1. King Saud University College of Nursing Health Assessment (NUR 224) General Survey & Health History Part 2 1

2. Learning objectives At the end of this module, the learner should be able to: 1. Define the Key terms. 2. Understand the concept of physical examination in terms of its requirements. 3. Discuss the concept of general survey in terms of its purpose, skills, and components. 4. Discuss the four basic physical examination techniques. 5. Identify commonly needed physical examination equipments and their functions.

3. Physical Examination  Physical examination is a systematic approach of collecting objective data about clients’ health status.  It employs through detailed evaluation of clients’ all body structures, organs, or systems.  It requires the nurse to apply special techniques, use equipments and knowledge base, to physically expose each region of clients’ body and examine it by looking, listening, touching, or smelling.

4. Purpose of physical Examination  Physical examination is performed in all health care settings, covering healthy and sick clients.  It serves for screening, detection, and prevention of disease.  It also provides an opportunity for health promotion (education & counseling) as well as the evaluation of disease process or treatment results.

5. Component of Physical Examination:  General survey (the nurses’ initial observation for the clients’ general appearance and behavior).  Vital signs measurement  Height and weight measurement  Body systems examination

6. 1- Physical Appearance Normal Range of FindingsAbnormal Findings 1- Age – the person appears his or her stated age. Appears older, smaller, or younger, as with chronic disease or retardation. 2- Sex – Sexual development is appropriate for gender and age Delayed or early puberty, or inappropriate to gender. 3- Level of consciousness – the person is alert and oriented, attends to your questions and responds appropriately. Alert. Alert. Follow commands and responds completely and appropriately to stimuli Lethargic. Lethargic. The patient is sleepy or drowsy and will awaken and respond appropriately to command. Stupor. Stupor. require vigorous stimulation for a response. Semi coma. Semi coma. The patient is not awake but will respond purposefully to deep pain Coma. Coma. The patient is completely unresponsive.

7. 1- Physical Appearance Normal Range of FindingsAbnormal Findings 4- Skin color – color tone is even, skin is intact with no obvious lesions Pallor, (loss of color) cyanosis, (bluish discoloration) jaundice Yellowish discoloration) lesions. 5- Facial features – symmetric with movement. 6- No signs of acute distress are present Immobile, masklike, asymmetric, drooping. shortness of breath, wheezing. facial grimace, holding body part. (Pain)

8. II- Body STRUCTURE 1- Stature – the height appears within normal range for age. Excessively short or tall 2- Nutritional status – the weight appears within normal range for height and body build. Underweight Obese

9. II- Body STRUCTURE 3- Symmetry – body parts look equal bilaterally Unilateral atrophy hypertrophy (enlargement of muscles.) 4- Posture – the person stands comfortably erect as appropriate for age. Rigid spine and neck (moves as one unit) e.g., arthritis. Stiff and tense.

10. 5- Position – the person sits comfortably in a chair or on the bed or examination table, arms relaxed at sides, head turned to examiner. Leaning forward with arms braced on chair arms (chronic pulmonary disease). Sitting straight up and resists lying down, (left-sided congestive heart failure). 7- Physical deformities– Absence of any congenital or acquired defects. Presence of deformities or congenital defect

11. III- Mobility 1-Gait: the walk is smooth, even, and well-balanced; and associated movements, (symmetric arm swing), are present. Limping with injury. Difficulty stopping 2-Range of motion – the person has full mobility for each joint. 3- Involuntary movement: absent Limited joint range of motion. Paralysis – absent movement. Movement jerky, uncoordinated Tics, tremors, seizers

12. IV- Behavior 1- Facial expression – the person maintains eye contact expressions are appropriate to the situation. Flat, depressed, angry, sad anxious. However, note that anxiety is common in ill people. 2- Mood and affect – the person is comfortable and cooperative with the examiner and interacts pleasantly. Hostile, distrustful, suspicious, crying

