Third Edition
EDITED BY
CAROL LYNN COX PhD, MSc, MA (Theology) MA (Education), PG Dip Education, BSc (Hons), RN, ENB 254, FHEA
Professor Emeritus, School of Health Sciences, City, University of London, London, UK
Clinic Manager and Director of Nursing, Health and Hope Clinics, Pensacola, FL, USA
Adapted from Lecture Notes on Clinical Skills (third edition) by:
THE LATE ROBERT TURNER MD, FRCP
Professor of Medicine and Honorary Consultant Physician
Nuffield Department of Clinical Medicine
Radcliffe Infirmary, Oxford, UK
ROGER BLACKWOOD MA, FRCP
Consultant Physician, Wexham Park Hospital, Slough, and Honorary Consultant Physician at Hammersmith Hospital, London, UK
This edition first published 2019 © 2019 by John Wiley & Sons Ltd
Edition History [2e, 2009]
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Library of Congress Cataloging‐in‐Publication Data
Names: Cox, Carol Lynn, editor. | Based on (work): Blackwood, Roger. Lecture notes on clinical skills. 2003.
Title: Physical assessment for nurses and healthcare professionals / edited by Carol Lynn Cox.
Other titles: Physical assessment for nurses.
Description: Third edition. | Hoboken, NJ : Wiley‐Blackwell, 2019. | Preceded by Physical assessment for nurses / edited by Carol Lynn Cox. 2nd ed. 2010. | Based on Lecture notes on clinical skills / Roger Blackwood, Chris Hatton. 4th ed. 2003. | Includes bibliographical references and index. |
Identifiers: LCCN 2018044840 (print) | LCCN 2018045696 (ebook) | ISBN 9781119108986 (Adobe PDF) | ISBN 9781119108993 (ePub) | ISBN 9781119108979 (pbk.)
Subjects: | MESH: Nursing Assessment
Classification: LCC RT48 (ebook) | LCC RT48 (print) | NLM WY 100.4 | DDC 616.07/5–dc23
LC record available at https://lccn.loc.gov/2018044840
Cover Design: Wiley
Cover Images: © Martin Barraud/Getty Images, © Hero Images/Getty Images, © XiXinXing/Getty Images, © Blend Images ‐ Jose Luis Pelaez Inc/Getty Images
Daniel Apau, MSc (Advanced Practice), PG Dip, BSc (Hons), RN, FHEA
Registered Nurse, Medical Intensive Care, Houston Northwest Medical Center, Houston, TX, USA
Michael Babcock, MD
College of Medicine, Florida State University, Pensacola, FL, USA
Graham M. Boswell, D Ed, MA Ed, BA (Hons), BSc (Hons) RGN, FHEA
Senior Lecturer, Department of Adult Nursing and Paramedic Science, Faculty of Education and Health, University of Greenwich, London, UK
Carrie E. Boyd, MSN, BSN, RN
Staff Nurse, Health and Hope Clinics, Pensacola, FL, USA
Patrick Callaghan, PhD, MSc, BSc (Hons), RN, FHEA
Professor of Mental Health Nursing and Chartered Health Psychologist
University of Nottingham and Nottinghamshire Health Care NHS Trust, Nottingham, UK
Carol Lynn Cox, PhD, MSc (Nursing), MA (Theology) MA Ed, PG Dip Ed, BSc (Hons), FD, RN, FHEA
Professor Emeritus, School of Health Sciences, City, University of London, London, UK
Clinic Manager, Health and Hope Clinics, Pensacola, FL, USA
Jennifer Edie, M Ed, MBA, TDCR, DMU
Senior Lecturer, Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
Helen Gibbons, MSc, PG Cert (Medical Education), ENB (Ophthalmic Practice), BA (Hons), RN
Clinical Nursing Lead (Education and Research), Moorfields Eye Hospital NHS Foundation Trust, London, UK
Course Director, PG Cert Ophthalmic Practice, University College London, London, UK
Jessica Ham, MSN, BSN, ASN, FNP, RN
Clinical Preceptor, College of Medicine, Faculty of Florida State University, Tallahassee, FL, USA
Clinical Director, Elevate Personalized Medicine, Pensacola, FL, USA
Siobhan Hicks, MSc (Advanced Practice), PG Cert (Academic Practice), PG Cert (Leadership), BSc (Hons), RN
Advanced Nurse Practitioner, Andrews Health Centre, London, UK
Lecturer in Advanced Practice, School of Health Sciences, City, University of London, London, UK
Victoria Lack, MSN, PG Dip (Academic Practice), BN (Hons), FNP, Non‐Medical Prescriber, DN(Cert), RN
Lecturer in Primary Care, Department of Health Sciences, University of York, York, UK
Advanced Nurse Practitioner, Beech House Surgery, Knaresborough, North Yorkshire, UK
Brandy Lunsford, MSN, BSN, APRN
Clinical Director, Health and Hope Clinics, Pensacola, FL, USA
Anthony McGrath, MSc, PGCE, BA (Hons) RMN, RGN, FHEA
Principal Lecturer, Head of Adult Nursing and Midwifery
London South Bank University, London, UK
Nicola L. Whiteing, MSc, PG Dip HE, BSc (Hons), RN, RNT, ANP
Lecturer in Nursing, Southern Cross University, Lismore, New South Wales, Australia
