Med-Surg · chapter 6 · Comprehensive Health Assessment and Physical Examination
Bedside Physical Assessment in Medical-Surgical Nursing
The 13 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 5 practice questions with the reasoning.
Key points
Focused versus bedside assessment
The nurse may only focus on a single system during a focused assessment, but they can get an inclusive view of the patient’s other systems during a bedside assessment.
Baseline findings
Not only does this help the nurse identify other potential areas of concern, but even normal findings will help establish a baseline for the patient.
Acute care assessment use
That, however, is often more valuable in primary care settings. In acute care settings, nurses mostly utilize bedside or focused assessments.
Bedside assessment scope
The nurse will perform a systematic exam of all patient body systems called a bedside assessment.
General survey content
The general survey assessment includes the patient’s height, weight, physical appearance, chronic wounds, personal hygiene, and general behavior. Also included are the vital signs, such as blood pressure, heart rate, oxygen saturation levels, body temperature, and respiratory rate.
Communication aid assessment
The nurse will also consider the patient’s verbal and nonverbal communication and must swiftly assess to determine if the patient needs a communication aid (such as a translation device).
HEENT assessment order
In a systemic approach, the head, ears, eyes, nose, and throat (HEENT) exam are the first systems to be assessed.
Cardiac assessment elements
The cardiac assessment requires inspection, palpation, and auscultation. This includes assessing cardiac rhythm, heart sounds, arterial pulse evaluation, capillary refill times, edema, circulation and sensation, and cyanosis.
Respiratory assessment elements
The respiratory assessment involves inspection, palpation, auscultation, and percussion. This includes breath sounds, respirations (e.g., effort and quality), presence of cough, production of sputum/secretions, abnormal visual/palpable masses, current respiratory treatment, and oxygen delivery.
Abdominal assessment elements
The abdominal assessment also relies on inspection, palpation, auscultation, and percussion. The nurse will assess the abdominal appearance, bowel sounds, and stool.
Focused assessment purpose
The focused assessment, like a focused history, starts with the patient’s chief complaint. The nurse will center the physical examination on the reason the patient is seeking care at the present time.
Safety assessment risks
It involves confirming the patient’s identity through wrist band identification, and assessing fall risk, use of ambulatory aids, environmental concerns, domestic and family violence risk, and suicidal ideation.
Preventable safety errors
The safety and surroundings assessment helps the nurse avoid preventable errors, such as patient misidentification, allergic reactions, and falls or other injuries.
Terms to know
- comprehensive physical assessment
- While a comprehensive physical assessment is a detailed, inclusive assessment of body systems to provide a big-picture, broad view of a patient’s overall health, a focused assessment is a physical examination centered on a patient’s chief complaint.
- focused assessment
- While a comprehensive physical assessment is a detailed, inclusive assessment of body systems to provide a big-picture, broad view of a patient’s overall health, a focused assessment is a physical examination centered on a patient’s chief complaint.
- bedside assessment
- The nurse will perform a systematic exam of all patient body systems called a bedside assessment.
- PERRLA
- The nurse will inspect the eyes according to the eye assessment PERRLA (pupils equal, round, reactive to light and accommodation).
- poikilothermia
- This includes pain, pallor of skin, inability to regulate core temperature (poikilothermia), pulselessness, paresthesia, and paralysis.
Practice questions
Stuck on select-all-that-apply? How to take them one option at a time.
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Every question here, with the answer
At 0700 at the beginning of a medical-surgical shift, you perform a systematic head-to-toe review instead of limiting the exam to one complaint. Which documentation heading best matches what you did?
- Focused Physical Assessment: chief-complaint system only
- Bedside Physical Assessment: systematic exam of patient body systems
- Safety/Surroundings Assessment: environment and potential risks only
- Comprehensive Health History: detailed interview about history and lifestyle
Answer: Bedside Physical Assessment: systematic exam of patient body systems
A bedside assessment is the systematic exam of patient body systems used in this setting. A focused assessment is limited to the chief complaint, a comprehensive health history is an interview, and safety/surroundings documentation addresses environmental and risk concerns.
At 0800, you are filling in the General Survey subsection after seeing a patient. Which entries belong there? Select all that apply.
- Height and weight
- PERRLA, visual acuity, and conjunctivae
- Physical appearance and personal hygiene
- Cardiac rhythm, heart sounds, and capillary refill
- Chronic wounds and general behavior
Answer: Height and weight, Physical appearance and personal hygiene, Chronic wounds and general behavior
Height, weight, appearance, chronic wounds, hygiene, and behavior are listed as General Survey content. PERRLA and visual acuity belong with HEENT, while rhythm, sounds, and capillary refill fit the cardiac assessment.
At 0900 during the HEENT portion of assessment, the patient says they usually use hearing aids, but none are in their ears. Which documentation best follows the section?
- Neuro-muscular: hearing aid status documented with gait and extremity strength
- Ears: no hearing documentation needed if the patient answers questions verbally
- General survey: possible communication issue noted; omit ear-specific hearing aid status
- Ears: document hearing loss or difficulty and whether hearing aids are worn or with the patient
Answer: Ears: document hearing loss or difficulty and whether hearing aids are worn or with the patient
The HEENT ear assessment includes hearing difficulty and whether hearing aids are being worn or are with the patient. The other entries either omit the ear-specific documentation or place it in the wrong assessment area.
At 1000, you are completing the safety/surroundings documentation for a hospitalized medical-surgical patient. Which risks or observations belong in this assessment? Select all that apply.
- Fall risk
- Domestic and family violence risk or suicidal ideation
- Use of ambulatory aids
- Bowel sounds and stool
- Environmental concerns in the room
- Pupils equal, round, reactive to light and accommodation
Answer: Fall risk, Domestic and family violence risk or suicidal ideation, Use of ambulatory aids, Environmental concerns in the room
The safety/surroundings assessment includes fall risk, ambulatory aids, environmental concerns, violence risk, and suicidal ideation. Bowel sounds and stool are abdominal assessment items, and PERRLA belongs in HEENT.
At 1300, the patient’s stated reason for seeking care is a sore throat. You need to document the assessment most aligned with a focused assessment. Which entry is best?
- Bedside assessment: all major body systems documented because focused assessments do not begin with the complaint
- Comprehensive health history only: past medical, family, medication, allergy, and lifestyle history documented without physical findings
- Focused assessment: HEENT findings documented because the exam is centered on the sore-throat complaint
- Safety/surroundings assessment: bed position, side rails, and call bell documented as the assessment for the sore throat
Answer: Focused assessment: HEENT findings documented because the exam is centered on the sore-throat complaint
A focused assessment centers the exam on the patient’s chief complaint, and the section specifically connects sore throat with HEENT. The other options describe broader or different assessment types rather than the focused documentation for this complaint.
Where every quote comes from
Section 6.4 Bedside Physical Assessment in Medical-Surgical Nursing of Medical-Surgical Nursing by Christy Bowen, Bridget Carey, Jessica Palozie, Maren Reinholdt, OpenStax, 2024. Read the whole section free at openstax.org.
The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.