Introduction

Performing an accurate physical assessment and being able to differentiate normal from abnormal findings is one of the most important roles for todays health care practitioner. If an accurate physical assessment cannot be performed, whether for baseline data or when the patients condition changes, then the patient is not receiving the level of competent care that should be given. The purpose of this home study presentation is to provide the reader with the information to enhance existing assessment skills and learn new information which can be applied to the clinical setting. You will work through the physical assessment on the basis of body systems and also include a psychosocial assessment. This program will cover the following systems in this order: Integumentary Respiratory Genitourinary Neurological Psychosocial Musculoskeletal Cardiovascular Endocrine Gastrointestinal

General Guidelines For Health History and Physical Assessment Review Available Data
Quickly review the chart prior to performing your assessment. Note the patients name, age, address, race, occupation, and religion. This will provide you with an idea of the patients lifestyle and will avoid asking repetitive questions.

Establish Rapport
Always greet the patient in a friendly, non-threatening manner. Use Mr., Mrs., or similar titles unless the patient is a child or adolescent. Explain your relationship to the patients care. During introductions many patients are often trying to figure out what they believe the examiner thinks of them. If the impression is good, the patient is more likely to be satisfied and cooperate with the examination. An example of an introductory statement in relation to health assessment performance is, I will be taking a health history and performing a physical assessment to help meet your health care needs. The assessment will also provide a baseline picture of your health status so that we can notice any changes in your condition.

Control Environment
If in a semi-private room, ensure maximum privacy by drawing the divider curtain. This is a time to excuse the family, if possible, so the patient can provide candid responses to sensitive issues of which the family may not be aware. Hostile or intoxicated people or persons who have been abusing chemical substances may feel trapped in a small room. For

this reason, and also for the examiners safety, leave the door open. Also, this type of patient may feel more relaxed if coffee or juice can be offered.

Position Patient
The patient should be wearing comfortable, loose fitting pajamas or a gown. During the rapport establishing phase of the relationship, the examiner should stay at least three feet away from the patient to avoid invading personal space. As the assessment progresses there will be a need to move closer than three feet, but the personal space should still be maintained when just conversing with the patient.

Follow a Systematic Assessment Flow

Although the patients condition often dictates what area is covered first in the assessment, one should still observe some type of systematic progression to avoid excluding important assessment areas.

Techniques Of Physical Assessment Inspection

A method of systematic observation. Inspection should begin with general observation of the patient progressing to specific body areas. Inspection is a physical assessment technique that is often used but seldom thought about.

Palpation
Process of examining patients by application of the hands. Used to determine: The consistency of tissue directly or indirectly with the palms of the hands or finger pads. Alignment and intactness of structures (such as the nasal septum or extremities). Presence of thrills. Thrills are fine vibrations and can sometimes be felt over aneurysms or Grade IV or stronger heart murmurs. Symmetry of body parts and movement. Transmission of sound through vibration (known as tactile fremitus). Areas of warmth and tenderness. For light palpation, press the skin gently with the tips of two or three fingers held close together. Note tenderness or warmth (although the backs of the examiners hands are most sensitive to skin temperature) as well as the size and position of structures and the existence of masses. For deep palpation, place one hand on top of the other and press down with the fingertips of both hands. For example, deep palpation of the right upper quadrant lets you estimate the size of the liver.

Percussion

Tapping of the body lightly but sharply to determine consistency of tissues and/or organs through vibration and areas of tenderness. Sounds that will be heard include: Resonance Loud, long low-pitched sound heard over hollow structures such as the lungs and abdomen. Hyperresonance Loud, very long sound, lower pitched than resonance, heard over areas such as overaerated lung tissue found in COPD. Hyperresonance sound lies between tympani and resonance. Tympany High-pitched, loud sound of medium duration heard over the stomach or gastric bubble. Dullness Medium-pitched, slightly louder than a flat sound heard over solid organs such as the heart, liver, or a distended bladder. Flatness Soft, high-pitched, short sound heard over bone and muscle. The technique of percussion involves putting the middle finger of the nondominant hand on the patients body and tapping it briskly with the middle finger of the dominant hand. If the examiners hands are small, the technique may not make a sound loud enough to be heard. In this case, try striking the finger with the side of the thumb instead.

Auscultation
Process of listening for sounds over body cavities to determine presence and quality of heart, lung, and bowel sounds. High-pitched tones are best heard with the diaphragm of the stethoscope while low-pitched tones are best heard with the stethoscopes bell (bell-low is an easy way to remember). Hold the diaphragm firmly against the skin to block out extraneous noise. The bell should be place more lightly on the skin.