Underpinning the appropriate delivery of healthcare is the Physical Assessment. This structured physical examination allows the healthcare professional to obtain a comprehensive assessment of the patient and is critically important in that it leads to clinical decisions which are crucial for the patients' care.
This volume, Physical Assessment for Nurses and Healthcare Professionals, provides a clear and easy‐to‐use guide to achieving an excellent physical assessment. It is specifically intended for those embarking on a career in healthcare and contains the techniques used by specialist/advanced practitioners.
In this book the need for a comprehensive and holistic approach to the Physical Assessment is excellently presented by Professor Cox. Professor Cox shows how important it is to develop a rapport with the patient in order to carefully assess their perceptions and how this relationship must be established from the very first meeting when information is exchanged between the healthcare professional and the patient. Fundamental to gaining this perspective is to listen. The importance of guiding the healthcare practitioner to engage in active listening cannot be underestimated and this is reflected in the fact that not being heard is an issue which is often raised as a point of criticism of healthcare professionals by patients and their families.
Careful observation and reports of subjective symptoms are the window through which healthcare professionals gain knowledge of their patients. Following on from the opening chapters this volume is structured to enable the healthcare professional to learn how to systematically gather information before moving on to an initial diagnosis and further investigations. The tools of inspection, palpation, percussion, and auscultation are key to this assessment and excellently laid out in the chapters covering the examination of the different organs of the body, different age groups, and some specialist topics. Professor Cox has also helpfully included in the appendix a number of the widely used standardised instruments to assess such areas as disability, activities of daily living, reading, and mental state.
It is key for healthcare professionals to be able to communicate the outcomes of their Physical Assessment to their professional colleagues. In the final chapter Professor Cox demonstrates her experience and understanding of the world of healthcare when she talks about the importance of this communication between professionals and how the Physical Assessment can bring together disparate professional views which will underpin the diagnostic process.
Professor Cox is a consummate professional who has been an educator for most of her career with a focus on clinical practice and the patient experience. She couples her educational activity with an extensive research record on nursing practice. In Physical Assessment for Nurses and Healthcare Professionals, Professor Cox has created an invaluable guide that will not only support practitioners as they enter into a clinical career in healthcare but which can be used as an ongoing reference book to support their careers as they move into advanced practice.
Over the past two to three decades, many changes have been seen in the roles of healthcare professionals. Significant changes have been seen in the allied health professions, nursing, and midwifery. It is common practice now to see the healthcare professional functioning as an independent practitioner with specialist/advanced practice qualifications. For example, to list but a few, it is not uncommon to find audiologists, nurses, midwives occupational therapists, opticians, physiotherapists, and radiotherapists with master's and doctoral degrees diagnosing and treating patients. These practitioners are expected to know how to provide expert holistic health‐oriented care for culturally diverse populations. Specialist/advanced practice health professionals view the patient as an individual with physical as well as emotional, psychological, intellectual, social, cultural, and spiritual needs. A comprehensive assessment of the patient is the foundation upon which healthcare decisions are made. The best way to develop assessment skills is to learn them systematically. The systematic approach involves taking a full health history, conducting a physical examination, and reviewing diagnostic tests/laboratory data. Use of advanced assessment skills are essential in clinical decision making that leads to the formulation of a differential diagnosis and final diagnosis.
