PHYSICAL ASSESSMENT
Nurses perform a complete physical assessment when the patient is admitted to the facility and partial reassessments as the patient's condition warrants. A complete assessment includes a thorough health history and physical examination. The health history includes the chief complaint, a history of the current illness, general medical and surgical histories, a family history, a social history, and a review of systems.
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Typically, the physical examination follows a methodical, head-to-toe format. Patient preparation includes providing a clear explanation of the examination as well as proper positioning and draping before and during the examination. During this procedure, the nurse must make every effort to recognize and respect the patient's feelings (particularly embarrassment and anxiety) as well as to provide comfort measures and follow appropriate safety precautions.
Equipment
Although equipment varies with the examination's focus, the following may be included: scale with height measurement bar • urine specimen container and laboratory request form (if ordered) • sphygmomanometer • watch with second hand • stethoscope • thermometer • gown (for patient) • examining table (with stirrups if necessary) • gloves • drapes (sheet, bath blanket, or towel, as needed) • adhesive tape • spotlight or gooseneck lamp • flashlight • laryngeal mirror • tongue blades • percussion (reflex) hammer • otoscope • tuning fork • tape measure • visual acuity chart • ophthalmoscope • test tubes of hot and cold water • containers of odorous materials (such as coffee or chocolate) • substances for taste assessment (sugar, salt, vinegar) • coin • pin and cotton • paper clip • fecal occult blood test kit • linen-saver pad • water-soluble lubricant • facial tissues • cotton-tipped applicators • nursing assessment form.
Preparation of equipment
Adjust the temperature in the examining room, and close the doors to prevent drafts. Cover the examining table with a clean sheet or disposable paper. Then assemble the appropriate equipment for the examination.
Implementation
  • Review the patient's health history to obtain subjective data about the patient and insight into problem areas and subtle physical changes. Investigate the patient's chief complaint. (See Exploring a patient's symptoms.)
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  • Obtain biographical data, including the patient's name, address, telephone number, contact person, gender, age and birth date, birthplace, Social Security number, marital status, education, religion, occupation, race, nationality, and cultural background as well as the names of persons living with the patient.
  • Ask about health and illness patterns, the chief complaint, current and past health status, family health status, and condition of body systems.
  • Ask about health promotion and protection patterns, including health beliefs, personal habits, sleep and wake cycles, exercise, recreation, nutrition, stress level and coping skills, socioeconomic status, environmental health conditions, and occupational health hazards.
  • Explore the patient's role and relationship patterns, including self-concept, cultural and religious influences, family roles and relationships, sexuality and reproductive patterns, social support systems, and any other psychosocial considerations.
  • Explain the physical examination and answer questions.
  • Instruct the patient to void if possible. Collect a urine specimen if ordered. Emptying the bladder increases patient comfort during the examination.
  • Help the patient undress, and provide a gown. Then measure and record height, weight, and vital signs.
  • Assist the patient onto the examination table. Requirements for positioning and draping vary with the body system and region being assessed. To examine the head, neck, and anterior and posterior thorax, have the patient sit on the edge of the examination table or the bed. For the abdomen and cardiovascular system, place the patient in a supine position and stand to his right. For a female patient, place a towel over her breasts and upper thorax during abdominal assessment. Pull the sheet down as far as her symphysis pubis, but no farther.
  • Perform a physical examination. (See Performing a head-to-toe assessment.)

Documentation
Document significant normal and abnormal findings in an organized manner according to the related body systems.