General Health History/Assessment

History Background Data Present occupation Provides information about possible health risks and psychosocial information Usual occupation Current occupations may be different than what a person normally does (for example the produce worker in the market may bea coal miner who is temporarily unable to perform his/her usual occupation). Military experience

Allows the examiner to assess if the patient has been exposed to atypical substances such as Agent Orange or out-of-country microorganisms. Also can provide psychosocial information. Out-of-country travel People oftentimes bring more home more than just souvenirs from out of country trips. Unexplained skin conditions and gastrointestinal problems may have originated from exposure to unfamiliar microorganisms. Note the location of the travel and the length of time since returning home. Expressed Health Concern Patients should be asked their reason for seeking medical help. It is important to get the expressed health concern or chief complaint in the patients own words. If the illness is chronic, they should be questioned as to what changes in their condition prompted them to seek help or when they last felt well. Basic Medical History Childhood diseases/Immunizations If appropriate, ask questions about the persons history of varicella, polio, measles, mumps, and rubella. Also ask about the persons DPT status and last immunization for tetanus. Major Illnesses Much information about a persons past health can be ascertained by asking the person, What is the sickest you have ever been? Hospitalizations/Surgical procedures Reasons for hospitalizations, years of occurrence, and outcome of illnesses should be assessed. Allergies The patient should be questioned as to food, drug, and airborne allergies. Reactions to allergens should be established. Assess past and current treatment for allergic reactions. Injuries/Fractures Past history of serious injuries and fractures should be established. Patients can be asked if they have ever been in a serious automobile or industrial accident. Medications

Name, dosage, and frequency of medications should be listed; include over-the-counter and folk medicines. Habits Habits include the use of alcohol, street drugs, caffeine, and tobacco use (include smokeless). These questions may be saved until the end of the examination when a better rapport has been established and the likelihood of honest responses are greater. Instead of asking How much do you drink?, the examiner should ask questions such as, Have you ever thought you drank too much? or Have your family or friends ever complained about the amount you drink? Family Medical History Include questions about the health status of the patients siblings, parents, grandparents, spouse, and children. Ask whether they are living and well or the cause of death if they are deceased. Specifically ask questions relating to cardiovascular problems and race specific illnesses such as sickle cell anemia.

General Assessment
Height Weight Build (thin, obese, emaciated, etc.) Temperature Radial Pulse Respirations Blood Pressure (sitting, standing, and lying if related to current illness or over age 50) Posture Speech (descriptive terms include: fast, slurred, thick, articulate, speaks no English, absence of speech) Emotion (descriptive terms include slightly nervous, comatose, calm, etc.) Stated Aged Versus Apparent Age (documentation would read appears chronological age or stated age 40, looks 50)

PHYSICAL ASSESSMENT I. General Survey Observe for the following: race, sex general physical state

mental state evidence of pain, restless behavior body position, stature, gait clothes, grooming, hygiene emotional status state of health

II. Vital Signs and Clinical Measurement III. Systemic Assessment

Rubrics and Their Many Uses

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What is a rubric and why is this performance-based assessment a valuable component in the nurse educator's toolbox? A rubric is a scoring tool that communicates expectations of quality concerning a particular type of work or assignment. It specifies in objective terms criteria for performance-based assessment. For each criterion there are levels of potential achievement. These levels are graduated benchmarks (for example, Superior, Strong, Adequate, Needs Improvement, Inadequate, or Superlative, Satisfactory, Poor) that are defined by clear and objective descriptors. These are linked to numerical scores (for example, 5, 4, 3, 2, 1 from highest to lowest). The scores for each criterion are added up and the summary score for the entire rubric is then converted into a letter grade, percentage, or pass-fail designation. Rubrics are useful for gauging student performance for assignments that are subjective in nature and otherwise difficult to grade accurately and fairly. Examples are writing assignments, careplans, teaching projects, portfolios, research posters, and student presentations. Rubrics should be shared with the learners at the beginning of the task or assignment process, to help

guide their efforts. It gives students a clear idea of what they need to do to earn a certain grade. There are two main types of rubrics: scoring rubrics and instructional rubrics. Scoring rubrics guide students in focusing on content, whereas instructional rubrics guide students in creating presentations and reports, both oral and written. Students tend to focus on content areas that will impact their grade. Rubrics may be adapted according to the type of assignment and student needs. The first step is to determine specific criteria that are crucial to the assignments outcomes. There should be no more than seven criteria, or the rubric will become unwieldy. The criteria become the rows in the grid. The second step is to describe the levels of achievement. The assessment scale may consist of three to six levels; these become the columns on the grid. The end product is a grid with columns and rows, such as this persuasive writing rubric or this brochure rubric. Questions to keep in mind while developing a rubric include the following:

What are the critical areas of quality work? What are the levels of achievement? What are the clear descriptors for the criteria at each level?

Here are just a few of the many resources available on the web concerning rubrics: RubiStar Free tool to help educators create quality rubrics. IRubric Another free rubric creator tool, as well as an extensive library of existing rubrics. Presentation Rubric Example of quality rubric to evaluate student presentations. Example of Peer Evaluation Rubric United States Essay Rubric Example of a quality detailed rubric. Grading stacks and stacks of essays or careplans is challenging. A good rubric, however, can make the grading task easier and helps our assessment of student work be fair, balanced, and authentic.

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