CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
I. ENVIRONMENT/SETTING
It is important to prepare the environment before starting the assessment. The time for the
physical assessment should be convenient to both the client and the nurse. As a nurse, the first thing
you need to do is to establish a relationship with the client. It is important that patients feel they are
being listened to and given information in a respectful, non-judgmental way; this will help build a
trusted relationship. Ask the client how they wish to be addressed such as Mrs. or Miss. In preparing the
client, the nurse should explain when and where physical examination will take place; why it is
important and; what will be happen during the examination.
Maintaining patient privacy is also essential. Most people are embarrassed if their bodies are
exposed or if others can overhear or view them during the assessment. Expose only areas of the body to
examine. Drapes should be arranged so that the area to be assessed is exposed and other body areas
are covered. Drapes provide not only a degree of privacy but also warmth. The environment also needs
to be well lighted and the equipment should be organized for efficient use. A client who is physically
relaxed will usually experience little discomfort. The room should be warm enough to be comfortable
for the client and should remove any distractions such as noise or object and avoid disruptions.
In the initial interview with the client, the nurse should avoid barriers such as desk to have an
effective communication, maintaining an appropriate social distance and maintain eye contact with a
patient. Using the therapeutic communication techniques and open-ended questions, it helps to obtain
complete information regarding the client’s symptoms and concerns. Permit ample time for the client to
answer your questions. The nurse should consider the client’s ability to assume a position. The client’s
physical condition, energy level, and age should be taken into consideration. Some positions are
embarrassing and uncomfortable and therefore should not be maintained for long.
Remaining culturally sensitive as well is vital. The nurse should consider religious and cultural
characteristics of the patient such as language, values and beliefs, health practices, eye contact, and
touch. Providing handouts and patient information in a patient's primary language should be offered, as
well as an interpreter if needed. These essential items help to develop trust and open the lines of
communication. For some patients, touch is a way to demonstrate compassion and caring, but nurses
should be aware of personal boundaries, as some patients prefer not to be touched.
Lastly, keep note-taking to a minimum so the client is the focus of attention.
To gather the health and physical assessments there are different types which are: Complete
assessment that it includes a complete health history and physical examination and forms a baseline
database; Focused assessment that focuses on a limited or short-term problem, such as the client’s
complaint; Episodic/Follow-up assessment that focuses on evaluating a client’s progress and;
Emergency assessment that involves the rapid collection of data, often during the provision of life-
saving measures.
CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
, CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
II. HEALTH HISTORY
In taking health history of the client, the nurse should determine the following:
• Biographic Data
The client’s name, address, age, sex, marital status, occupation, religious preference, health care
financing, and usual source of medical care.
• General State of Health
The nurse should assess the body features and physical characteristics, body movements, body
posture, level of consciousness, nutritional status and speech of the client.
• Chief complaint (Reason for seeking care)
The answer given to the question, “What is troubling you?” or “Can you tell me the reason of
you came to the hospital today?” The chief complaint should be recorded in the client’s own
words.
• History of Present Illness (HPI)
In documenting the history of present illness, the nurse asks the client: when the symptoms
started; whether the onset of symptoms was sudden or gradual; how often the problem occurs;
exact location of the distress; character of the complaint (e.g., intensity of pain or quality of
sputum, emesis, or discharge); activity in which the client was involved when the problem
occurred; phenomena of symptoms associated with the chief complaint and; factors that
aggregate or alleviate the problem.
• Family History
To ascertain risk factors for certain disease, the ages of siblings, parents, and grandparents and
their current state of health or, if they are deceased, the cause of death are obtained. Particular
attention should be given to disorders such as heart diseases, cancer, diabetes, hypertension,
obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and any mental health disorders.
• Social History
It includes the data about the client’s lifestyle, with a focus on factors that may affect health. In
gathering the data, the nurse should include the personal habits, diet, sleep/rest patterns, ADLs,
and recreation/hobbies of the client. Information about alcohol, drug, and tobacco use; sexual
practices; tattoos; body piercing; travel history; and work setting to identify occupational
hazards are also included.
