1. Assessing Health: Physical Examination

2. Health Assessment: Performing a Physical Examination
An Overview

3. The Nursing Physical Examination
Part of a general health assessment
Used to gather data about the client
Focuses on functional abilities and responses to illness/stressor

4. Purposes Establish baseline data
The nurse performs a physical examination to:
Establish baseline data
Identify nursing diagnoses, collaborative problems, or wellness diagnoses
Monitor the status of an identified problem
Screen for health problems

5. Types of Physical Examinations
Comprehensive:
Interview plus complete head-to-toe examination
Focused:
“Focused” on presenting problem
Ongoing:
Performed as needed to assess status
Evaluates client outcomes

6. Organizing the Examination
Head-to-toe
Starts at the head
Progresses “down” the body
System-related data found throughout:
Heart sounds - chest
Pulses - periphery

7. Organizing the Examination
Body systems
Gathers system-related data all at once
May be done in a predetermined order that mimics head-to-toe:
Neurological
Cardiovascular
Respiratory
Gastrointestinal

8. Preparing Yourself: What the Nurse Needs
Theoretical knowledge
A & P, techniques
Self-knowledge
Skill and comfort level
Willingness to seek help
Knowledge about client situation
Purpose of examination
Client diagnosis

9. Preparing the Environment
Privacy is key
Draping
Use of curtains
Noise control
TV/radio off
Enable visualization
Adequate lighting
Flashlight if needed

10. Preparing the Client Develop rapport - OEWIPES Explain the procedure
Promote client comfort:
Develop rapport - OEWIPES
Explain the procedure
Respect cultural differences
Use proper positioning

11. Positioning Sitting—used to take vital signs
Supine—allows relaxation of abdominal muscles
Dorsal recumbent—used for patients having difficulty maintaining supine position
Sim’s—assessment of rectum or vagina
Prone—assessment of hip joint and posterior thorax
Lithotomy—assessment of female rectum and vagina; used for brief period only
Knee-chest—assessment of the rectal area; used for brief period only
Standing—assessment of posture, gait, and balance

12. Equipment Ophthalmoscope—visualizes the interior structures of the eye
Otoscope—examines the external ear canal and tympanic membrane
Snellen’s chart—screens for distant vision
Nasal speculum—visualizes the lower and middle turbinates of the nose
Vaginal speculum—examines the vaginal canal and cervix
Tuning fork—tests auditory function and vibratory perception
Percussion hammer—tests deep tendon reflexes and determines tissue density

13. Physical Assessment Skills
Four major skills used:
Inspection
Palpation
Percussion
Auscultation

14. techniques
Inspection—assess size, color, shape, position, and symmetry
Palpation—assess temperature, turgor, texture, moisture, vibrations, and shape
Percussion—assess location, shape, size, and density of tissues
Auscultation—assess the four characteristics of sound, i.e., pitch, loudness, quality, and duration

15. Inspection Use of sight to gather data
Used throughout physical examination
Tools to enhance inspection
Otoscope
Ophthalmoscope
Penlight
Examples: Skin color, gait, general appearance, behavior

16. Palpation Use of touch to gather data
Begin with light pressure, moving to deep palpation
Use caution with deep palpation
Parts of the hands used:
Fingertips: Tactile discrimination
Dorsum: Temperature determination
Palm: General area of pulsation
Grasping (fingers and thumb): Mass evaluation
Examples: Edema, moisture, anatomical landmarks, masses

17. Percussion Tapping on skin to elicit sound
Direct
Indirect
Useful for assessing abdomen, lungs, underlying structures
Examples: Distended bladder

18. Types of Sounds Heard When Using Percussion
Flat — soft, e.g., thigh area
Dull — medium, e.g., liver
Resonance — loud, e.g., normal lung
Hyper resonance — very loud, e.g., emphysematous lung
Tympany — loud, e.g. puffed-out cheek

19. Using Hands to Produce Sound Waves During Percussion

20. Auscultation Use of hearing to gather assessment data
Direct auscultation:
Listening without an instrument
Indirect auscultation:
Use of a stethoscope to listen
Diaphragm - high-pitched sounds
Bell – low-pitched sounds
Examples: Heart sounds, lung sounds

21. Characteristics of Sound Heard When Using Auscultation
Pitch — ranging from high to low
Loudness — ranging from soft to loud
Quality — e.g., gurgling or swishing
Duration — short, medium, or long

22. Abnormal Breath Sounds

23. Pattern Used for Palpation, Percussion, and Auscultation of the Chest

24. Age Modifications for the Physical Examination
Infants:
Parents hold
Attend to safety
Toddlers:
Allow to explore and/or sit on parent’s lap
Invasive procedure last
Offer choices
Use praise

25. Age Modifications for the Physical Examination
Preschoolers:
Use doll for demonstration
Still may want parental contact
Allow child to help with examination
School-Aged Children:
Show approval and develop rapport
Allow independence
Teach about workings of the body

26. Age Modifications for the Physical Examination
Adolescents:
Provide privacy
Concerned that they are “normal”
Use examination to teach healthy lifestyle
Screen for suicide risk
Young/ Middle Adults:
Modify in presence of acute or chronic illness

