Health Assessment & Physical Examination
Key Takeaways
- The chief complaint (CC) should be documented in the patient's own words, focusing on symptoms rather than clinical diagnoses.
- Standard physical examination follows the IPPA sequence (Inspection, Palpation, Percussion, Auscultation) for all systems except the abdomen.
- Abdominal assessment uses the IAPP sequence to prevent palpation and percussion from altering bowel sound frequency.
- Objective documentation must be factual, measurable, and free of vague, interpretive terminology like 'appears comfortable'.
- SBAR (Situation, Background, Assessment, Recommendation) is the standardized handover tool used to communicate urgent patient changes.
1. The Nursing Health History
The nursing health history is a structured interview designed to gather subjective data—information reported directly by the patient or their family. This history provides context for the physical examination and helps establish a therapeutic nurse-patient relationship.
Biographical Data and Chief Complaint
- Biographical Data: Includes name, age, biological sex, contact details, occupation, and language preference. In the multicultural healthcare landscape of Dubai, identifying language barriers and arranging certified medical translators is a critical first step under Dubai Health Authority (DHA) standards.
- Chief Complaint (CC): The primary reason the patient is seeking care. It must be documented using the patient's exact words in quotation marks (e.g., Patient states: "I have had a throbbing headache for three days"). It should focus on the primary symptom rather than a self-diagnosis.
History of Present Illness (HPI)
The HPI is a chronological, detailed description of the chief complaint. Nurses utilize structured mnemonics like OLDCARTS or PQRST to ensure comprehensive data collection:
- Onset: When the symptom began (e.g., "started yesterday morning").
- Location: Where the symptom is located and if it radiates (e.g., "left lower quadrant of the abdomen").
- Duration: How long the symptom lasts or if it is constant or intermittent (e.g., "pain is continuous but peaks after eating").
- Characteristics: The quality of the symptom (e.g., "sharp, stabbing pain" vs. "dull, aching soreness").
- Aggravating/Alleviating factors: What makes the symptom better or worse (e.g., "walking makes the pain worse; lying flat helps").
- Radiation: Whether the pain moves to other areas (e.g., "radiates to the left shoulder").
- Treatment: Interventions already attempted by the patient (e.g., "took 500 mg of paracetamol with no relief").
- Severity: Quantifiable measurement of intensity (e.g., "8 out of 10 on the numerical rating scale").
Past Medical, Family, and Psychosocial History
- Past Medical History: Known medical conditions (e.g., hypertension, diabetes mellitus), surgical history, allergies (including specific reactions), and a complete medication reconciliation (prescriptions, over-the-counter drugs, and herbal supplements).
- Family History: Genetic predispositions to conditions such as cardiovascular disease, diabetes, renal disorders, and hereditary cancers. This is typically documented using a genogram.
- Psychosocial & Lifestyle History: Details regarding occupational hazards, dietary habits, sleep hygiene, substance use, and support networks. In the UAE, understanding cultural aspects, fasting status during Ramadan, and religious dietary preferences is vital for patient-centered care.
2. Physical Examination Techniques and Sequence
Physical examination provides objective data—measurable, observable findings. The standard physical assessment relies on four basic techniques: Inspection, Palpation, Percussion, and Auscultation (IPPA). These techniques must be performed in this specific order for all systems except the abdomen.
Inspection
Inspection is the visual examination of the patient. It begins the moment the nurse meets the patient. The nurse assesses size, shape, color, symmetry, position, drainage, and abnormalities. Adequate lighting and proper exposure of the area being examined are essential.
Palpation
Palpation involves using the sense of touch to assess texture, temperature, moisture, organ size, vibration, rigidity, and tenderness.
- Palmar surface of fingers: Best for assessing fine tactile discrimination, texture, moisture, and presence of masses.
- Dorsum (back) of the hand: Best for determining skin temperature (dermal layers are thinner and more sensitive to heat variations).
- Ulnar surface of hand: Best for detecting vibrations (tactile fremitus).
- Light Palpation: Depressing the skin 1–2 cm to assess skin temperature, turgor, moisture, and superficial tenderness. Always perform light palpation before deep palpation.
- Deep Palpation: Depressing the skin 4–5 cm to assess deep abdominal organs and masses. Contraindicated in suspected aortic aneurysm, appendicitis, or abdominal transplant.
