An interval history (including an update of complaints, reason for visit, review of systems and past
family and/or social history) should be done.
... [Show More] Usually family health histories are completed across three
generations looking specifically for patterns in genetic issues that negatively impact quality of life.
The health history gives picture of the patient’s current health and behavior risk status. Additional
information than what is on a form may be required depending on the specialized service(s) to be
provided or if the person presents with special needs or conditions. So a health history maybe may be
problem focused, expanded problem focused, detailed, or comprehensive. Regardless, documentation
must be completed for each visit and/or assessment.
Mental status evaluation may be done while doing health history (see neuro review).
***********************************************************************************************
Physical Examination
A comprehensive physical examination should be performed according to age specific preventive
health guidelines. American Medical Association clinical practice guidelines recognize the following
body areas and organ systems for purpose of the examination:
◊ Body Areas: Head (including the face); Neck; Chest (including breasts and axillae); Abdomen;
genitalia, groin, buttocks; Back (including spine); and each extremity.
◊ Organ Systems: Constitutional (vital signs, general appearance), Eyes, Ear, Nose, Throat;
Cardiovascular; Gastrointestinal; Genitourinary; Musculoskeletal; Dermatological; Neurological;
Psychiatric; Hematological/lymphatic/immunological
◊ Integumentary: Both overall body and organ systems should have skin assessments integrated
into them. Integument includes skin, hair and nails.
Normal and abnormal findings should be recorded on a health history and physical examination form.
***********************************************************************************
Measurements
Body measurements include length or height, weight, and head circumference for children from birth to
36 months of age. Thereafter, body measurements include height and weight. The assessment of
hearing, speech and vision are also measurements of an individual’s function in these areas. The
Denver Development Screening Test measures an infant’s and young child’s gross motor, language,
fine motor-adaptive and personal-social development milestones. If developmental delay is suspected
based on an assessment of a parent’s development/behavior concern or if delays are suspected after a
screening of development benchmarks, a written referral is to a physician or pediatric nurse practitioner
is imperative.
A patient’s measurements can be compared with a standard, expected, or predictable measurement for
age and gender. Deviation from standards helps identify significant conditions requiring close
monitoring or referral to a physician or pediatric nurse practitioner.
The significance of measurements and actions to take when they deviate from normal expectations are
age-specific.
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 4 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
How to measure Height:
1. Obtain height by measuring the recumbent length of children less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary
headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used.
a) Lay the child flat against the center of the board. The head should be held against the
headboard by the parent or an assistant and the knees held so that the hips and knees are
extended. The foot piece is moved until it is firmly against the child’s heels. Read and
record the measurement to the nearest 1/8 inch.
b) A modified technique in home settings is to lay the child flat and straight where the head
should be held by the parent and the knees held so that the hips and knees are extended,
mark the flat surface at the top of the head and tip of the heels. Move child and measure
the distance between the marks with a tape measure. Read and record the measurement
to the nearest 1/8 inch.
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36
months growth chart. When a standing height is obtained for a two year old, plot the finding on
the 2 year to 18 year chart. After plotting measurements for children on age and gender
specific growth charts, evaluate, educate and refer according to findings.
3. Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults,
using a portable stadiometer. The patient is to be wearing only socks or be bare foot. Have
the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees
are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The
flat surface of the stadiometer is lowered until it touches the crown of the head, compress the
hair. A measuring rod attached to a weight scale should not be used.
Measuring weight:
1. Balance beam or digital scales should be used to weigh patients of all ages. Spring type
scales are not acceptable. CDC recommends that all scales should be zero balanced and
calibrated. Scales must be checked for accuracy on an annual basis and calibrated in
accordance with manufacturer’s instructions.
2. Prior to obtaining weight measurements, make sure the scale is “zeroed”.
3. Weigh infants wearing only a dry diaper or light undergarments. Weigh children after removing
outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal
clothing.
4. Place the patient in the middle of the scale. Read the measurement and record results
immediately. Plot measurements on age and gender specific growth charts and evaluate
accordingly
Measuring Body Mass Index.
1. The Body Mass Index (BMI) is a measure that can help determine if a person is at risk for a
weight-related illness.
2. Instructions for obtaining the BMI are included within the chart in this section for adults. To
calculate BMI for children, see BMI Tables for Children and Adolescents for guidance.
Measuring Head and Chest Circumference.
1. Obtain head circumference measurement on children from birth to 36 months of age by
extending a non-stretchable measuring tape around the broadest part of the child’s head.
For greatest accuracy, the tape is placed three times, with a reading taken at the right side, at
the left side, and at the mid-forehead, and the greatest circumference is plotted. The tape
should be pulled to adequately compress the hair.
2. Head circumference should be measured each visit.
3. Chest: This is measured at the nipple line.
4. In a newborn, the head circumference will be about 2 cm larger than the chest circumference. As
the child ages, the chest circumference becomes larger than the head circumference.
