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136 PHYSICAL EXAMINATION
A. Position of hands for posterior thorax
percussion
B. Percussion strike
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UNIT 2
4. Flex the middle nger of the dominant hand, called the plexor. The
ngernail of the plexor nger should be very short to prevent undue
discomfort and injury to the pleximeter. The other ngers on this hand
should be fanned.
5. Flex the wrist of the dominant hand and place the hand directly over the
pleximeter nger of the nondominant hand.
6. With a sharp, crisp, rapid movement from the wrist of the dominant hand,
strike the pleximeter with the plexor. At this point, the plexor should be
perpendicular to the pleximeter. The blow to the pleximeter should be
between the distal interphalangeal joint and the ngernail. Use the nger pad
rather than the ngertip of the plexor to deliver the blow. Concentrate on the
movement to create the striking action from the dominant wrist only.
7. As soon as the plexor strikes the pleximeter, withdraw the plexor to avoid
dampening the resulting vibrations. Do not move the pleximeter nger.
8. Note the sound produced from the percussion.
9. Repeat the percussion process one or two times in this location to conrm
the sound.
10. Move the pleximeter to a second location, preferably the contralateral
location from where the previous percussion was performed. Repeat the
percussion process in this manner until the entire body surface area being
assessed has been percussed.
FIGURE 5.12 Technique of indirect
percussion
Recognising percussion sound
When using direct and indirect percussion, the change from resonance to dullness
is more easily recognised by the human ear than is the change from dullness to
resonance. It is often helpful to close your eyes and concentrate on the sound
in order to distinguish whether a change in sounds occurs. This concept has
implications for patterns of percussion in areas of the body where known locations
have distinct percussible sounds. For example, the techniques of
excursion
a more dened pattern because percussion can be performed from an area of
resonance to an area of dullness. Another helpful hint is to validate the change in
sounds by percussing back and forth between the two areas where a change is noted
to conrm this change.
As stated earlier, the percussion technique can take considerable time to develop
and master. Practising the technique at home or in a teaching environment can be a
helpful learning experience; see Clinical reasoning practice tip: Percussion practice.
and liver border percussion (advanced practitioner) can proceed in
diaphragmatic
CLINICAL REASONING
Practice tip: Percussion practice
> Percuss two glasses – one lled with water, the other empty. Compare the sounds.
> Percuss the wall of a room and listen for the change in tones when a wall stud is reached.
> Percuss your thigh. Puff your cheeks and percuss them. Compare the sounds.
Fist percussion
Direct and indirect st percussion are advanced practitioner assessment skills. Note
that caution must be exercised when direct or indirect st percussion is used. Avoid
hitting the consumer too hard because this may injure him or her.
Auscultation
Auscultation is the act of active listening to body organs to gather information
on a consumer’s clinical status. Auscultation includes listening to sounds that
PHYSICAL EXAMINATION TECHNIQUES 137
Earpiece
Tension bar
(low pitch)
(high pitch)
Partition
Central shaft
Open-bell
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are voluntarily and involuntarily produced by the body. The deep inspiration
a consumer takes with the lung assessment illustrates a voluntary sound, and
heart sounds illustrate involuntary sounds. A quiet environment is necessary for
auscultation. Auscultated sounds should be analysed in relation to their relative
Binaurals
intensity, pitch, duration, quality and location. There are two types of auscultation:
direct and indirect.
Direct auscultation
Direct or immediate auscultation is the process of listening with the unaided
ear. This can include listening to the consumer from some distance away or placing
the ear directly on the consumer’s skin surface. An example of direct auscultation is
listening to the wheezing that is audible to the unassisted ear in a person having a
severe asthmatic attack.
Indirect auscultation
Indirect or mediate auscultation describes the process of listening with
some amplication or mechanical device. The nurse most often performs indirect
auscultation with an acoustic stethoscope, which does not amplify the body sounds,
but instead blocks out environmental sounds. Amplication of body sounds can be
achieved with the use of a
the use of an acoustic stethoscope is recommended.