27. Age Modifications for the Physical Examination
Older Adults:
May need special positioning related to mobility
Adapt examination to vision and hearing changes
Assess for change in physical ability
Assess for ability to perform activities of daily living
Provide periods of rest as needed

28. Basic Components of a Comprehensive Examination: The General Survey
Begins at first contact
Overall impression of client
Deviations lead to focused assessments
Appearance/behavior
Grooming/hygiene
Body type/posture
Mental state
Speech
Vital signs
Height/weight

29. Mental Status - Emotional and cognitive functions – inferred through behaviors
Consciousness
Language
Mood & affect
Orientation
Attention
Memory
Abstract reasoning
Thought process
Thought content
Perceptions

30. Appearance
Posture & Position
Body movement
Dress
Grooming & Hygiene

31. Behavior
Facial expression
Speech
Mood/affect

32. Cognitive function Orientation Attention span Memory - Recent & Remote
Person
Place
Time
Attention span
Memory - Recent & Remote
Judgment

33. Thought Processes & Perceptions
Logical
Goal directed
Coherent
Relevant
Thought content
Consistent & logical
Perceptions
Screen for suicidal thoughts

34. Whole person, general status, any obvious physical characteristics
General Survey
Whole person, general status, any obvious physical characteristics

35. Physical appearence Age Sexual development Level of consciousness
Alert, oriented, responds appropriately
Skin color
Facial features - symmetry

36. Body structure Stature Nutrition Symmetry Posture Position
Body build, contour
Physical deformities

37. Mobility
Gait
Range of motion

38. Behavior
Facial expression
Mood & affect
Speech
Dress
Personal hygiene

39. Measurements Height Weight Vital signs
Skinfold thickness – estimates body fat
Infant/child – head circumference
Birth & every visit until age two
Yearly from two-six years of age

40. Skin Color Temperature Moisture Texture Thickness Mobility & turgor
anterior chest under clavicle
Vascularity or bruising
Tatoos
Lesions
Color, elevation, pattern/shape, size, location, exudate?
Edema
Pitting Edema scale
1+ (mild)- 4+(very deep)

41. Shapes of lesions (pg.51-54)
Iris or target – resemble eye
Linear – scratch, line, streak, stripe
Polycyclic – annular that grow together
Zosteriform – linear lesions along nerve route
Annular – circular (ring worm)
Confluent – run together (urticaria)
Discrete – remain separate
Grouped – clusters (contact dermatis)
Gyrate – twisted, coiled, snakelike

42. Primary skin lesions Macule (patch) flat, color change, circumscribed
Papule (plaque) solid, elevated circumscribed
Nodule ( tumor) solid, elevated, hard or soft
Wheal (urticaria -hives) superficial, raised, transient, erythematous, slightly irregular shape

43. Primary skin lesions
Vesicle (bulla) elevated cavity containing clear fluid
Pustule - turbid(pus) filled cavity, circumscribed and elevated
Cyst – encapsulated, fluid-filled cavity in dermis or subcutaneous layers

44. Secondary skin lesions
Crust-thicken dried-out exudate
Scale- compact, desiccated flakes, dry/greasy, silvery/white
Fissure- linear crack with abrupt edges dry/moist

45. Secondary skin lesions
Erosion-moist, superficial, scooped-out , shallow depression – no scar
Ulcer deeper, irregularly shaped, may bleed – leaves scar
Excoriation, abrasion, superficial sometimes crusted

46. Secondary skin lesions
Scar - Collagen formation after tissue lost heals
Atrophic- depressed r/t thinning epidermis
Lichenification-thicken skin produces tightly packed papule
Keloid- hypertropic scar- skin is elevated r/t excessive scar tissue

47. Hair Nails Color Texture Lesions Shape & contour Consistency Color
Clubbing (heart & lung disease)
Spoon (iron deficiency)
Consistency
Smooth, regular, brittle, splitting, thickness
Color
Capillary refill

48. Abnormal findings Pallor Cyanosis
Anemia, arterial insufficiency, albinism, vitiligo
Cyanosis
Chronic heart & lung disease
Exposure to cold, anxiety

49. Abnormal findings Erythema Jaundice
Hyperemia – inflammation, fever, alcohol intake, blushing
Polycythemia - >RBCs, capillary stasis
CO poisoning
Venous stasis- decreased blood flow
Jaundice
> bilirubin r/t liver inflammation, hemolytic disease
Carotenemia r/t eating food high in carotene
Uremia r/t renel failure

50. Abnormal findings Brown-tan Addison’s disease – cortisone defiency
Café-au-lait spots - > melanin pigment

51. Basic Assessments: Skin, Head
Integumentary:
Skin characteristics
Color
Temperature
Moisture
Texture
Turgor
Lesions
Hair
Nails

52. Basic Assessments: Skin, Head
Eyes
External eye
Sclera
Pupils PERRLA-pupils round, react to light,& accomemdating
Visual acuity
Vision examinations
Acuity, distance, near, color, visual fields
Internal structures
Head:
Skull and Face
Size
Shape
Facial features