This text for healthcare professionals is based on Turner and Blackwood's Lecture Notes on Clinical Skills that was written for medical students. It is intended to be used as a reference book that can be reviewed near the patient in the clinical setting. In general, the pages are arranged with simple instructions on the left, with important aspects requiring action marked with a bullet (•). Subsidiary lists are marked with a dash (–). On the right are brief details of clinical situations and diseases that are relevant to abnormal findings. In this edition, colour photographs of assessment techniques have been added as well as case studies to assist healthcare practitioners in their assessment of the patient.
Turner and Blackwood's Lecture Notes on Clinical Skills has been used in the Oxford Clinical Medical School for over 40 years and is viewed as an essential guide for medical students globally. It should be noted that although some doctors may use slightly different techniques in taking a history and physical examination, it is recommended that healthcare practitioners embarking on a career as specialist/advanced practitioners use the techniques recommended in this text because they provide a sound approach for developing and employing clinical decision making.
Special thanks are extended to Robert Turner and Roger Blackwood for granting permission for their text, Lecture Notes on Clinical Skills, to be revised as a text originally for nurses. I am grateful to my students for encouraging me to revise the original text so that they could have an accessible resource for reference purposes in the clinical setting. The Turner and Blackwood text still serves as a reference for the third edition which has been expanded for all healthcare practitioners. Sincere gratitude is expressed to Sandra Kerka for thoroughly reviewing this book and correcting a multitude of errors therein and to Vincent Rajan, Production Editor, for efficiently bringing the book to completion. Finally, I am grateful to the Health and Hope Clinics of Pensacola Florida; City University, London, England; and the University of Latvia, Department of Optometry and Vision Science, Latvia, for supporting this project through their generous provision of physical assessment technique photographs. Any faults or omissions in this book are entirely my own.
Figures appearing on pp. 36, 37, 41, 49 (Figure 3.1), 52 (Figure 3.2), 53 (Figure 3.3), 54, 55 (Figure 3.4), 56 (Figure 3.5), 69 (Figure 3.11), 75 (Figures 4.1 and 4.2), 76 (Figure 4.3), 77 (Figures 4.4 and 4.5), 78 (Figure 4.6), 81 (Figure 4.7), 82 (Figure 4.9) and 83 (Figure 4.10) are reproduced with permission of City University from Advanced Practice: Physical Assessment (1997), Carol Lynn Cox, Professor, City University London, St Bartholomew School of Nursing and Midwifery, ISBN 1900804255, Reprinted 2002.
The visual acuity reading charts (Appendices A and B) are reproduced courtesy of Keeler Ltd.
Carol Lynn Cox
It is important to understand that for the purposes of examination, assessment, and diagnosis, doctors are framing their approach to the patient from the perspective of the medical model. However, you must recognise that as an allied healthcare practitioner, you are employing the medical model within your frame of practice. Therefore, to be wholistic, the approach incorporates all aspects of your particular discipline (e.g. audiology, nursing, midwifery, physiotherapy, occupational therapy, radiography, respiratory therapy, speech therapy).
When you approach a patient there are four initial objectives you should consider:
Remember medicine is just as much about worry as disease. Whatever the illness, whether chest infection or cancer, anxiety about what may happen is often uppermost in the patient's mind (Clark 1999; Japp and Robertson 2013; NHS Wales 2010).
Engage in active listening
The following notes provide a guide as to how the healthcare practitioner obtains the necessary information.