Figure 5.13 illustrates the acoustic stethoscope. The earpieces come in various
sizes. Choose an earpiece that ts snugly in the ear canal without causing pain. The
earpieces block noises from the environment. The earpieces and binaurals should
be angled toward the nose. This angle permits the natural direction of the ear canal
to be accessed. In this manner, sounds will be directed towards the adult tympanic
membrane. The rubber or plastic tubing should be between 30.5 and 40cm long.
Stethoscopes with longer tubing will diminish the body sounds that are auscultated.
Doppler ultrasonic stethoscope. Throughout this text,
FIGURE 5.13 Acoustic stethoscope
Rubber or
plastic
tubing
Bell
Diaphragm
CHAPTER 5
CLINICAL REASONING
Practice tip: Headpiece mnemonic
The word ‘bellow’ can be used to remember the frequency that is transmitted by the
headpiece of the stethoscope. The ‘bell’ transmits ‘low’ sounds.
The acoustic stethoscope has two listening heads: the bell and the diaphragm. The
diaphragm is at, and the bell is a concave cup. The diaphragm transmits high-pitched
sounds, and the bell transmits low-pitched sounds. Breath sounds and normal heart
sounds are examples of high-pitched sounds. Bruits and some heart murmurs are
examples of low-pitched sounds. Another commonly used stethoscope has a singlesided, dual-frequency listening head. This stethoscope has a single chest piece. The
nurse applies different pressures on the chest piece to auscultate high- and low-pitched
sounds. In addition, some practitioners are using digital stethoscopes to enhance sound
Figure 5.14). These stethoscopes can amplify natural sounds up to 30 times; they
Another type of stethoscope is the stereophonic stethoscope (Figure 5.15). This type
Prior to auscultating, remove jewellery such as necklaces and bracelets that
clarity (
can also function as a traditional acoustic stethoscope with the bell and the diaphragm.
The volume can be adjusted on the digital stethoscope, and a mute feature to block the
sound of crying children is available.
of stethoscope is a two-channel device that augments right- and left-sided auscultatory
could move during the examination and cause false noises. Warm the headpieces of
the stethoscope in your hands prior to use, because shivering and movement can
obscure examination ndings. To use the diaphragm, place it rmly against the skin
surface to be auscultated. If the consumer has a large quantity of hair in this area, it
may be necessary to wet the hair to prevent it from interfering with the sound that
FIGURE 5.14 Digital stethoscope
sound
chamber
FIGURE 5.15 Stereophonic stethoscope
138 PHYSICAL EXAMINATION
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UNIT 2
FIGURE 5.16 Doppler ultrasonic
stethoscope:
is being auscultated. Otherwise, a grating sound may be heard. To use the bell, place
it lightly on the skin surface that is to be auscultated. The bell will stretch the skin
and act like a diaphragm and transmit high-pitched sounds if it is pressed too rmly
on the skin. In both instances, auscultation requires a great deal of concentration. It
may be helpful to close your eyes during the auscultation process to help you isolate
the sound. Sometimes you can hear more than one sound in a given location.
Try to listen to each sound and concentrate on each separately. It is important to
clean your stethoscope after each consumer to prevent the transfer of pathogens.
Remember, auscultation is a skill that requires practice and patience.
Amplication of body sounds can also be achieved with the use of a Doppler
ultrasonic stethoscope (
Figure 5.16). An electronic stethoscope amplies body sounds as
it lters extraneous sounds. Both high and low frequencies can be auscultated with one
headpiece. With the Doppler ultrasonic stethoscope, water-soluble gel is placed on the
body part being assessed, and the stethoscope is placed directly on the consumer. The
device amplies the sounds in that region. Fetal heart tones and unpalpable peripheral
pulses are frequently assessed via a Doppler ultrasonic stethoscope.
