What preparation needs to be completed by the nurse before conducting the physical assessment of the client?

If you are a nurse, you know that a comprehensive patient health assessment is an important first step in developing a plan to deliver the best patient care. Health assessments are a key part of a nurse's role and responsibility. The assessment is a tool to learn about your patient's concerns, symptoms and overall health.

"It is a critical step because this is where comprehensive data including physiological, psychological, socioeconomic, social determinants of health, spiritual and lifestyle information is gathered to help determine nursing diagnoses, which are used to develop nursing care plans that aim to improve health outcomes," says U.S. Public Health Service Commander Derrick Wyatt, MSN, RN-BC, a health scientist administrator for the Agency for Healthcare Research and Quality (AHRQ).

During the assessment, nurses may notice signs of potential or underlying health issues that need to be addressed, as well.

"I am reminded of how law enforcement officers gather detailed information using interviews, physical evidence and observations to help solve cases. Nurses use the information gathered during the comprehensive health assessment to achieve similar goals for solving complex problems with the interdisciplinary team," says Wyatt.

There are many components to a comprehensive health assessment. Before beginning the assessment, nurses should try to develop a rapport with their patients, introducing themselves, explaining what they will be doing during the assessment, and why. Depending on the setting or reason for the visit, the patient may be anxious, and establishing a rapport can help put the person at ease. Social, cultural and behavioral factors influencing the patient's health are also important to keep in mind.

A comprehensive health assessment usually begins with a health history, which includes information about the patient's past illnesses or injuries (including childhood illnesses and immunizations), hospitalizations, surgeries, allergies and chronic illnesses. It also includes finding out about diseases that run in the patient's family.

During the health history component of an assessment, the patient is asked to describe his or her symptoms, when they started, and how they developed before moving on to the physical exam. The physical exam begins with a complete set of vital signs (blood pressure, heart rate, respiratory rate and temperature).

With the increase in chronic conditions and the growing elderly population, learning how to be in tune with unique patient characteristics is an important component of an RN to BSN program.

Wyatt says the approach to conducting a comprehensive health assessment will remain the same no matter the age or health status of a patient; however, "It is essential for students to understand and address nuances when conducting assessments on different populations, such as pediatric and geriatric patients or with patients with specific disease processes and family dynamics."

Once the comprehensive health assessment has been performed, the next step is to put all of the information together, analyzing the objective and subjective data and developing a care plan. Those critical thinking skills are part of the training for a BSN degree, and they will be needed more than ever in the future.

"I think complex medical conditions, the shift to value-based care, and the industry changing to a proactive care model, will place an emphasis on health assessments to identify opportunities to screen for preventative care and promote healthier lifestyles in the elderly population." says Wyatt.

The online program that Texas A&M International University (TAMIU) offers is affordable, flexible, and designed to deepen your knowledge and skills to conduct comprehensive health assessments through the life span for patients of different ages and with specific health conditions. The ACEN-accredited program at TAMIU also covers nursing research, cultural determinants of health behavior, nursing history, global health nursing, community nursing and more.

The RN to BSN curriculum also helps nurses advance to leadership roles and sharpen their skills in critical thinking, effective communication, ethical and legal handling of issues, conflict resolution, quality improvement, and change initiation.

Learn more about TAMIU's online RN to BSN program.

Sources:

Nurse.org: How to Conduct a Head-to-Toe Assessment

University of New England Center for Excellence: Center for Excellence in Health Innovation

Agency for Healthcare Research and Quality (AHRQ)

Derrick Wyatt, MSN, RN-BC, health science administrator for AHRQ (email interview Nov. 30, 2018)

Have a question or concern about this article? Please contact us.

Chapter 2. Patient Assessment

A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment specific to the affected body system.

A physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 outlines the steps to take.

Checklist 17: Head-to-Toe Assessment


Perform hand hygiene. Check room for contact precautions. Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.g., name and date of birth). Explain process to patient. Be organized and systematic in your assessment. Use appropriate listening and questioning skills. Listen and attend to patient cues. Ensure patient’s privacy and dignity. Assess ABCCS (airway, breathing, circulation, consciousness, safety)/suction/oxygen/safety. Apply principles of asepsis and safety. Check vital signs. Complete necessary focused assessments.

