Examination skills for the practice nurse

Examination is an essential step in reaching a diagnosis but there is more to this skill than the simple physical task: it is an integral part of the consultation and can help to establish rapport with your patient

Most practice nurses will have been examining patients for their entire working lives.

Examination is a high level skill that we develop and perfect throughout our careers. We are initially taught to examine to help us reach a diagnosis, by searching for physical signs. However, examination also offers an opportunity to further the therapeutic partnership usefully. This is about far more than diagnosis. It includes establishing rapport, gaining trust, formulating a differential diagnosis and testing it, giving the patient confidence in your assessment and clinical skill, ruling out sinister possibilities, and forming a partnership with the patient.

WHY DO WE EXAMINE?

The following gives some idea of what a useful examination can achieve, although it’s not just the examination that you undertake, but how you present it and how you do it that matter.¹

Reassurance

The patient and health professional can feel that the problem has been assessed so that they can have confidence in your diagnosis and you know you haven’t missed something serious. We may perform examinations specifically to show the patient that their symptoms are not due to sinister causes, e.g. a young person with musculoskeletal chest pain whose father recently died of a heart attack might need auscultation and ECG.

Make thinking time

If it’s not obvious to you what’s wrong with the patient, examination helps you clarify and you can think as you do it. Thinking aloud with the patient as you examine may be helpful, e.g. ‘I’m pressing on the rash and it blanches like this – look. So it doesn’t look like a meningococcal rash…’

Form a partnership

Partnership with our patients is essential to functional consultations. Clear, well signposted examination shows the patient that you are taking their problem seriously and giving it your professional attention. They may feel there is a mystique to your examination. Anyone can ask questions, but now you are doing something that only a health professional knows how to do.

Examining also builds relationships for the future. The first time a teenager is examined may be critical in how likely they are to return in the future.

Breaks down barriers

Examination is an intimate act compared to normal social behaviour. It generally involves touching the patient. This helps break down the barriers of ‘strangerness’. Touch is a connection.

Of course touch can be misinterpreted. Explaining yourself clearly and reading your patient’s responses are enormously important. This is particularly true in encounters where the patient has pre-existing worries about being examined or exposed. This is more likely in consultations about psychosexual health, and in intimate examinations generally. However it may also occur in an apparently innocuous exam, because of misunderstandings or previous unhappy experience.

It is important to talk to patients before, during and after examination. Explaining what you are doing and why before you do it will help you take the patient ‘with you’ through your consultation.

Ruling out serious diagnoses

We use examination to rule out diagnoses that must always be considered in certain circumstances. For example if we see an elderly woman complaining of a breast lump that turns out, on first inspection, to be a sebaceous cyst in the skin we would still check for other lumps.

Record data for future care

Examination can help track the progress of a condition. An obvious example would be marking the edge of redness on an area of spreading cellulitis.

An opportunity to talk to the patient in a different way

Patients intermingle telling their story with the clinician’s examination, and tend to see these as two parts of a whole. The period of the consultation when you are examining the patient breaks down some of the formality that naturally exists between two strangers. Patients with sexual problems sometimes share relevant information at the time of the genital examination, when barriers to intimacy have been lowered.²

May be therapeutic

Patients who are anxious or afraid of serious diagnosis may find examination very therapeutic. Many patients with COPD will come to the surgery just for you to listen to their chest, even though they know they need antibiotics. They feel better knowing it sounds the same as usual.

May be medicolegally important

Everything you do may be medicolegally important, of course, but the examination is an area in which what you did may be particularly important. If you look for something and do not find it (even though it is there) you may be unlucky, or inexpert, or it may be that the physical sign was not detectable at that point. If you fail to look for it at all you may be negligent.

May detect non-organic problems

Patients may believe their symptoms have a physical cause, or it may be that they realise this is not the case but presenting with physical symptoms is a way of opening the subject. Normal examination can give them an opening to tell you the real problem. For example, a postnatal patient complaining of dyspareunia should be examined. Finding that everything is normal may then allow the patient to express other reasons for a lost sex drive.