• Domestic violence screening
CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
, CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
It is conducted during a 1-to-1 interview with the client while obtaining the health history. It is
done to determine whether the client is experiencing any form of domestic violence.
III. MENTAL STATUS EXAM
The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that describes
the mental state and behaviors of the person being seen. It includes both objective observations of the
clinician and subjective descriptions given by the patient.
• Appearance
The appearance of the patient gives the examiner an overall impression of the patient. The
patient's physical appearance (apparent vs. stated age), grooming (immaculate/unkempt),
dress (subdued/riotous), posture (erect/kyphotic), and eye contact (direct/furtive) are all
pertinent observations. An inappropriate appearance and poor hygiene may be indicative of
depression, manic disorder, dementia, organic brain disease, or another disorder.
• Behavior
In assessing the level of consciousness of the patient, the nurse should assess the alertness and
awareness and the client’s ability to interact appropriately with the environment. A normal level
of consciousness is one in which the patient is able to respond to stimuli at the same lower level
of strength as most people who are functioning without neurologic abnormality. Clouded
consciousness is a state of reduced awareness whose main deficit is one of inattention. Stimuli
may be perceived at a conscious level but are easily ignored or misinterpreted. Delirium is an
acute or subacute (hours to days) onset of a grossly abnormal mental state often exhibiting
fluctuating consciousness, disorientation, heightened irritability, and hallucinations. It is often
associated with toxic, infectious, or metabolic disorders of the central nervous
system. Obtundation refers to moderate reduction in the patient's level of awareness such that
stimuli of mild to moderate intensity fail to arouse; when arousal does occur, the patient is slow
to respond. Stupor may be defined as unresponsiveness to all but the most vigorous of stimuli.
The patient quickly drifts back into a deep sleep-like state on cessation of the stimulation. Coma
is unarousable unresponsiveness. The most vigorous of noxious stimuli may or may not elicit
reflex motor responses. When examining patients with reduced levels of consciousness, noting
the type of stimulus needed to arouse the patient and the degree to which the patient can
respond when aroused is a useful way of recording this information.
In assessing the facial expression of the client, the nurse should check for appropriate eye
contact and determine whether facial expressions and body language are appropriate to the
situation. This assessment also provides information regarding the client’s mood and affect.
Affect is the patient's immediate expression of emotion; mood refers to the more sustained
emotional makeup of the patient's personality. Patients display a range of affect that may be
CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
, CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
described as broad, restricted, labile, or flat. Broad is displaying a full range of emotional
expressions. Restricted is displaying a one type of expression, usually serious of somber. Labile
is
when the client exhibits unpredictable and rapid mood swings from depressed and crying to
euphoria with no apparent stimuli. Flat is showing no facial expressions. Affect is inappropriate
when there is no consonance between what the patient is experiencing or describing and the
emotion he is showing at the same time (e.g., laughing when relating the recent death of a loved
one). Both affect and mood can be described as dysphoric (depression, anxiety, guilt), euthymic
(normal), or euphoric (implying a pathologically elevated sense of well-being).
In assessing the speech of the client, the nurse should assess the speech pattern for articulation
and appropriateness of conversation. Listening to spontaneous speech as the patient relates
answers to open-ended questions yields much useful information. One might discern problems
in output or articulation such as the hypophonia of Parkinson's disease, the halting speech of
the patient with word-finding difficulties, or the rapid and pressured speech of the manic or
amphetamine-intoxicated patient. Overall motor activity should also be noted, including any tics
or unusual mannerisms. Slowness and loss of spontaneity in movement may characterize a
subcortical dementia or depression, while akathisia (motor restlessness) may be the harbinger
of an extrapyramidal syndrome secondary to phenothiazine use.
Facial tic disorder common in adult
• Cognitive level of functioning
The parameters of cognitive function to be tested and examples of how to test them include the
following:
▪ In orientation, the nurse should assess the client’s orientation to person (what is your
name?), place (What is the name of this place?) and time (What is today’s date?).