ISTOCK.COM/ETORRES69
Articial intelligence (AI) is being used to interpret cough sounds and other
audio signals during consumer assessment (Son & Lee, 2022). The COVID-19
pandemic has accelerated investigations using AI diagnostic technology and
smartphone-based breathing recordings (Alkhodari & Khandoker, 2022).
Equipment
The physical examination will proceed in an efcient manner if you have gathered
all of the necessary equipment beforehand. Ensure your equipment is arranged in
order of use and within easy reach. The equipment needed to perform a complete
physical examination of the adult consumer includes:
> pen and paper
> marking pen
> tape measure
> ruler
> clean gloves
> penlight or torch
> scales
> thermometer
> sphygmomanometer
> a lamp/good lighting
> tongue depressor
> stethoscope
> otoscope
> nasal speculum
> ophthalmoscope (advanced practice)
> transilluminator
> visual acuity charts
> visual occluder
> tuning fork
> reex hammer
> sterile needle
> cotton balls
> odours for cranial nerve assessment (coffee, lemon, owers, etc.)
> small objects for neurological assessment (paper clip, key, cotton ball, pen, etc.)
> water-soluble lubricant
> various sizes of vaginal speculums (advanced practice)
> cervical brush (advanced practice)
> cotton-tip applicator
> cervical spatula (advanced practice)
> slide and xative
PHYSICAL EXAMINATION TECHNIQUES 139
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> guaiac material (for testing for faecalmaterial)
> specimen container
> goniometer.
The use of these items is discussed in the chapters describing the assessments
for which they are used.
Figure 5.17 illustrates some of the equipment used in the
physical assessment.
CHAPTER 5
1. Tuning fork
2. Visual occluder
3. Ruler
4. Visual acuity chart
5. Reex hammer (brush at bottom)
6. Reex hammer
7. Pen and marking pen
8. Penlight (torch)
9. Thermometer
10. Sphygmomanometer
11.
Slide and xative
12. Specimen container
13. Vaginal speculum
Lubricant
14.
15. Goniometer
16.
Clean gloves
17. Cervical spatula (Ayre spatula)
Cervical brush (cytobrush)
18.
19. Cotton-tip applicator
20. Tongue depressor
21. Guaiac material
Tape measure
22.
23.
Stethoscope
24. Ophthalmoscope
25.
Otoscope with speculum
26. Objects for neurological examination (key and
cotton ball)
Sterile needle
2 7.
FIGURE 5.17 Equipment used in physical examination
140 PHYSICAL EXAMINATION
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CHAPTER RESOURCES
REVIEW QUESTIONS
UNIT 2
For answers to these questions, see Answer section at the end of
the book.
1. Which of the following statements accurately reect standard
precautions? Select all that apply.
a. Recommendations to decrease pathogen transmission in
all healthcare settings
b. Guidelines to maximise precautions to prevent pathogen
transmission
c. Use of a mask when a pregnant woman is given an
epidural anaesthetic
d. The use of alcohol-based hand rub as the primary means
of cleaning hands
e. The disposal of single-use equipment when it is nished
being used
f. The use of EPA-approved disinfectants for use in
healthcare settings
2. The nurse palpates the consumer’s abdomen, assessing skin
texture, moisture and muscle guarding. Which assessment
skill is most likely being used?
a. Light palpation
b. Direct percussion
c. Deep palpation
d. Indirect percussion
Questions 3 and 4 refer to the following situation:
A 53-year-old male is admitted to your unit with a suspected bowel
obstruction.
