Chapter 27 Physical Assessment

Purposes of Physical Examination Determine client’s level of health and functioning Identify risk for problems Determine areas of preventive nursing Confirm issues to perform ADLs (continued)

Purposes of Physical Examination Identify needs for testing or examinations Evaluate outcomes of treatment

Preparation for Physical Examination Environment Equipment Positioning and draping

Environment Accommodate special needs Place equipment on clean, immovable surface Keep room quiet, warm, and well-lit Ensure privacy

Equipment Wash hands Collect necessary equipment Gather assessment forms Secure supply of clean gloves

Positioning and Draping Position client to access body part being assessed Drape client to prevent unnecessary exposure

General Survey Signs of distress Health, stature, and sexual development Weight, height, and vital signs Posture, motor activity, and gait Dress, grooming, and personal hygiene Facial expressions and behaviors Reactions to people and environment (continued)

General Survey Quality of speech Level of consciousness Sexual history Older adults Disabled clients Abused clients Sexual assault nurse examiner (SANE)

Assessment Techniques Inspection Palpation Percussion Auscultation

Integument Skin Hair Nails

Head and Neck Skull and face Eyes Ears Nose and sinuses Mouth and pharynx Neck

Thorax and Lungs Normal breath sounds Vesicular Bronchovesicular Bronchial (continued)

Thorax and Lungs Adventitious breath sounds Crackles Rhonchi Wheezes Pleural friction rub Stridor

Heart and Vascular System Aortic area Pulmonic area Erb’s point Tricuspid area Mitral area (continued)

Heart and Vascular System Skin temperature Color Sensation Pulses

Breasts and Axillae Inspection Palpation ACS Guidelines for Breast Cancer Screening (2003) Breast self-examination (BSE) Clinical breast examination (CBE) Mammogram

Abdomen Inspection Auscultation of four quadrants Percussion Light palpation

Musculoskeletal System Inspection Palpation Range of motion (ROM) Muscle testing

Neurologic System Mental status Cognitive abilities and mentation Physical appearance and behavior Communication Level of consciousness Cognitive abilities and mentation Sensation (continued)

Neurologic System Cranial nerves Motor function Cerebellar function Coordination Balance and gait Reflexes

Reproductive System Female genitalia Male genitalia

Anus and Rectum Position Gloves Lubricant Prostate gland palpation

Post Assessment Care of the Client Outpatient setting Inpatient setting

Data Documentation Use specific forms Record as data collected Report information as needed Include subjective and objective findings Address all abnormal findings