WHEN IN THE CONSULTATION SHOULD I EXAMINE?

We often think of examination as following history taking, but the consultation should not be this rigid. You may start to examine very early in a consultation – for instance if a patient holds out an injury to you.

You need to adapt to the situation: examination should not be a separate part of the consultation, preformed in silence once the history taking is done.

Flexibility is very important. Roger Neighbour’s view of the examination is that there are no rules, we should be able adapt the intertwining of our history taking and examination in order to produce the best outcome.³

DIFFICULTIES WITH EXAMINATION

Examination may be physically difficult – for example if the patient has a physical disability preventing them from accessing the couch.

Examinations on the patient’s own bed can be very difficult, due to awkward angles, lack of lighting and soft mattresses.

However, the most important difficulty is TIME. Examination takes up precious time, particularly if the patient needs to undress and you need to go and find a chaperone. (Box 1)

The challenge is to perform enough of an examination to achieve your, and the patient’s, goals, without spending too much time on areas that are unnecessary.

WHEN IS AN EXAMINATION INTIMATE?

The answer is when either patient or nurse feels it is.⁴ Most of us would agree that genital and breast examinations are intimate, but for some patients any examination will be intimate, particularly if it moves you closer to them or means that you touch them. You have crossed the ‘personal space’ barrier.

This can be an issue of culture, gender or sexuality and it can relate to your or the patient’s age (or your relative ages). It’s impossible to second guess it so don’t – explain what you plan to do and assess cues to be sure the patient is comfortable before you proceed.

TALKING TO THE PATIENT DURING YOUR EXAMINATION

You need to keep the patient informed of what you’re doing – particularly if you are deviating from what you told them you would do, or if you are likely to cause pain. You may also need the patient to answer questions during examination.

Avoid personal comments during examinations. General chat may help the patient relax and feel normal, but personal comments are likely to make patients feel uncomfortable. This is particularly acute where intimate examination is concerned, as patients will feel particularly exposed and the power relationship between you at that point is very tilted towards you.

POWER IN THE CONSULTATION

Your encounter with the patient falls outside the rules of normal social encounters for many reasons, but one is that your positions are not equal. You have more power than the patient. There are multiple reasons for this: It’s your room, generally. You have disproportionate skill and knowledge, generally. The patient may be lying down and partially clothed. You possess diagnostic tools. You have a whole organisation behind you.

When you hold the power in an encounter it is particularly important to give the other person every possible opportunity to control what’s happening, as they may not feel able to speak out otherwise.

COMFORT AND MODESTY

Make sure they are comfortable. Avoid letting patients become cold. Try to warm your own hands before putting them onto them.

Be conscious of yourself. Hands are very important. Long fingernails clearly don’t belong on health professionals who examine patients. Consider how the patient may feel if you have a spicy or garlicky meal.

Using a sheet of paper to cover the patient’s stomach while performing intimate examination allows patients to feel a sense of privacy.

Remember embarrassment. Gender and age factor into this, but not always in the way you might expect if it were you. Patients who have not been examined may feel your age and gender are very important in the exam and it may make them more, or less relaxed. Don’t assume that because you are relaxed they will be. Try to find words to put them at their ease, always being impersonal and making the reasons for examination clear.

If the patient is a small child the explanation needs to go to the carer. In this case, if your examination may be uncomfortable for the child you need to make this clear.

We do not hurt patients at all if we can help it – causing unexpected pain in examination used to be a cause of failing medical school finals. However, there are times when eliciting pain is needed for your examination, e.g. when looking for rebound tenderness.

PRINCIPLES OF EXAMINING PATIENTS: A FOCUSED EXAMINATION

The principles of examination are simple, and involve being measured, controlled and thoughtful.