3. In what order would you conduct the physical assessment of
the abdomen?
a. Percussion, inspection, palpation, auscultation
b. Inspection, auscultation, percussion, palpation
c. Auscultation, palpation, percussion, inspection
d. Palpation, percussion, inspection, auscultation
4. What position best facilitates the abdominal assessment?
a. Sims’
b. Knee to chest
c. Horizontal recumbent
d. High Fowler’s
5. The nger pads are used to assess what aspects of a physical
examination? Select all that apply.
a. Oedema
b. Moisture
c. Organ size
d. Temperature
e. Texture
f. Vibration
6. Which percussion sound is soft in intensity, short in duration,
high in pitch, and has a at quality?
a. Flatness
b. Dullness
c. Resonance
d. Tympany
7. Which percussion technique is usually used to assess
costovertebral tenderness of a kidney?
a. Direct percussion
b. Indirect percussion
c. Direct st percussion
d. Indirect st percussion
8. Which characteristics best describe hyperresonance?
a. Soft intensity, short duration, high pitch
b. Moderate intensity, moderate duration, high pitch
c. Loud intensity, long duration, high pitch
d. Very loud intensity, long duration, very low pitch
9. The bell of the stethoscope is used to assess which of the
following sounds?
a. Breath sounds
b. Bowel sounds
c. Low sounds
d. Apical heart rate
10. Which of the following positions is the best to assess the
female genitalia and conduct a Pap smear when a woman
cannot tolerate the lithotomy position?
a. Semi-Fowler’s
b. Horizontal recumbent
c. Sims’
d. Prone
CLINICAL SKILLS
The following Clinical Skills are relevant to this chapter and
can be found in Tollefson & Hillman, Clinical Psychomotor
Skills, 8th edition:
> 25 Clinical handover
> 26 Documentation.
PHYSICAL EXAMINATION TECHNIQUES 141
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FURTHER RESOURCES
> Association for Professionals in Infection Control and
Epidemiology (APIC): http://www.apic.org/
> Australasian Society of Clinical Immunology and Allergy:
http://www.allergy.org.au
> Australian Commission on Safety and Quality in Health Care:
http://www.safetyandquality.gov.au/
> Australian Council on Healthcare Standards: http://www.achs.
org.au
> Australian Government Department of Health: http://www.
health.gov.au/
> Better Health Channel: http://www.betterhealth.vic.gov.au/
> BloodSafe ELEARNING Australia: https://bloodsafelearning.
org.au/course/clinical-transfusion-practice/
REFERENCES
Alkhodari, M., & Khandoker, A. H. (2022). Detection of COVID-19 in
smartphone-based breathing recordings: A pre-screening deep
learning tool. PloS One, 17(1), e0262448–e0262448. https://doi.
org/10.1371/journal.pone.0262448
Australian Commission on Safety and Quality in Health Care (ACSQHC).
(2017). National Safety and Quality Health Service Standards
(2nd ed.). Retrieved 18 May 2022 from https://www.safetyandquality.
gov.au/sites/default/les/migrated/National-Safety-and-QualityHealth-Service-Standards-second-edition.pdf
Australian Commission on Safety and Quality in Health Care (ACSQHC).
(2019). The state of patient safety and quality in Australian hospitals
2019. Retrieved 18 May 2022 https://www.safetyandquality.gov.
au/publications-and-resources/state-patient-safety-and-qualityaustralian-hospitals-2019
Australian Commission on Safety and Quality in Health Care (ACSQHC).
(2021). COVID-19: Infection prevention and control risk management.
Retrieved 17 May 2022 https://www.safetyandquality.gov.au/
publications-and-resources/resource-library/covid-19-infectionprevention-and-control-risk-management-guidance
Gelfman, D. M. (2021). Will the traditional physical examination be another
casualty of COVID-19? The American Journal of Medicine, 134(3),
299–300. https://doi.org/10.1016/j.amjmed.2020.10.026
Health Quality & Safety Commission New Zealand. (2022). Infection
prevention and control. Retrieved 18 May 2022 from https://www.hqsc.
govt.nz/our-work/infection-prevention-and-control/ipc-practices/
precautions-standard-and-transmission-based
Infection Control Expert Group (ICEG). (2021, June). Guidance on
the use of personal protective equipment (PPE) for health care
workers in the context of COVID-19. Australian Government.