Percussion
Percussion involves tapping body parts with fingers or hands to produce sounds. This technique helps determine the density of underlying tissues and locate the boundaries of organs.
- Resonance: Clear, hollow sound heard over normal lung tissue.
- Hyperresonance: Loud, low-pitched, booming sound heard over hyperinflated lungs (e.g., emphysema or pneumothorax).
- Tympany: High-pitched, drum-like sound heard over air-filled cavities (e.g., stomach and intestines).
- Dullness: Soft, high-pitched, thud-like sound heard over solid organs (e.g., liver, spleen) or fluid-filled cavities (e.g., pleural effusion, consolidated lung).
- Flatness: Very soft, high-pitched, flat sound heard over dense tissue like bone or muscle.
Auscultation
Auscultation is the process of listening to sounds produced within the body using a stethoscope.
- Diaphragm: The larger, flat side. Best for high-pitched sounds such as normal heart sounds (S1, S2), breath sounds, and bowel sounds. Apply firm pressure.
- Bell: The smaller, cup-shaped side. Best for low-pitched sounds such as abnormal heart sounds (S3, S4) and vascular murmurs or bruits. Apply light pressure.
3. The Abdominal Assessment Exception
- Critical Clinical Guideline: For the abdominal exam, the sequence is altered to Inspection, Auscultation, Percussion, and Palpation (IAPP).
- Physiological Rationale: Palpation and percussion stimulate the intestines, which increases peristalsis (bowel motility). Performing these techniques before listening can artificially alter the frequency and character of bowel sounds, leading to an inaccurate clinical assessment.
4. Documentation and Handover Frameworks
Accurate, timely, and objective documentation is a legal and professional requirement. Under UAE Federal Law No. 4 of 2016 on Medical Liability, medical records are legal documents that must document the standard of care provided.
SOAP / SOAPIE Notes
This structured approach ensures comprehensive documentation:
- S (Subjective): Patient statements regarding symptoms, pain scale, and history.
- O (Objective): Measurable assessment data, vital signs, physical exam findings, and lab results.
- A (Assessment): Nursing diagnosis, clinical reasoning, or patient progress summary.
- P (Plan): Scheduled interventions, diagnostic testing, and discharge goals.
- I (Intervention): Nursing actions executed.
- E (Evaluation): The patient's response to the interventions.
Guidelines for Professional Documentation
- Objective Language: Use factual, measurable descriptors. Avoid subjective phrases like "patient appears uncooperative" or "slept well." Instead, write: "Patient refused to participate in morning physical therapy; states, 'I am too tired today'" or "Patient observed sleeping with eyes closed, respirations 14/min, even and unlabored."
- Timeliness: Document as soon as possible after care is provided. Do not document interventions before they are completed.
- Error Correction: In paper charting, draw a single line through the error, write "error" and your initials. In Electronic Medical Records (EMR), follow institutional protocols to enter an addendum. Never use correction fluid or erase entries.
SBAR Handover Tool
SBAR is the standard communication tool used during patient handovers or when reporting a change in patient condition to a physician to ensure key information is communicated:
- S (Situation): Define the immediate reason for communication (e.g., "This is Nurse Fatima on Ward 3. I am calling about Mr. Patel in bed 5, who is experiencing sudden shortness of breath and chest pain.").
- B (Background): Provide relevant history (e.g., "Mr. Patel is a 58-year-old post-op day 2 total knee replacement patient. He has a history of deep vein thrombosis.").
- A (Assessment): Give current vital signs and physical findings (e.g., "His heart rate is 112 bpm, blood pressure is 90/60 mmHg, respiratory rate is 28/min, and oxygen saturation is 88% on room air. I hear diminished breath sounds on the right.").
- R (Recommendation): State what action you suggest (e.g., "I recommend that we start him on high-flow oxygen, obtain an immediate portable chest X-ray and arterial blood gas, and have the medical team review him immediately.").
A nurse is performing a physical assessment on a patient reporting generalized abdominal pain. In which sequence should the nurse perform the components of the abdominal assessment?
During a cardiovascular assessment, the nurse hears a low-pitched, blowing sound over the carotid arteries. Which part of the stethoscope should the nurse use to evaluate this sound, and what does it suspect?
The nurse is preparing to document an admission assessment. Which of the following entries represents the most appropriate, objective documentation of a patient's status?