The Physical Examination and Health Assessment Essay Example

📌Category: Health, Health Care, Medicine, Nursing
📌Words: 1582
📌Pages: 6
📌Published: 05 September 2021

The physical examination and health assessment allow the nurse or health care provider to do the assessment, talk with the patient, and build rapport with them. The Physical exam allows the nurse or provider to look at the patient using a systemic process, by which each visual assessment of the body can be broken down into sections, then added into one report. The nurse will typically do an assessment in order of inspection to visually assess the patient from the time the nurse enters the room. Inspection is followed by palpation, which uses your sense of touch to examine things like the temperature of the body or organ size, on certain areas of the body to confirm what was noted during the inspection. Next, percussion is done. This required tapping the patient`s skin using short and blunt strokes to assess structures beneath the skin. Finally, auscultation is done with a stethoscope to listen to the organs, such as the lungs and stomach. By breaking the assessment into small sections, it will permit a more precise depiction of subjective and objective data to be recorded in the patient chart and enable a greater understanding of how to create an individualized plan of care for each patient.  

Along with the Physical examination, then the patient will be asked about their health history. This is sometimes called an interview, or health history assessment. For example, the patient or their caregiver would be asked What medications they normally take, what they normally eat, how often they exercise a week, or what recent changes prompted them to come to the hospital or their primary physician's office. “The vehicle that carries you and your client through the interview is communication” (Jarvis, 2020, p.23). 

The first focused health history assessment is on Mrs. Jane Doe who is a 30-year-old female who reports to her primary physician's office complaining of sharp right inner ear pain for the last 3 days, which is now becoming unbearable. Once she is in a room, the nurse begins the physical assessment. In an adult, such as Mrs. Doe, to visualize her tympanic membrane; also known as the eardrum, you would turn on the otoscope and pull the top part of the ear, called the pinna, up and back. She will observe both ears for comparison. The nurse will look for any findings that may be abnormal. While in the room the nurse will also ask questions to search for probable causes of the problem. The nurse will also ask about things that make the ear pain better or worse. 

The tympanic membrane separates the external and middle ear and is obliquely tilted to the ear canal facing forward and slightly downwards. Normally the tympanic membrane has an appearance that is “translucent with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is a reflection of the otoscope light” (Jarvis, 2020, p.318).  An abnormal assessment would reveal a bulging eardrum due to increased pressure. “Perforations are also abnormal with a dark oval area or a larger opening on the drum” (Jarvis, 2020, p.327). 

Along with a visual inspection when doing the physical exam, a whisper test is done to observe any hearing loss in both the right and the left ear. Testing one ear at a time and masking the ear not being tested by placing the finger over the tragus and pushing it in, the nurse will move 1-2 feet away from the patient`s ear being tested. The normal result would be represented by the patient being able to correctly repeat each letter or number after the nurse has whispered it. Since no hearing loss was detected, no other tests were performed. 

The nurse has now obtained a NANDA-approved diagnosis for Mrs. Doe, as well as her SOAP documentation note in Mrs. Jane Doe`s EMR.  The nurse's chart documentation SOAP note looks like this: 

S: Complains of a sharp worsening inner ear pain for 3 days now. States that she has had recurring ear infections over the last two years. The NANDA diagnosis for Mrs. Does is acute pain and deficient knowledge related to her recurring otitis media ear infection 

O: Right ear examination showed a sequelae of repeated ear infections by the white and dense patches of scarring. The tympanic membrane in the right ear also appeared to be bulging. The right ear was also warm to the touch and red in color. The left ear was within normal limits. The patient is fever-free currently and is not taking any home or OTC medications for this problem. 

A: Acute pain and deficient knowledge based on recurring otitis media ear infection from lack of compliance with antibiotics and lifestyle changes.  

P: Given information on how to prevent ear infections, as well as instructed to complete all antibiotics, regardless of ear pain. She is to follow up with the primary doctor in two weeks.  

For the second focused health history assessment, Mr. John Doe, a 68-year-old male has come to his primary care provider with complaints of difficulty swallowing and speaking. This is due to a lump that has appeared on the anterior portion of his throat. He has noticed the lump for two weeks now, however, swallowing and sometimes speaking are causing him to put forth an increased effort. Mr. Doe has a 25-year long history of Graves’ Disease.  