https://www.health.gov.au/committees-and-groups/infectioncontrol-expert-group-iceg
> Centers for Disease Control and Prevention: http://www.cdc.gov
> Health Quality & Safety Commission New Zealand: https://
www.hqsc.govt.nz/
> Healthdirect Australia: http://www.healthdirect.gov.au/
> Ministry of Health-infection control and prevention:
https://www.health.govt.nz/our-work/infection-preventionand-control#:~:text=Make%20hand%20hygiene%20
information%2C%20hand,single%20room%20(if%20available).
> My Stethoscope: The Stethoscope Experts: http://www.
mystethoscope.com
> New Zealand Legislation: http://legislation.govt.nz
> New Zealand Ministry of Health: http://www.health.govt.nz/
> Standards New Zealand: https://www.standards.govt.nz/
Ministry of Health Manatu Hauora. (2022). Infection prevention and control.
New Zealand Government. Retrieved 18 May 2022 https://www.health.
govt.nz/our-work/infection-prevention-and-control
Monaghesh, E., & Hajizadeh, A. (2020). The role of telehealth during COVID-19
outbreak: A systematic review based on current evidence. BMC Public
Health, 20(1), 1193. https://doi.org/10.1186/s12889-020-09301-4
National Health and Medical Research Council (NHMRC). (2019).
Australian Guidelines for the Prevention and Control of Infection
in Healthcare, (2019), v11.10 31/8/21. Canberra: Commonwealth of
Australia. Retrieved 17 May 2022 from https://www.nhmrc.gov.au/
about-us/publications/australian-guidelines-prevention-and-controlinfection-healthcare-2019
Patterson, B., Marks, M., Martinez-Garcia, G., Bidwell, G., Luintel, A.,
Ludwig, D., Parks, T., Gothard, P., Thomas, R., Logan, S., Shaw, K.,
Stone, N., & Brown, M. (2020). A novel cohorting and isolation
strategy for suspected COVID-19 cases during a pandemic. The
Journal of Hospital Infection, 105(4), 632–7. https://doi.org/10.1016/j.
jhin.2020.05.035
Son, M.-J., & Lee, S.-P. (2022). COVID-19 diagnosis from crowdsourced
cough sound data. Applied Sciences, 12(4), 1795. https://doi.
org/10.3390/app12041795
Standards New Zealand (2021). Health and disability services standard.
https://www.standards.govt.nz/shop/nzs-81342021/
World Health Organization (WHO). (2009). WHO guidelines on hand hygiene
in health care. Retrieved 19 May 2022 from: https://www.who.int/
publications/i/item/9789241597906
World Health Organization (WHO). (2022a). WHO Coronavirus (COVID-19)
dashboard. https://covid19.who.int Retrieved 24 May 2022.
World Health Organization (WHO). (2022b). World hand hygiene day.
Retrieved 24 May 2022 https://www.who.int/campaigns/world-handhygiene-day
CHAPTER 5
142
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CHAPTER
6
EXAMINATION REQUIREMENTS FOR
EVERY CONSUMER
LEARNING OUTCOMES
By the end of this chapter you should be able to:
1 describe the general approach to assessment for all consumers
2 identify factors impacting on assessment for all consumers.
BACKGROUND
A complete physical examination is initiated by performing a general
observation of the consumer. This includes a general survey of the physical
and psychological status as well as obtaining the consumer’s
and pain assessment. The general survey commences at the time of the
initial consumer encounter and provides data about their general health
status. Focused observational skills are required to prepare for the physical
examination, which centres on the characteristics of illness, demeanour
and facial affect or expression, hygiene and grooming, and posture and
gait. Vital signs include the consumer’s respirations, pulse, temperature,
blood pressure (BP) and oxygen saturations. Pain assessment includes the
use of an appropriate framework, such as OPQRST and pain intensity scale.