1. General appearance: Affect/behaviour/anxiety Level of hygiene Body position Patient mobility Speech pattern and articulation	Alterations may reflect neurologic impairment, oral injury or impairment, improperly fitting dentures, differences in dialect or language, or potential mental illness. Unusual findings should be followed up with a focused neurological system assessment. Assess general appearance
This is not a specific step. Evaluating the skin, hair, and nails is an ongoing element of a full body assessment as you work through steps 3-9. 2. Skin, hair, and nails: Inspect for lesions, bruising, and rashes. Palpate skin for temperature, moisture, and texture. Inspect for pressure areas. Inspect skin for edema. Inspect scalp for lesions and hair and scalp for presence of lice and/or nits. Inspect nails for consistency, colour, and capillary refill.	Check for and follow up on the presence of lesions, bruising, and rashes.Variations in skin temperature, texture, and perspiration or dehydration may indicate underlying conditions. Redness of the skin at pressure areas such as heels, elbows, buttocks, and hips indicates the need to reassess patient’s need for position changes. Unilateral edema may indicate a local or peripheral cause, whereas bilateral-pitting edema usually indicates cardiac or kidney failure. Check hair for the presence of lice and/or nits (eggs), which are oval in shape and adhere to the hair shaft.
3. Head and neck: Inspect eyes for drainage. Inspect eyes for pupillary reaction to light. Inspect mouth, tongue, and teeth for moisture, colour, dentures. Inspect for facial symmetry.	Check eyes for drainage, pupil size, and reaction to light. Drainage may indicate infection, allergy, or injury. Slow pupillary reaction to light or unequal reactions bilaterally may indicate neurological impairment. Check pupillary reaction to light Dry mucous membranes indicate decreased hydration. Facial asymmetry may indicate neurological impairment or injury. Unusual findings should be followed up with a focused neurological system assessment.
4. Chest: Inspect: Expansion/retraction of chest wall/work of breathing and/or accessory muscle use Jugular distension Auscultate: For breath sounds anteriorly and posteriorly Apices and bases for any adventitious sounds Apical heart rate Palpate: For symmetrical lung expansion	Chest expansion may be asymmetrical with conditions such as atelectasis, pneumonia, fractured ribs, or pneumothorax. Use of accessory muscles may indicate acute airway obstruction or massive atelectasis. Jugular distension of more than 3 cm above the sternal angle while the patient is at 45º may indicate cardiac failure. The presence of crackles or wheezing must be further assessed, documented, and reported. Unusual findings should be followed up with a focused respiratory assessment. Auscultate anterior chest; blue dots indicate stethoscope placement for auscultation Auscultate posterior chest; blue dots indicate stethoscope placement for auscultation Auscultate apical pulse at the fifth intercostal space and midclavicular line Note the heart rate and rhythm, identify S1 and S2, and follow up on any unusual findings with a focused cardiovascular assessment.
5. Abdomen: Inspect: Abdomen for distension, asymmetry Auscultate: Palpate: Four quadrants for pain and bladder/bowel distension (light palpation only) Check urine output for frequency, colour, odour. Determine frequency and type of bowel movements.	Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis. Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction. Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileum. Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus. Pain and tenderness may indicate underlying inflammatory conditions such as peritonitis. Unusual findings in urine output may indicate compromised urinary function. Follow up with a focused gastrointestinal and genitourinary assessment. Unusual findings with bowel movements should be followed up with a focused gastrointestinal and genitourinary assessment. Auscultate abdomen
6. Extremities: Inspect: Arms and legs for pain, deformity, edema, pressure areas, bruises Compare bilaterally Palpate: Radial pulses Pedal pulses: dorsalis pedis and posterior tibial CWMS and capillary refill (hands and feet) Assess handgrip strength and equality. Assess dorsiflex and plantarflex feet against resistance (note strength and equality). Check skin integrity and pressure areas.	Limitation in range of movement may indicate articular disease or injury. Palpate pulses for symmetry in rate and rhythm. Asymmetry may indicate cardiovascular conditions or post-surgical complications. Unequal handgrip and/or foot strength may indicate underlying conditions, injury, or post-surgical complications. CWMS: colour, warmth, movement, and sensation of the hands and feet should be checked and compared to determine adequacy of perfusion. Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position. Assess dorsiflexion Assess plantarflexion Assess CWMS – colour, warmth, movement, and sensation Assess bilateral hand strength Palpate and inspect capillary refill and report if more than 3 seconds. Assess pedal pulses Check capillary refill To check capillary refill, depress the nail edge to cause blanching and then release. Colour should return to the nail instantly or in less than 3 seconds. If it takes longer, this suggests decreased peripheral perfusion and may indicate cardiovascular or respiratory dysfunction. Unusual findings should be followed up with a focused cardiovascular assessment. Clubbing of nails, in which the nails present as straightened out to 180 degrees, with the nail base feeling spongy, occurs with heart disease, emphysema, and chronic bronchitis.
7. Back area (turn patient to side or ask to sit up or lean forward): Inspect back and spine. Inspect coccyx/buttocks.	Check for curvature or abnormalities in the spine. Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position.
8. Tubes, drains, dressings, and IVs: Inspect for drainage, position, and function. Assess wounds for unusual drainage.	Note amount, colour, and consistency of drainage (e.g., Foley catheter), or if infusing as prescribed (e.g., intravenous). Urinary catheter bag Assess wounds for large amounts of drainage or for purulent drainage, and provide wound care as indicated.
9. Mobility: Check if full or partial weight-bearing. Determine gait/balance. Determine need for and use of assistive devices.	Assess patient’s risk for falls. Document and follow up any indication of falls risk. Note use of mobility aids and ensure they are available to the patient on ambulation. Patient position prior to standing
10. Report and document assessment findings and related health problems according to agency policy.	Accurate and timely documentation and reporting promote patient safety.
Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Stephen et al., 2012

You are assessing a patient at the beginning of your shift. Which assessment would be the most appropriate?
You come back from a break to find your patient complaining that she feels short of breath. Which assessment would be the most appropriate?