signs of inflammation/discharge

 

         3)  Always inspect testis if patient presents with abdomen pain or urinary tract symptoms

 

      (c)  Palpate suprapubic areas and note

 

         1)  Tenderness

 

         2)  Distension

 

   (8)  Musculoskeletal 

 

      (a)  Inspection and palpation

 

         1)  Gait

 

         2)  Muscles

 

            a)  Bilateral symmetry

 

            b)  Tenderness

 

            c)  Strength/tone

 

         3)  Joints

 

            a)  Note active/passive range of motion (ROM) - Joint movements include flexion, extension, hyperextension, abduction, adduction, pronation, supination.

  

            b)  Palpate joints and note - Pain, swelling, nodules, crepitation (grating sound heard on movement)

 

         4)  Bones

 

            a)  Note normal contour or prominences, symmetry

 

            b)  Document pain, enlargement, and changes in contour