These measurements provide information about the consumer’s baseline
physiological status. In some instances, for example in the emergency
department, neurological status should also be assessed by using the AVPU
assessment scale (alert, voice, pain, unresponsive), Glasgow Coma Scale
(GCS) (Akgun et al., 2018) and/or the Mini Mental Examination (MME). It is
important to recognise the normal health-related parameters for the consumer
you are assessing, as the nurse must observe for any deviations as potential
signs of deterioration. This is because nurses are required to assess and respond
to a consumer’s acutely deteriorating physiological or mental status in an
appropriate and timely way (ACSQHC, 2022).
Refer to Chapter 1 for guidance on a systematic approach for examination
requirements.
vital signs
URGENT FINDING
Recognition of physiological deterioration
Nurses must be alert for any red ags that can identify a consumer’s physiological
deterioration and understand their responsibility in being vigilant, take into consideration
the following:
>>
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 143
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>>
Vital signs
> Frequency of assessment should suit clinical acuity.
> Regular monitoring as part of a systematic physical assessment includes:
· respiratory rate
· oxygen saturation
· heart rate
· blood pressure
· temperature
· level of consciousness and pain assessment.
> Monitor and document observations in a chart that provides visual graphical information,
displaying trends that can be tracked over time.
> The response or action required when deviations from normal are detected and timely
interventions for the safety of the consumer maintained.
Other physiological observations and assessment
> Depending on the clinical situation, to support timely recognition of deterioration,
other assessment data and observations should also be monitored and taken into
consideration. These include uid balance, occurrence of seizures, chest pain,
respiratory distress, pallor, capillary rell, pupil size and reactivity, sweating, nausea
andvomiting, as well as additional biochemical and haematological analyses.
Note: It is each healthcare professional’s responsibility to be aware of the protocol in their
facility regarding escalation of care, as an essential requirement for responding
appropriately to clinical deterioration. Protocols are safety nets that set out an
organisation’s process required to respond to deterioration (including response to abnormal
vital signs and deviations from normal physiological observations and assessments).
For more information on standards and protocols related to the deteriorating consumer
visit ACSQHC – National Consensus Statement: Essential elements for recognising and
responding to acute physiological deterioration (3rd edn.), https://www.safetyandquality.gov.
au/publications-and-resources/resource-library/national-consensus-statement-essentialelements-recognising-and-responding-acute-physiological-deterioration-third-edition
CHAPTER 6
PLANNING FOR PHYSICAL EXAMINATION
The planning phase refers to evaluating subjective data to narrow the focus of the
physical examination, determining what objective data needs to be gathered, as well
as considering the environment and equipment that will be required.
Objective data is:
> collected during the physical examination of the consumer
> usually collected after subjective data
> information that is measured or observed by the clinician as opposed to being
reported by the consumer
> vital to the overall health assessment, to enable you to make clinical decisions
that are representative of the whole consumer picture.
Environment
General survey, vital signs, level of consciousness and pain assessment can be
undertaken in most physical environments in healthcare settings. Adequate privacy
and lighting is required as for any health assessment, as well as minimal noise for
accurate auscultation and data collection.
Equipment
> Stethoscope
> Watch with a second hand
144 PHYSICAL EXAMINATION
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UNIT 2
EXAMINATION IN BRIEF
> Thermometer (gloves and lubricant if using a rectal thermometer)
> Sphygmomanometer
> Pulse oximeter
> Pen light (torch)
> Relevant documentation
CLINICAL REASONING
Practice tip: Additional observational cues
When observing the consumer, take a moment to look more broadly for clues about their
health status. For example, in the immediate environment you may notice an inhaler, a nasal
spray, a hearing aid, orthotic inserts in shoes or used tissues. These clues provide additional
information about the individual’s health status.
IMPLEMENTATION: CONDUCTING THE GENERAL SURVEY
Initial observations include collecting information about the consumer’s physical
status, psychological status, and signs and symptoms of distress.
