1. Chapter 27
Physical Assessment

2. 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)

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

4. Preparation for Physical Examination
Environment
Equipment
Positioning and draping

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

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

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

8. 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)

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

10. Assessment Techniques
Inspection
Palpation
Percussion
Auscultation

11. Integument
Skin
Hair
Nails

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

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

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

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

16. Heart and Vascular System
Skin temperature
Color
Sensation
Pulses

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

18. Abdomen Inspection Auscultation of four quadrants Percussion
Light palpation

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

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

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

22. Reproductive System
Female genitalia
Male genitalia

23. Anus and Rectum
Position
Gloves
Lubricant
Prostate gland palpation

24. Post Assessment Care of the Client
Outpatient setting
Inpatient setting

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