Physical assessment - Overview

A physical assessment is an important nursing skill that is used to collect objective data about a client’s status by using the senses, like seeing a rash or hearing wheezes in the lungs. A physical assessment can also validate subjective information gathered from a health history, such as a client’s report of pain or dizziness. Additionally, assessment is the first step in the nursing process, which can be used to develop a plan of care or to evaluate the effectiveness of an intervention. Let’s review the process of completing a physical assessment.

Now, the two most common types of assessments you’ll do as a nurse are a comprehensive assessment and a focused assessment. A comprehensive assessment, sometimes referred to as a head-to-toe assessment, includes all body systems, and is usually performed during a general wellness visit or when a client is admitted to the hospital or other facility. This approach is most useful when you want to collect information about your client’s general health status.

On the other hand, a focused assessment depends on the situation, and is often based on a client’s presenting symptoms. For example, if your client has abdominal pain, you’ll focus most of your assessment on their gastrointestinal system. Likewise, if your client is having difficulty breathing, a focused assessment would include their respiratory system as well as skin, vital signs, and level of consciousness. A focused assessment may also be needed if you are administering certain medications; for example, when you’re administering a cardiotonic medication, you’ll focus your assessment on your client’s heart rate and blood pressure.

Okay, there are a few things to consider before performing a physical assessment. First, check to see if your client requires any precautions in addition to standard precautions such as transmission-based precautions, and don the appropriate personal protective equipment, or PPE. Then, explain the procedure to your client and be sure to answer any questions they might have before obtaining verbal consent. If your client refuses any part of the examination, be sure to document this and inform the healthcare provider.

Next, provide privacy by closing the door and drawing the curtains. Promote comfort by ensuring your client is comfortable in the position needed for the exam, adjusting the temperature of the room as needed, ensuring your hands and stethoscope are warm, and offering blankets to help prevent chilling. Also ensure your client is properly draped during the assessment, and remember to only expose the part of the body that is currently being assessed.

Once you have finished examining an area, make sure to promptly reapply the drape. Now, if you are performing an assessment that might include a sensitive area, like the breasts or genitals, consider requesting a chaperone to be present for the safety of both you and your client. This is especially important when assessing the opposite sex. Also be sure to explain each step as you conduct the assessment, so your client can anticipate and understand what they are experiencing during the examination. Finally, remember you’ll need to have adequate light to effectively conduct your physical assessment.

The supplies needed for the assessment will vary depending on the type of assessment; however, there are a few supplies you will use often, like a reflex hammer, penlight, measuring tape, washable skin marker, and a stethoscope.

Your stethoscope should have both a diaphragm and a bell, so you can listen for different types of sounds. The diaphragm is used to detect high-frequency sounds, like bowel or lung sounds, while the bell is used to detect low-frequency sounds, like heart sounds. When using the bell, remember to place it lightly on your client’s skin; if you apply too much pressure, it will function like a diaphragm and will not effectively transmit the low-frequency sounds. Also, when putting the earpieces into your ears, be sure they are pointed in the same direction as your ear canals, which means they should be pointing towards your nose.