Chapter 2: Admissions and assessment
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Definition
Physical examination is the systematic assessment of all body systems; it is concerned with identifying strengths and deficits in the patient's functional abilities. Physical assessment provides objective data that can be used to validate the subjective data gained when taking the patient's history (Wilkinson [91]).
The patient's history is one of the most important components of a physical assessment; the history guides the nature of the physical assessment that needs to be carried out (Peacock [60]).
The components of a thorough health history are (Bickley and Szilagyi [9]):
- chief complaint
- history of chief complaint
- past medical history
- family history
- social history
- systems review.
The findings of the history will determine which body system to examine and what investigations are required; the nurse will determine whether a focused or comprehensive physical examination is required based on the patient's clinical presentation (Baid [5]).
The aims of the physical examination are:
- to identify potential diagnoses
- to make a diagnosis
- to obtain information on the patient's overall health status
- to enable additional information to be obtained about any symptoms reported by the patient
- to detect changes in the patient's condition
- to evaluate how the patient is responding to interventions
- to establish the patient's fitness for surgery or anaesthetic (Abbott and Ranson [1]; Crouch and Meurier [17]).
During the physical assessment, a systematic approach is taken to build on the patient's history, using the key assessment skills of inspection, palpation, percussion and auscultation (Figure 2.3).
Figure 2.3 Physical assessment framework. Source: Reproduced from Baid ([5]) with permission of MA Healthcare Limited.
