1. 1 Islamic University of Gaza Faculty of Nursing Chapter 4 PHYSICAL ASSESSMENT

2. 2 HEALTH ASSESSMENT Physical Examination

3. 3 Objectives Five assessment techniques during a physical examinationFive assessment techniques during a physical examination Differences between subjective and objective dataDifferences between subjective and objective data Immediate and mediate percussion techniqueImmediate and mediate percussion technique Five percussion sounds produced in different body regionsFive percussion sounds produced in different body regions Uses of stethoscopeUses of stethoscope Equipment preparation for a health assessment Equipment preparation for a health assessment

4. 4 Purposes Ascertain client’s level of health & physiological functionAscertain client’s level of health & physiological function Identify important factorsIdentify important factors Confirm alterations, disease or inability to perform ADLsConfirm alterations, disease or inability to perform ADLs Identify need for additional testing / examinationIdentify need for additional testing / examination Aid in evaluating outcome of treatment / therapyAid in evaluating outcome of treatment / therapy

5. 5 Subjective and Objective Data Subjective Data.Subjective Data. History – what the patient tells/communicates to you Objective Data.Objective Data. Exam – what you discover through your physical assessment

6. 6 Possible Client Position During an Examination

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8. 8 Equipment Preparation For a Health Assessment

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10. 10 Indications for the Physical Exam Routine screeningRoutine screening Eligibility prerequisite for health insurance, military service, job, sports, schoolEligibility prerequisite for health insurance, military service, job, sports, school Admission to a hospital or long term care facilityAdmission to a hospital or long term care facility

11. 11 STEPS OF ASSESSMENT ThinkThink OrganizeOrganize Don’t forget…Nutrition / Height & Weight Environment:Environment: Accommodate special needs (cultural sensitivity)Accommodate special needs (cultural sensitivity) Equipment - clean surface & clean equipment Room - quiet, warm & well litEquipment - clean surface & clean equipment Room - quiet, warm & well lit Maintain privacyMaintain privacy Observe & ListenObserve & Listen

12. 12 DON’T FORGET…… REVIEWING GENERAL INFORMATIONREVIEWING GENERAL INFORMATION INTRODUCTION TO CLIENTINTRODUCTION TO CLIENT OBTAINING THE HEALTH HISTORYOBTAINING THE HEALTH HISTORY PAIN ASSESSMENTPAIN ASSESSMENT THIS IS KEY TO HOLISTIC APPROACHTHIS IS KEY TO HOLISTIC APPROACH

13. 13 Five Assessment Techniques During A Physical Examination InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation OlfactionOlfaction

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15. 15 Inspection Use vision& smellUse vision& smell Always firstAlways first Look for symmetryLook for symmetry Use good lightingUse good lighting Use good exposureUse good exposure

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17. 17 Principles of Accurate Inspection Good lightening either day light or artificial light is suitable.Good lightening either day light or artificial light is suitable. Expose body parts being observed only.Expose body parts being observed only. look before touching.look before touching. warm room for examination of the client “not cold not hot".warm room for examination of the client “not cold not hot". Observe for color, size, location, texture, symmetry, odors, and sounds.Observe for color, size, location, texture, symmetry, odors, and sounds. Compare each area inspected with the opposite side of body if possible.Compare each area inspected with the opposite side of body if possible. Use pen light to inspect body cavities.Use pen light to inspect body cavities.

18. 18 Palpation Touch & feel with hands to determine:Touch & feel with hands to determine:  Texture – use fingertips  Temperature – use back of hand  Moisture  Organ location and size Slow and systematicSlow and systematic Light to deepLight to deep Light palpation (tenderness)Light palpation (tenderness) Deep palpation (abdominal organs/masses)Deep palpation (abdominal organs/masses)

19. 19 Light palpation

20. 20 Deep palpation

21. 21 Principles for Accurate Palpation Examiner finger nails should be short.Examiner finger nails should be short. Use sensitive part your hand.Use sensitive part your hand. Light Palpation precedes deep palpation.Light Palpation precedes deep palpation. Start with light then deep palpationStart with light then deep palpation Tender area are palpated lastTender area are palpated last Client must relax during palpation.Client must relax during palpation. Tell client to take slow deep breath to enhance muscle relaxation.Tell client to take slow deep breath to enhance muscle relaxation. Examine condition of the abdominal organsExamine condition of the abdominal organs Depressed areas must be approximately “2cm” Depressed areas must be approximately “2cm” Assess turger of skin measured by lightly grasping the body part with finger tips.Assess turger of skin measured by lightly grasping the body part with finger tips.

22. 22 Percussion

23. 23 Percussion Tapping of body part to assess tenderness, Size, location, densityTapping of body part to assess tenderness, Size, location, density Direct: with one or two fingers e.g. SinusesDirect: with one or two fingers e.g. Sinuses Indirect: middle finger of left hand against the body surface with palm and fingers remaining off the skin,Indirect: middle finger of left hand against the body surface with palm and fingers remaining off the skin,  and the tip of the middle finger of the right hand strikes the base of the distal joint.  Use a quick & sharp stroke

24. 24 Five Percussion Sounds Produced in Different Body Regions Resonant – normal lungResonant – normal lung Hyper resonant – infant lung, emphysemaHyper resonant – infant lung, emphysema Tympany – air filled (stomach)Tympany – air filled (stomach) Dull – organ (liver, spleen)Dull – organ (liver, spleen) Flat – no air (thigh muscle, bone, tumor )Flat – no air (thigh muscle, bone, tumor )