General survey, vital signs, pain, neurological status
Examination of physical status
> Stated age versus apparent age
> General appearance
> Body fat
> Body conformation and posture
> Motor activity
> Body and breath odours
Examination of psychological status
> Mental status and cognitive function
> Facial expressions
Examination of physical status
Observe the consumer’s:
E
1. stated age versus apparent age
2. general appearance
3. body fat
4. body conformation and posture
5. motor activity
6. body and breath odours.
Stated age versus apparent age
N
The consumer’s stated chronological age should be congruent with the
apparent age.
A
It is signicant for a consumer to appear older or younger than the stated
chronological age.
> Endocrine deciencies of growth hormone associated with dwarsm can
P
manifest in a younger-than-chronological-age appearance in younger life and
premature ageing later in life.
> Dress, grooming and personal hygiene
> Mood and manner
> Speech and communication
> Distress
Examination of vital signs
> Respiration
> Pulse
> Temperature
> Blood pressure
> Oxygen saturation
> Pain assessment
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 145
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> Genetic syndromes (e.g. Turner) manifest in an ‘old-person’ facial
appearance.
> Chronic disease, severe illness (such as cancer and AIDS), and prolonged sun
exposure that causes facial wrinkling can all lead to a consumer looking older
than his or her chronological age.
General appearance
E
Observe body symmetry, any obvious anomaly, and the consumer’s apparent
level of wellness (
of a walker, assistance from a caregiver, or distinctive markings (e.g. multiple
piercings, tattoos).
N
The consumer should exhibit body symmetry, no obvious deformity, and a well
appearance. The level of gross normal observations is varied.
Asymmetry is seen when a paired body part does not look the same on the
A
contralateral side.
The unilateral facial drooping of Bell’s palsy, a limb appearing at an abnormal
P
angle, and unilateral paralysis are examples of body asymmetry.
A missing limb, cleft lip, and burned facial skin are examples of
A
obvious anomalies.
The pathophysiology of each of these is varied and needs to be investigated
P
further via history and physical assessments.
The consumer who shows signs of being ill, such as pain, respiratory distress,
A
pallor, sweating, nausea and vomiting is an abnormal nding.
A consumer who appears ill needs to be carefully assessed via the history and
P
physical examination, to quickly identify if there are signs of acute physiological
or mental health deterioration, and immediate action taken.
E
Observe for skin colouration (see Chapter 8 for detailed information).
N
Normally, the skin is a uniform whitish-pink or brown colour, depending on the
consumer’s race.
The appearance of cyanosis (dusky blue), jaundice (yellow-green to orange cast
A
or colouration) or pallor of skin, sclera or mucous membranes is abnormal in
both light- and dark-skinned individuals.
The pathophysiology of each of these is varied and needs to be investigated
P
further via health history and physical examination.
Figure 6.1). In addition, note any gross observation such as use
FIGURE 6.1 The nurse can make
observations about the consumer’s
general appearance while talking with
them and preparing for the
physical examination.
CHAPTER 6
Body fat
N
Body fat should be evenly distributed. Research has indicated that it is body fat
content, not body weight that is most closely linked to pathology. For example,
a person can be within normal limits on height and weight charts but have a
high proportion of body fat to lean body mass.
Obesity occurs when there are large amounts of body fat. This poses a serious
A
health risk to the consumer and warrants a comprehensive nutritional
assessment (see Chapter 15).
Excess caloric intake and decreased energy expenditure are the most common
P
causes of obesity.
Some disease processes such as hypothyroidism, which slows the basic metabolic
P
rate, may result in obesity.
Cushing syndrome manifests in a rounded, moonlike face, truncal obesity, fat
A
pads on the neck, and relatively thin limbs.
Excessive production of cortisol resulting from an anterior pituitary tumour or
P
large doses of prolonged steroid therapy produces Cushing syndrome.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
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