Upon physical assessment, Mr. Doe needs to have his anterior and posterior thyroid gland palpated. This will help the nurse and provider confirm what they are seeing with what they are feeling, compared to the patient`s complaint. For the anterior thyroid assessment, the nurse needs to stand facing Mr. Doe. Then place the thumb 3 cm below the thyroid cartilage as Mr. Doe swallows. Next, the nurse will need to ask him to slightly tip his head forward and to the right. The nurse will use her right thumb to displace the trachea faintly to the right. At the same time, the nurse will hook the left thumb and fingers around the sternomastoid muscle feeling any lobe enlargement as Mr. Doe swallows. Then she would repeat these steps on the other side of his neck. For the posterior thyroid examination, the nurse will stand behind Mr. Doe. Asking Mr. Doe to sit up as straight as he can for this exam and bend the head slightly forward and to the right, to relax the neck muscles. While he does so, the nurse will use the fingers of the left hand to push the trachea faintly to the right. Then repeat on the other side of the neck. The nurse will assess diffuse enlargement or nodular lumps in the patient. Upon physical assessment, the nurse will need to auscultate the thyroid gland as well due to enlargement. Any abnormal sounds on the thyroid gland are best heard with the bell of the stethoscope. 

Normally the thyroid is difficult to palpate. Any abnormal findings will result in palpating enlarged lobes. These are easily palpated before the patient is asked to swallow or is tender to palpations. Also, any visual lumps and/or nodules are considered to be abnormal findings. Upon thyroid auscultation if a bruit, soft and pulsatile blowing whooshing is heard, this is abnormal. A bruit is not normally present; but occurs with hyperthyroidism. 

To test Mr. Doe for thyroid complications, he would need to partake in a series of tests. The physical examination for any nodules or lumps is a great non-invasive screening tool to start with. He will also need lab work done to check his T3, T4, and TSH levels. Normal ranges for the T3 are between 100 – 200 while the T4 is between 5.0 and 12.0 Micrograms per deciliter. For TSH the normal range is 0.5 - 5.0 mIU/L. Mr. Doe can also have a CT scan or MRI to determine the size and spread of his goiter. Normally goiters are not present.  

The nurse has now obtained a NANDA-approved diagnosis for Mr. Doe, as well as the SOAP documentation note in Mr. John Doe`s EMR.  The nurse's chart documentation SOAP note appears like this: 

S: In today for a new lump that has been there for approximately two weeks, on the anterior throat, making swallowing difficult. No pain is associated with the lump. He has not found anything to make it better. Lying back or flat makes swallowing the most difficult. Nothing seems to help with improving pain with talking. He has had a history of Graves' Disease for the last 25 years. The NANDA diagnosis for Mr. Doe consists of risk for imbalanced nutrition: less than body requirement and risk for impaired tissue integrity.  

O: Results of the physical exam show a goiter on the anterior portion of the thyroid gland. 

A: Risk for imbalanced nutrition: less than body requirement and risk for impaired tissue integrity AEB the new onset of difficulty to swallow and speak from increasing goiter size. 

P: Going forward Mr. Doe will take a thyroid hormone to help reduce the size of the thyroid goiter. He will go for a CT scan to determine the size of his goiter with a repeat scan in two weeks. He has been instructed on when and how to take the medication and is scheduled for a follow follow-up in 1 week. He is to call immediately if he has any worsening changes, as well as has been instructed to go to the ER right away if he has any trouble breathing.  

From the two focused health assessments depicted above, it`s incontrovertible how the physical examination is pertinent to the care provided to our patients. Without physical examination, we could be reckless with our patient diagnosis and choice of treatment. We need to include this step in all patient care to confirm that what they`re telling us matches what the body is saying. Other times, the body can give us clues to things that may be going on that the patient is unaware of. The nursing diagnosis helps to guide the care and goal outcomes for patients who are entrusted with our care. Documenting all findings, testing results, and assessment data will lead to better goal outcomes and management of patient care plans.

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