▪ In attention span, the nurse should assess the client’s ability to concentrate. Ask the
CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
THE ADULT CLIENT 2022 update
I. ENVIRONMENT/SETTING
It is important to prepare the environment before starting the assessment. The time for the
physical assessment should be convenient to both the client and the nurse. As a nurse, the first thing
you need to do is to establish a relationship with the client. It is important that patients feel they are
being listened to and given information in a respectful, non-judgmental way; this will help build a
trusted relationship. Ask the client how they wish to be addressed such as Mrs. or Miss. In preparing the
client, the nurse should explain when and where physical examination will take place; why it is
important and; what will be happen during the examination.
Maintaining patient privacy is also essential. Most people are embarrassed if their bodies are
exposed or if others can overhear or view them during the assessment. Expose only areas of the body to
examine. Drapes should be arranged so that the area to be assessed is exposed and other body areas
are covered. Drapes provide not only a degree of privacy but also warmth. The environment also needs
to be well lighted and the equipment should be organized for efficient use. A client who is physically
relaxed will usually experience little discomfort. The room should be warm enough to be comfortable
for the client and should remove any distractions such as noise or object and avoid disruptions.
In the initial interview with the client, the nurse should avoid barriers such as desk to have an
effective communication, maintaining an appropriate social distance and maintain eye contact with a
patient. Using the therapeutic communication techniques and open-ended questions, it helps to obtain
complete information regarding the client’s symptoms and concerns. Permit ample time for the client to
answer your questions. The nurse should consider the client’s ability to assume a position. The client’s
physical condition, energy level, and age should be taken into consideration. Some positions are
embarrassing and uncomfortable and therefore should not be maintained for long.
Remaining culturally sensitive as well is vital. The nurse should consider religious and cultural
characteristics of the patient such as language, values and beliefs, health practices, eye contact, and
touch. Providing handouts and patient information in a patient's primary language should be offered, as
well as an interpreter if needed. These essential items help to develop trust and open the lines of
communication. For some patients, touch is a way to demonstrate compassion and caring, but nurses
should be aware of personal boundaries, as some patients prefer not to be touched.
Lastly, keep note-taking to a minimum so the client is the focus of attention.
To gather the health and physical assessments there are different types which are: Complete
assessment that it includes a complete health history and physical examination and forms a baseline
database; Focused assessment that focuses on a limited or short-term problem, such as the client’s
complaint; Episodic/Follow-up assessment that focuses on evaluating a client’s progress and;
Emergency assessment that involves the rapid collection of data, often during the provision of life-
saving measures.
CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
, CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
II. HEALTH HISTORY
In taking health history of the client, the nurse should determine the following:
• Biographic Data
The client’s name, address, age, sex, marital status, occupation, religious preference, health care
financing, and usual source of medical care.
• General State of Health
The nurse should assess the body features and physical characteristics, body movements, body
posture, level of consciousness, nutritional status and speech of the client.
• Chief complaint (Reason for seeking care)
The answer given to the question, “What is troubling you?” or “Can you tell me the reason of
you came to the hospital today?” The chief complaint should be recorded in the client’s own
words.
• History of Present Illness (HPI)
In documenting the history of present illness, the nurse asks the client: when the symptoms
started; whether the onset of symptoms was sudden or gradual; how often the problem occurs;
exact location of the distress; character of the complaint (e.g., intensity of pain or quality of
sputum, emesis, or discharge); activity in which the client was involved when the problem
occurred; phenomena of symptoms associated with the chief complaint and; factors that
aggregate or alleviate the problem.
• Family History
To ascertain risk factors for certain disease, the ages of siblings, parents, and grandparents and
their current state of health or, if they are deceased, the cause of death are obtained. Particular
attention should be given to disorders such as heart diseases, cancer, diabetes, hypertension,
obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and any mental health disorders.
• Social History
It includes the data about the client’s lifestyle, with a focus on factors that may affect health. In
gathering the data, the nurse should include the personal habits, diet, sleep/rest patterns, ADLs,
and recreation/hobbies of the client. Information about alcohol, drug, and tobacco use; sexual
practices; tattoos; body piercing; travel history; and work setting to identify occupational
hazards are also included.