Rather as with history taking, focused examination in primary care starts from the full, all-systems examination we are taught in training. Focused examination uses your brain to draw from that examination the techniques and skills you need in order to fully assess the patient’s problem, including ruling out sinister diagnoses.

You should be thinking about your examination and building your diagnosis and your plan every step of the way.

Observation

Examination begins with observation when the patient enters the room. This includes whether they look ill or in pain, whether they move comfortably, their colour and expression and their state of dress.

It continues as the patient talks and you listen and assess things such as breathlessness, level of pain, mental state.

Once you come to the part of the consultation which you flag as the exam make sure you consider all the basic elements: observe, touch, feel, assess, measure, record. You may not have to use all of them – remember you are being focused and flexible – but don’t forget they are there.

Observe. This means exposing the affected area. (A classic mistake is to diagnose musculoskeletal pain through a patient’s T-shirt, never noticing the shingles. Look for the rash, the bruise, the swelling, the mark, the asymmetry, the redness).

Touch. Touch before you prod or palpate. This checks for hypersensitivity and helps clarify what you’re going to do. ‘I’m just going to go over your stomach lightly then press more firmly and I want you to tell me if it hurts…’

Feel/palpate. This will help you assess the problem more specifically. How you do it depends on what you’re examining – for solid masses you are attempting to feel shape, size, mobility, consistency and nature. For abdominal pain you are assessing pain level, and associated signs such as guarding, peritonism and rebound tenderness.

Assess function. This will vary with the examination you’re doing, e.g. for the lungs you will look at expansion, tracheal deviation and may percuss for resonance. You may check vocal resonance. You will listen to the breath sounds and may also examine the heart and pulse.

For the musculoskeletal system you’ll assess power, tone, reflexes and sensation, and how function is affected.

For mental health you will be assessing for mood disorder, thought disorder, memory testing and disorders of perception.

Measure. Some numerical data can be usefully recorded if it is relevant to the problem e.g. vital signs, leg length, size of lump.

RECORDING YOUR EXAMINATION

The computer has many joys and many limitations but you need to try to record what you examined, both positive findings and your negative ones.

Some computer programmes allow you to record diagrams. Many have templates for specific examinations. You need to be familiar with the software you’re using so that you

• Enter information accurately and efficiently
• Enter it in a way that others can understand it
• Enter specific information in retrievable format (e.g. blood pressure).

Occasionally a photograph may help the clinical record, particularly if trying to record how, for instance, a wound is changing.

THE USEFULNESS OF NOT EXAMINING

Balint⁵ said: ‘Our patients are trained from childhood to expect a more or less thorough physical examination.’ However, sometimes there is a purpose in NOT examining the patient – usually around reassurance and around patient education and service use.

We make the decision not to examine every time we do a telephone consultation and decide that we can manage the patient without seeing them.

Once the patient is in our surgery, however, there is a temptation always to examine. This can perpetuate the idea in the patient that their problem needed to be examined. Encouraging self-management by educating the patient is essential if we are to manage demand – explaining clearly why they do not need to be examined is an important part of this. Indeed to tell them they didn’t need to come but to then examine them is potentially confusing for patients.

Summary

Examination is an important part of the consultation. When used in primary care it should be used as a part of the consultation. It should ideally be focused and efficient, should help move the consultation forwards to a satisfactory solution for both nurse and patient.

REFERENCES

1. Connan A.L., The Consultation and Physical Examination: BJGP 2009: July 1 59(564):544-545 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2702026/

2. Institute of Psychosexual Medicine. Prospectus for the Institute of Psychosexual Medicine. London: IPM; 2004 Prospectus: http://www.ipm.org.uk/23/information

3. Neighbour R. The inner consultation. 2nd edn. Oxford: Radcliffe Publishing; 2005.

4. GMC: Intimate Examinations and chaperones: http://www.gmc-uk.org/guidance/ethical_guidance/21168.asp

5. Balint M. The doctor his patient and the illness. 2nd edn. Edinburgh: Churchill Livingstone; 1964.