Learning Objectives
By the end of this section, you will be able to:
- Review the different parts of the bedside assessment
- Describe a focused physical assessment
- Discuss the importance of assessment of the safety and surroundings in medical-surgical nursing
While a comprehensive physical assessment is a detailed, inclusive assessment of body systems to provide a big-picture, broad view of a patient’s overall health, a focused assessment is a physical examination centered on a patient’s chief complaint. In this section, you will learn about the parts of a broader physical assessment—the bedside assessment—and how this more thorough approach differs from the focused assessment and contributes to the care of a hospitalized patient. The nurse may only focus on a single system during a focused assessment, but they can get an inclusive view of the patient’s other systems during a bedside assessment. Not only does this help the nurse identify other potential areas of concern, but even normal findings will help establish a baseline for the patient. The comprehensive physical assessment, which includes all body systems along with the patient’s history, gives the nurse a more complete picture of the patient’s overall health situation and status. That, however, is often more valuable in primary care settings. In acute care settings, nurses mostly utilize bedside or focused assessments. Table 6.4 summarizes the types of assessments.
| Assessment Type | Description | Components | Purpose |
|---|---|---|---|
| Focused Physical Assessment | Zeroes in on the patient’s chief complaint, targeting the specific body system or area relevant to the presenting problem. | Varies depending on the chief complaint (e.g., cardiovascular assessment for chest pain, respiratory assessment for shortness of breath). | To timely identify and address the immediate concern or issue. |
| Bedside Physical Assessment | A systematic head-to-toe review of the patient‘s major body systems, often conducted upon admission or at the beginning of a shift. | General survey (height, weight, appearance), HEENT, cardiac, respiratory, abdominal, peripheral vascular, neuro-muscular, integumentary, genitourinary assessments. | To establish a baseline for the patient’s condition and identify any potential issues that may require further investigation or intervention. |
| Comprehensive Physical Assessment | The most thorough assessment, encompassing all body systems, along with a detailed health history. | All body systems, plus a detailed history including past medical history, medications, allergies, family history, and lifestyle factors. | To provide a holistic view of the patient’s health status and guide the development of a comprehensive care plan. |
| Safety/Surroundings Assessment | Critical for preventing adverse patient outcomes, this assessment focuses on the patient’s environment and potential risks. | Patient identification, fall risk, ambulatory aids, environmental hazards, domestic violence risk, suicidal ideation, isolation precautions, bed position, side rails, call bell accessibility. | To ensure a safe environment for the patient and prevent harm or injury. |
| Comprehensive Health History | A detailed interview with the patient to gather information about their past and current medical conditions, medications, allergies, family history, and lifestyle factors. | Medical history, surgical history, medication history, allergies, family history, social history (lifestyle, occupation, habits), review of systems. | To understand the patient’s overall health status, identify risk factors, and tailor the care plan to their individual needs. |
This section will also describe the importance of the safety/surroundings part of the assessment. This section will clarify how the comprehensive physical exam supports the comprehensive health assessment.
The Bedside Assessment of a Medical-Surgical Nurse
The nurse will perform a systematic exam of all patient body systems called a bedside assessment. This will include the general survey, HEENT, cardiac, respiratory, abdominal (gastrointestinal), peripheral vascular, neuro-muscular, skin, genitourinary, and activity (Figure 6.5).
General Survey
The general survey assessment includes the patient’s height, weight, physical appearance, chronic wounds, personal hygiene, and general behavior. Also included are the vital signs, such as blood pressure, heart rate, oxygen saturation levels, body temperature, and respiratory rate. The nurse will also consider the patient’s verbal and nonverbal communication and must swiftly assess to determine if the patient needs a communication aid (such as a translation device). The nurse will appropriately document all findings in the physical assessment area of the patient’s chart.
HEENT Assessment
In a systemic approach, the head, ears, eyes, nose, and throat (HEENT) exam are the first systems to be assessed.
- Head: The nurse will inspect and palpate the patient’s head for abnormalities and look at the hair for obvious signs of illness (e.g., thinning, hair loss).
- Eyes: The nurse will inspect the eyes according to the eye assessment PERRLA (pupils equal, round, reactive to light and accommodation). They will also assess visual acuity (e.g., does the patient need glasses or contacts, when was their last eye exam), check for nystagmus, and confirm that the conjunctivae are clear.
- Ears: The nurse will inspect and document any hearing loss or difficulty, including whether the patient needs hearing aids. If so, the nurse should determine whether the patient is wearing their hearing aids or has the devices with them.
- Nose: The nurse will inspect and ask about any olfactory symptoms, including altered sense of smell, congestion, or irritation. The nurse will ask if the patient has had any surgeries or procedures on the nasal area.
- Throat: The nurse will inspect and document any signs or symptoms related to the mouth and throat. This includes assessing the gums, teeth, mucosa, tongue (e.g., appearance and deviation), pharynx, and tonsils.
Cardiac Assessment
The cardiac assessment requires inspection, palpation, and auscultation. This includes assessing cardiac rhythm, heart sounds, arterial pulse evaluation, capillary refill times, edema, circulation and sensation, and cyanosis.
Respiratory Assessment
The respiratory assessment involves inspection, palpation, auscultation, and percussion. This includes breath sounds, respirations (e.g., effort and quality), presence of cough, production of sputum/secretions, abnormal visual/palpable masses, current respiratory treatment, and oxygen delivery.