In taking a history or conducting a physical examination there are several complementary aims:
For each symptom or sign you need to think of a differential diagnosis and of other relevant information (from the history, physical examination, and/or investigative tests) that will be needed to support or refute possible diagnoses. A good history, physical examination, and investigation include these two facets and can be viewed as either positive (support) or negative (refute) findings. To achieve a formal diagnosis, following differential diagnosis, critical thinking/clinical decision making is used to examine positive and negative findings. Healthcare practitioners frequently find that using the first two components of the Subjective, Objective, Assessment, and Plan (SOAP) (Clark 1999) format can help them formulate their diagnosis. You should never approach the patient with just a set series of rote questions. Frequently in preassessment clinics, ambulatory services (outpatient) clinics, or general practice settings, standard assessment forms within an electronic patient record (EPR) are used as a guide to history taking. However, there are some instances in which paper records are employed. These tools provide the necessary basis for a later, more inquisitive approach that should develop as knowledge about the patient's problem is acquired. Key to the process of achieving a diagnosis and formulating a plan of care is listening carefully to the patient, taking time, not assuming a diagnosis when the patient initially expresses their chief complaint, and understanding your own values, attitudes, and beliefs as they relate to diverse patient populations (Japp and Robertson 2013).
Focus on the patient
The ‘subjective’ and objective components of the SOAP format provide a basis for diagnosis. Within the subjective component, the patient's perspective of the problem/illness is stated in their own words. This is often listed as the patient's chief complaint. In addition, the patient's ‘subjective’ view of their health history (e.g. childhood diseases and immunisations) as well as family history, present medications, how and when the patient takes the medications, and chronological ordering of sequelae leading to the presenting problem are documented. The objective component consists of your physical examination and investigative tests. Assessment involves the formulation of a diagnosis from the history, physical examination, and investigative tests. Plan involves the development of the plan of care for the patient as well as where, when, how, and by whom the plan will be implemented (Bickley and Szilagyi 2013).
You must take your own history, make your own examination, and write your own clinical records. After a month or two you should be sufficiently proficient that your notes can become part of the final medical record. You should add a summary including your assessment of the problem list, provisional diagnoses, and preliminary investigations. Initially when developing your assessment/examination skills these will be incomplete and occasionally incorrect. Nevertheless, the exercise will help to inculcate an enquiring approach and to highlight areas in which further questioning, investigation, or study/reading is needed.
At the basis of all practice is clinical competence. No amount of knowledge will make up for poor technique.
Over the first few weeks it is essential to learn the basics of history taking and physical examination. This involves:
There is nothing inherently difficult about history taking and physical examination. You will quickly become clinically competent if you:
Common sense is the cornerstone of good practice.
Many mistakes are made by being sidetracked by aspects that are not important. Remain focused on the patient.
Your clinical skills and knowledge can soon develop with good organisation.
At first history taking and physical assessment seem like a huge subject and each fact you learn seems to be an isolated piece of information. How will you ever be able to learn what is required? You will find after a few months that the information related to each system interrelates with other systems. The pieces of the jigsaw puzzle begin to fit together and then your confidence will increase. Although you will need to learn many facts, it is equally important to acquire the attitude of questioning, reasoning, and knowing when and where to go to seek additional information.
Understand the scientific background of disease, including the advances that are being made and how these could be applied to improve care. (The world wide web is a good resource as well as scientific journals for gaining knowledge that will assist you in building your knowledge.)
Good relationships with patients and clinical colleagues are essential. You should maintain a natural, sincere, receptive, and supportive relationship with your patients and clinical colleagues. Your ultimate goal in working with patients and clinical colleagues is to achieve good care (Department of Health, Social Services and Public Safety in Northern Ireland 2016; Jarvis 2015).
Your role as an advanced healthcare practitioner extends the boundaries of the scope of professional practice. The skills and practices associated with advanced practice involve using advanced clinical assessment techniques, interpreting diagnostic tests including diagnostic imaging, implementing and monitoring therapeutic regimes, prescribing pharmacological interventions, initiating and receiving appropriate referrals, and discharging patients (NMC 2005; HCPC 2013a, b; HCPC 2016).
Practice associated with the advanced practice role in healthcare involves:
It is essential that you develop sound skills within the framework delineated here if you expect to be competent at the specialist/advanced practice level.