• Domestic violence screening
CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
, CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
It is conducted during a 1-to-1 interview with the client while obtaining the health history. It is
done to determine whether the client is experiencing any form of domestic violence.
III. MENTAL STATUS EXAM
The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that describes
the mental state and behaviors of the person being seen. It includes both objective observations of the
clinician and subjective descriptions given by the patient.
• Appearance
The appearance of the patient gives the examiner an overall impression of the patient. The
patient's physical appearance (apparent vs. stated age), grooming (immaculate/unkempt),
dress (subdued/riotous), posture (erect/kyphotic), and eye contact (direct/furtive) are all
pertinent observations. An inappropriate appearance and poor hygiene may be indicative of
depression, manic disorder, dementia, organic brain disease, or another disorder.
• Behavior
In assessing the level of consciousness of the patient, the nurse should assess the alertness and
awareness and the client’s ability to interact appropriately with the environment. A normal level
of consciousness is one in which the patient is able to respond to stimuli at the same lower level
of strength as most people who are functioning without neurologic abnormality. Clouded
consciousness is a state of reduced awareness whose main deficit is one of inattention. Stimuli
may be perceived at a conscious level but are easily ignored or misinterpreted. Delirium is an
acute or subacute (hours to days) onset of a grossly abnormal mental state often exhibiting
fluctuating consciousness, disorientation, heightened irritability, and hallucinations. It is often
associated with toxic, infectious, or metabolic disorders of the central nervous
system. Obtundation refers to moderate reduction in the patient's level of awareness such that
stimuli of mild to moderate intensity fail to arouse; when arousal does occur, the patient is slow
to respond. Stupor may be defined as unresponsiveness to all but the most vigorous of stimuli.
The patient quickly drifts back into a deep sleep-like state on cessation of the stimulation. Coma
is unarousable unresponsiveness. The most vigorous of noxious stimuli may or may not elicit
reflex motor responses. When examining patients with reduced levels of consciousness, noting
the type of stimulus needed to arouse the patient and the degree to which the patient can
respond when aroused is a useful way of recording this information.
In assessing the facial expression of the client, the nurse should check for appropriate eye
contact and determine whether facial expressions and body language are appropriate to the
situation. This assessment also provides information regarding the client’s mood and affect.
Affect is the patient's immediate expression of emotion; mood refers to the more sustained
emotional makeup of the patient's personality. Patients display a range of affect that may be
CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
, CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
described as broad, restricted, labile, or flat. Broad is displaying a full range of emotional
expressions. Restricted is displaying a one type of expression, usually serious of somber. Labile
is
when the client exhibits unpredictable and rapid mood swings from depressed and crying to
euphoria with no apparent stimuli. Flat is showing no facial expressions. Affect is inappropriate
when there is no consonance between what the patient is experiencing or describing and the
emotion he is showing at the same time (e.g., laughing when relating the recent death of a loved
one). Both affect and mood can be described as dysphoric (depression, anxiety, guilt), euthymic
(normal), or euphoric (implying a pathologically elevated sense of well-being).
In assessing the speech of the client, the nurse should assess the speech pattern for articulation
and appropriateness of conversation. Listening to spontaneous speech as the patient relates
answers to open-ended questions yields much useful information. One might discern problems
in output or articulation such as the hypophonia of Parkinson's disease, the halting speech of
the patient with word-finding difficulties, or the rapid and pressured speech of the manic or
amphetamine-intoxicated patient. Overall motor activity should also be noted, including any tics
or unusual mannerisms. Slowness and loss of spontaneity in movement may characterize a
subcortical dementia or depression, while akathisia (motor restlessness) may be the harbinger
of an extrapyramidal syndrome secondary to phenothiazine use.
Facial tic disorder common in adult
• Cognitive level of functioning
The parameters of cognitive function to be tested and examples of how to test them include the
following:
▪ In orientation, the nurse should assess the client’s orientation to person (what is your
name?), place (What is the name of this place?) and time (What is today’s date?).
▪ In attention span, the nurse should assess the client’s ability to concentrate. Ask the
CHAPTER 15: HEALTH AND PHYSICAL ASSESSMENT OF
THE ADULT CLIENT 2022 update