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 5 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
Vital Signs
Vital signs, generally described as the measurement of temperature, pulse, respirations and blood
pressure, give an immediate picture of a person’s current state of health and well being. Normal and
abnormal ranges with management guidelines follow for children and adults.
Equipment Needed
1. Stethoscope
2. Blood Pressure Cuff
3. Watch Displaying Seconds
4. Thermometer
General Considerations
1. The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise
within 30 minutes of the exam.
2. Ideally the patient should be sitting with feet on the floor and their back supported. The
examination room should be quiet and the patient comfortable.
3. History of hypertension, slow or rapid pulse, and current medications should always be
obtained.
A. Temperature
1. Temperature can be measured is several different ways:
a) Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C)
b) Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)
c) Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)
d) Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)
2. Of these, axillary is the least and rectal is the most accurate.
3. Use back of hand (dorsal aspect) to assess skin temperature
B. Respiration
1. Best done immediately after taking the patient's pulse. Do not announce that you are measuring
respirations
2. Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or
labored?
3. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.
4. In adults, normal resting respiratory rate is between 14-20 breaths/minute.
5. Rapid respiration is called tachypnea.
C. Pulse – see also Cardiovascular Exam
1. Sit or stand facing your patient.
2. Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right
or patient's left with your left). There is no reason for the patient's arm to be in an awkward
position, just imagine you're shaking hands.
3. Compress the radial artery with your index and middle fingers.
4. Count the pulse for 15 seconds and multiply by 4.
5. Always count for a full minute if the pulse is irregular.
6. Record the rate and rhythm
Note whether the pulse is regular or irregular:
Regular - evenly spaced beats, may vary slightly with respiration
Regularly Irregular - regular pattern overall with "skipped" beats
Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 6 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
Interpretation
1. A normal adult heart rate is between 60 and 100 beats per minute (see below for children).
2. A pulse greater than 100 beats/minute is defined to be tachycardia. A pulse less than 60
beats/minute is defined to be bradycardia.
3. Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at
rest (superior conditioning). Tachycardia is a normal response to stress or exercise.
D. Blood Pressure – see also Cardiovascular Exam
Blood pressure (BP) is the pressure by circulating blood on the walls of blood vessels. Arterial refers
systemic circulation. During each heartbeat, blood pressure varies between a maximum systolic and a
minimum diastolic pressure. The blood pressure in the circulation is principally due to the pumping
action of the heart. Differences in mean blood pressure are responsible for blood flow from one location
to another during circulation. The rate of mean blood flow depends on the resistance to flow presented
by the blood vessels. Mean blood pressure decreases as the circulating blood moves away from the
heart through arteries, capillaries and veins due to viscous losses of energy. Mean blood pressure
drops over the whole circulation, although most of the fall occurs along the small arteries and arterioles.
Gravity affects blood pressure via hydrostatic forces (e.g., during standing) and valves in veins,
breathing, and pumping from contraction of skeletal muscles also influence blood pressure in veins.
The measurement blood pressure without further specification usually refers to the systemic arterial
pressure measured at a person's upper arm and is a measure of the pressure in the brachial artery,
major artery in the upper arm. A person’s blood pressure is usually expressed in terms of the systolic
pressure over diastolic pressure and is measured in millimeters of mercury (mmHg).
To measure Blood Pressure
The patient should not have eaten, smoked, taken caffeine, or engaged in vigorous exercise within
the last 30 minutes. The room should be quiet and the patient comfortable.
1. Position the patient's arm so the antecubital fold is level with the heart.
2. Center the bladder of the cuff over the brachial artery approximately 2 cm above the antecubital
fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls
between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed
at the elbow.
3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate
of the systolic pressure.
4. Place the stethoscope over the brachial artery.
5. Inflate the cuff 20 to 30 mmHg above the estimated systolic pressure.
6. Release the pressure slowly, no greater than 5 mmHg per second.
7. The level at which you consistently hear beats is the systolic pressure
8. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic
pressure.
9. Record the blood pressure as systolic over diastolic (120/70).
Interpretation
1. Higher blood pressures are normal during exertion or other stress. Systolic blood pressures
below 80 may be a sign of serious illness or shock.
2. Blood pressure should be taken in both arms on the first encounter. If there is more than 10
mmHg difference between the two arms, use the arm with the higher reading for subsequent
measurements.
3. Always recheck "unexpected" blood pressures yourself.
4. It is frequently helpful to retake the blood pressure near the end of the visit. Earlier pressures
may be higher due to the "white coat" effect.
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 7 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
In children, pulse and blood pressure vary with the age. The following table should serve as a rough
guide:
Average Pulse and Blood Pressure in Normal Children
Age Birth 6mo 1yr 2yr 6yr 8yr 10yr
Pulse 140 130 115 110 103 100 95
Systolic BP 70 90 90 92 95 100 105
Blood Pressure Classification in Adults
Category Systolic Diastolic
Normal <130 <85
High Normal 130-139 85-89
Mild Hypertension 140-159 90-99
Moderate Hypertension 160-179 100-109
Severe Hypertension 180-209 110-119
Crisis Hypertension >210 >120 [Show Less]