25. 25 Auscultation

26. 26 Auscultation Listening to body soundsListening to body sounds Movement of air (lungs)Movement of air (lungs) Blood flow (heart)Blood flow (heart) Fluid & gas movement (bowels)Fluid & gas movement (bowels) Remember the sound changes in the abdomen…Remember the sound changes in the abdomen…

27. 27 HOW TO BEGIN… Positions for physical examPositions for physical exam Using a stethoscope:Using a stethoscope: longer the tube – more sound has to travellonger the tube – more sound has to travel Hold diaphragm firmly against client’s skin (NOT THROUGH CLOTHING!!)Hold diaphragm firmly against client’s skin (NOT THROUGH CLOTHING!!) If using bell – less pressureIf using bell – less pressure Warm in your hands first!Warm in your hands first! Listen / Concentrate on the soundsListen / Concentrate on the sounds

28. 28 Olfaction Another skill that used during assessment, certain alteration is body function create characteristic body odors, smelling can detect abnormalities that unrecognized by other means.

29. 29 Assessment of Characteristic Odors Alcohol odor from oral mouth ingestion of alcohol.Alcohol odor from oral mouth ingestion of alcohol. Ammonia from urine means urinary tract infection.Ammonia from urine means urinary tract infection. Bad odor from skin, (e.g. under arms and beneath breasts) means poor hygiene, excess perspiration (bromidrosis) foal. Smelling, foul smelling perspiration.Bad odor from skin, (e.g. under arms and beneath breasts) means poor hygiene, excess perspiration (bromidrosis) foal. Smelling, foul smelling perspiration. Feces odor from wound site means wound abscess, but this odor from vomitus this means bowel obstruction, and if the odor from rectal area this means fecal incontinence.Feces odor from wound site means wound abscess, but this odor from vomitus this means bowel obstruction, and if the odor from rectal area this means fecal incontinence. Foul smelling stool in infant means mal absorption syndrome.Foul smelling stool in infant means mal absorption syndrome.

30. 30 Assessment of Characteristic Odors…cont Halitosis from oral cavity means poor dental hygiene.Halitosis from oral cavity means poor dental hygiene. Sweat, fruity ketenes from mouth DKA Sweat, fruity ketenes from mouth DKA Musty odor from organ with cast part means infection inside cast.Musty odor from organ with cast part means infection inside cast. Fetid odor from tracheotomy or mucous secretions means infectionFetid odor from tracheotomy or mucous secretions means infection

31. 31 Basic Guidelines for Physical Assessment Obtain a nursing history.Obtain a nursing history. Maintain Privacy.Maintain Privacy. Explain the procedure and purpose of each examine part of the client.Explain the procedure and purpose of each examine part of the client. Follow a planned order of examination for each body system.Follow a planned order of examination for each body system.

32. 32 Basic Guidelines for Physical Assessment cont.. inspect, palpate, percuss, and then auscultate, except in the abdomen auscultate then percuss to avoid alteration in the bowel soundsinspect, palpate, percuss, and then auscultate, except in the abdomen auscultate then percuss to avoid alteration in the bowel sounds Compare symmetrical sides of the body and organs.Compare symmetrical sides of the body and organs. Assess both structure and function of each body part and organ e.g. (the appearance and condition of the ear as well as its hearing function) Assess both structure and function of each body part and organ e.g. (the appearance and condition of the ear as well as its hearing function)

33. 33 Basic Guidelines for Physical Assessment cont.. If there is abnormality assess for further data. e.g. radiation of pain, effect on eating? bowels? ADLs?If there is abnormality assess for further data. e.g. radiation of pain, effect on eating? bowels? ADLs? Assess self physical assessment (e.g. exam of the breast, testicular exam, foot care for the diabetic)Assess self physical assessment (e.g. exam of the breast, testicular exam, foot care for the diabetic) Allow time for client questions Allow time for client questions “Remember: the most important guideline for adequate physical assessment is, continuous practice of physical assessment skills”“Remember: the most important guideline for adequate physical assessment is, continuous practice of physical assessment skills”

34. 34 Variation in Physical Assessment of the Pediatric Client Sequence of physical assessment depends on the development level of the clientSequence of physical assessment depends on the development level of the client Establishment of report with the child and significant other is the most essential step in physical assessment data.Establishment of report with the child and significant other is the most essential step in physical assessment data. Reduce fearing of child prior to beginning the examination.Reduce fearing of child prior to beginning the examination. You may require physical restraint of the client with help of another adult.You may require physical restraint of the client with help of another adult.

35. 35 Variation in Physical Assessment of the Pediatric Client…cont Assistance from the child’s significant caregiver may facilitate examinationAssistance from the child’s significant caregiver may facilitate examination Assessment approach of the child based on child's responseAssessment approach of the child based on child's response Uncooperative attitude to ward the examiner is a normal finding in children from birth to early adolescence.Uncooperative attitude to ward the examiner is a normal finding in children from birth to early adolescence.

36. 36 Variations for Physical Assessment of the Geriatric Client Remember: normal variation related to aging.Remember: normal variation related to aging. Divide the physical assessment into parts in order to avoid fatigueDivide the physical assessment into parts in order to avoid fatigue Provide room with comfortable temperature.Provide room with comfortable temperature. Allow sufficient time for client to respond to directions.Allow sufficient time for client to respond to directions. If possible assess the elderly clients in a setting position.If possible assess the elderly clients in a setting position. Give him fulltime to understand you.Give him fulltime to understand you.

37. 37 THANK YOU