Read the Electronic Health Record
Assessment of a Patient with Abdominal Pain
Patient Information
Name: Tanecia Smith
Age: 37 years
Sex: Female
- Severe abdominal pain, primarily in the upper right quadrant, for the past 3 days
- Diagnosed with hyperlipidemia 3 years ago
- History of vaginal delivery to a set of healthy twin boys 12 weeks ago
- Previous episodes of mild spasms related to gallstones, treated successfully with antispasmodics and diet change
- Temperature: 89.3°F (38.5°C)
- Heart rate: 125 bpm
- Blood pressure: 140/90 mm Hg
- Respiratory rate: 26 breaths per minute
- Oxygen saturation: 99% on room air
- BMI: 38
- WBC count: 14,000/µL (elevated)
- Hemoglobin: 13.5 g/dL (normal)
- Hematocrit: 40.5% (normal)
- Platelets: 250,000/µL (normal)
- Amylase: 180 U/L (elevated)
- Lipase: 166 U/L (elevated)
- Sodium: 138 mmol/L (normal)
- Potassium: 4.0 mmol/L (normal)
- Chloride: 102 mmol/L (normal)
- CT scan of abdomen and pelvis: Findings consistent with acute cholecystitis; presence of inflamed gallbladder, blockage of the biliary duct to the pancreas; no abscess or free air noted
- Patient reports increased severity of abdominal pain and tenderness over the past 3 days after ingesting some pizza.
- Appetite has decreased, and she has experienced nausea after drinking even water.
- Vomiting noted today resembling biliary juices; steatorrhea noted.
- Patient has been compliant with reduced-fat diet until 3 days ago.
- Mild diaphoresis observed upon admission.
- Acetaminophen 500 mg every 6 hours as needed for pain
- Dicycloverine 10 mg up to three times a day to relieve spasms
Abdominal Assessment
The abdominal assessment also relies on inspection, palpation, auscultation, and percussion. The nurse will assess the abdominal appearance, bowel sounds, and stool. The nurse will also inquire about the patient’s nutrition (e.g., current diet) and appetite.
Peripheral Vascular Assessment
The peripheral vascular assessment uses inspection, palpation, and auscultation. This includes pain, pallor of skin, inability to regulate core temperature (poikilothermia), pulselessness, paresthesia, and paralysis.
Neuro-muscular Assessment
The neuro-muscular assessment relies on inspection. It includes orientation (e.g., person, place, and time), level of consciousness, Glasgow Coma Scale (GSC), speech assessment, gait assessment, movement and strength of extremities (e.g., equal or unequal), and pain.
Skin Assessment
The skin assessment uses inspection and palpation. This includes turgor, integrity, color, temperature, Braden Risk Assessment to assess for pressure sore risk, chronic wounds, and skin breakdown.
Genitourinary Assessment
The genitourinary assessment involves inspection of the urinary and reproductive system. This includes the character of voiding and discharge, urinary difficulty, or presence of a catheter. It also includes specific reproductive health concerns, such as menstrual/menopause, vaginal bleeding, and painful intercourse.
Link to Learning
Watch this video to see an example of a head-to-toe physical assessment at the patient’s bedside.
The Focused Assessment of a Medical-Surgical Nurse
The focused assessment, like a focused history, starts with the patient’s chief complaint. The nurse will center the physical examination on the reason the patient is seeking care at the present time. For example, the focus for a patient who presents with a sore throat will be head/eye/ear/nose/throat (HEENT). By focusing the exam on the patient’s problem, the nurse will efficiently retrieve information that will help the health care team make the correct diagnosis and, if needed, appropriate plan of treatment.
Safety and Surroundings Assessment
The safety and surroundings assessment is critical to preventing adverse patient outcomes. It involves confirming the patient’s identity through wrist band identification, and assessing fall risk, use of ambulatory aids, environmental concerns, domestic and family violence risk, and suicidal ideation. The safety and surroundings assessment helps the nurse avoid preventable errors, such as patient misidentification, allergic reactions, and falls or other injuries. It is also a method to guard against safety threats the health care professionals may face (for example, if a patient has an infectious disease or is violent). The patient safety assessment during hospitalization may include documenting:
- Patient activity
- Intravenous insertion sites, drains, pumps
- Oxygen delivery system
- Allergy wristband
- Isolation precautions
- Family in the room
- Bed position, side rails up
- Call bell within reach
Clinical Safety and Procedures (QSEN)
QSEN Competency: Informatics
Disclaimer: Always follow the agency’s policy for medication administration.
Definition: Follow effective strategies to reduce human error when providing patient care. Examples include using allergy ID bands and checking that the bed is in the lowest setting.
Knowledge: The nurse will identify essential information that must be available in a common database to support patient care. Examples include staying up to date with current signs and symptoms of medication reactions.
Skill: Use clear and concise communication to raise awareness of observed concerns. Examples include contacting the provider if the patient exhibits signs of being a fall risk or has a potential medication reaction.
Attitude: The nurse will value national safety campaigns by implementing current safety initiatives into everyday practice guidelines. Examples include implementing safety checks and rounding on patients every thirty minutes.
(QSEN Institute, n.d.)