53. Basic Assessments: Ears, Nose, Mouth
Head:
Ears/hearing
External ear
Inner ear
Tympanic membrane
Hearing
Weber’s test
Rinne’s test
Balance
Romberg’s test
Nose
Smell
Mouth
Lips
Buccal mucosa
Teeth
Hard and soft palates

54. Basic Assessments: Neck, Breasts
Musculature
Trachea
Thyroid gland
Cervical lymph nodes
Breasts:
Size
Shape
Nipple characteristics
Tissue
Include axillae

55. Basic Assessments: Lungs
Chest and Lungs:
Describe size and shape of chest
Relate findings to landmarks
Breath Sounds: (pg 122 J)
Bronchial
Bronchovesicular
Vesicular
Adventitious
Diminished or misplaced
Abnormal vocal sounds

56. Basic Assessments: Heart, Vessels
Cardiovascular–Heart:
Inspection
PMI-point of maximal impulse located at 5th ICS
Heaves/Lifts
Palpation
Thrill
Heart sounds
Location:
Aortic, Pulmonic, Tricuspid, Mitral
Components:
S1, S2, S3, S4
Murmurs

57. Basic Assessments: Heart, Vessels
Cardiovascular–Vessels:
Central vessels
Carotid arteries
Palpate pulsation
* Special precautions
Auscultate for bruit (whooshing sound caused by turbulent blood flow)
Jugular veins
Peripheral vessels
Blood pressure
Peripheral pulses
Signs of inadequate oxygenation
Varicosities

58. Variations in Arterial Pulses
Absent 0
Weak “thready” 1+
Hard to palpate, may fade in and out, easily obliterated by pressure
R/t >cardiac output, PAD, aortic valve stenosis

59. Variations in Arterial Pulses
Normal 2+
Bounding 3+
Full – easily palpable, pounds under fingertips r/t hyperkinetic states(exercise, anxiety) anemia, hyperthyroidism
Corrigan’s - >normal force, then collapses suddenly r/t Aortic valve regurgitation

60. Variations in Arterial Pulses
Pulses bigeminus – rhythm is coupled with every other beat comes early or normal beat followed by premature beat r/t PVC or PAC
Pulse alternans - regular rhythm but force varies r/t CHF

61. Basic Assessments: Abdomen
Different order for assessment skills
Inspect
Auscultate
Percuss
Palpate

62. Order of assessment Abdomen Inspection Auscultation – four quadrants
Increased, normal, decreased, absent
Listen for several minutes in each quadrant
High pitched tinkling or rushes indicates bowel obstruction
Do before percussion/palpation so presence or absence of bowel sound and pain is not altered
Percussion
Palpation
Light -tenderness, muscle tone & surface characteristics
Deep-tenderness, masses, and aortic pulsation
Abdomen should be soft, relaxed and free from tenderness

63. Characteristics of Masses Determined by Palpation
Shape
Size
Consistency
Surface
Mobility
Tenderness
Pulsatile

64. Basic Assessments: Bones, Muscles, Joints
Joint mobility:
Color change
Deformity
Crepitus
Coordination:
Finger-thumb opposition
Movement
Balance:
Romberg’s test
Body shape/symmetry:
Posture
Gait
Spinal curvature-normal, kyphosis, lordosis, list, scoliosis
(pg. 191 J)
Muscle strength:
Range of motion
Resistance

65. Basic Assessments: Neurological
Staff nurse Uses Focused Neuro Assessment:
Cerebral Functioning:
Level of consciousness
Arousal - response to stimuli
Orientation - time, place, person
Mental status/cognitive function
Behavior, appearance, response to stimuli, speech, memory, communication, judgment
Cranial nerve assessment

66. Basic Assessments: Neurological
Reflexes:
Automatic responses
Responses on a graded scale
0 No response
1+ diminished
2+ average
3+Brisk
4 + hyperactive with Clonus (short jerking motion)
Example: deep tendon reflexes
Motor/Cerebellar Function:
Movement/coordination
Tone
Posture
Equilibrium
Proprioception (body postion)

67. Basic Assessments: Neurological
Sensory Function:
Light touch
Light pain
Temperature
Vibration
Position
Sense
Stereognosis –recognise solid objects
Graphesthesia -recognize #, outlines and symbols
Two-point discrimination
Point localization
Extinction

68. Genitourinary Assessment
Male:
Includes reproductive information
External genitalia: penis, urethral opening, scrotum, lymph nodes, pubic hair
Examine for the presence of a hernia
Female:
Female external genitalia: labia, clitoris, urethral opening, vaginal orifice, pubic hair, lymph nodes

69. Genitourinary Assessment
Other:
Kidneys [CVA (costovertebral angle) tenderness]
Bladder (palpation of the abdomen)
NP/MD responsible for anus, rectum, prostate examination
NP/MD responsible for pelvic examination

70. Purposes of Documentation
Identify actual and potential health problems
Make nursing diagnoses
Plan appropriate care
Evaluate patient’s responses to treatment