13.  Vital signs are the key physiologic measures of the person’s general health state. The nurse obtains vital signs to: a. Establish baseline measurement. b. Identify physiologic problems. c. Monitor clients’ response to therapy. Signs range  Pulse rate 60 - 100 beats/min  Respiratory rate 12 - 20 breath/min  Blood pressure 100/70 to 140/90 mmHg  Temperature 36.5 - 37.5 C  Pain

14. 3- Measuring Height and weight  Body mass index _Weight_(kg)____ (Height) 2 (Height) 2  Where  Weight is measured in kilograms.  Height is measured in meters  BODY MASS INDEX FINDING  < 20 PERSON IS UNDER WEIGHT  =20-25 PERSON IS NORMAL WEIGHT  =25-30 PERSON IS OVERWEIGHT  >30 PERSON IS OBESE

15. EXAMPLE:-  Calculate body mass index of person, his weight is 98kg, his height is172 cm.  Answer steps:  Transfer height from cm to meter =172/100=1.72m  Body mass index (BMI) = 98/(1.72)2 =33  BMI = 33 SO the person is obese.

16. 4- Body systems examination Body systems examination is the systematic objective evaluation of client’s body structures, parts, and organs, using the examiners’ sense Body systems examination is the systematic objective evaluation of client’s body structures, parts, and organs, using the examiners’ sense

17.  Review client health history  Prepare equipment  Examine client in a warm & quiet room  Examine client in well- lighted room  Consider patients’ privacy and comfort  Practice and adhere to standard precaution of Infection control  Explain procedure to client & reassure client along the examination. Begin examination with the patient in sitting position( if possible). This facilitates front and back examination  Use appropriate Draping, such that only body part being examined is exposed

18. Physical examination equipments:  Ophthalmoscope Otoscope  Tuning fork  Nasal speculum  Percussion hammer  Snellen chart

19. Basic Physical examination techniques Physical examination utilizes four techniques  Inspection  Palpation  Percussion  Auscultation

20. 1.Inspection  means Observing the client in a close, focused manner using vision, and smell senses. *It begins during the first contact with client and continues throughout the assessment *It provides information about body parts’: color, size, location, movement, texture, symmetry, odor, and sound

21. 2.Palpation  Palpation is the use of hands and fingers to feel different body parts for data collection.  The nurse uses pads of the fingers and palms to touch and feel the patient’s body parts with his hands to examine: size texture location tenderness body temperature lumps or masses

22. Types of palpation 1. Light palpation  Using the flat part of the right hand or the pads of the fingers, not the fingertips  The fingers should be together  Depress the skin 1 to 2 cm with your finger pads, usually the lightest touch possible.

23. Light palpation

24. 2.Deep palpation  Used to determine organ size as well as the presence of abdominal masses  The flat portion of the right hand is placed on the abdomen  Depress the skin 4 to 5 cm with firm, deep pressure. Pressure should be applied to the abdomen gently but steadily  The patient should be instructed to breathe quietly through the mouth and to keep arms at the sides

25. 3.Percussion  A methods of “ striking” of body parts during physical examination with fingers to evaluate the size, consistency, borders and presence of fluid in body organs  Percussion of a body part produces a sound that indicates the type of tissue within the organ  It is particularly important in examining the chest and abdomen

26. Methods of Percussion 1. Direct percussion:  Using one or two fingers, tap directly on the body part. Ask the patient to tell you which areas are painful and watch his/her face for signs of discomfort.  Direct percussion is commonly used to assess an adult patient's sinuses for tenderness.

27. 2.Indirect Percussion  Press the distal part of the middle finger (pleximeter) of your nondominant hand firmly on the body part(left hand).  Keep the rest of your hand off the body surface.  Flex the wrist of your dominant hand.  Using the middle finger (plexor or striking finger) of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient's skin. The motion of the striking finger should come from the wrist and not from the elbow  Deliver 2 - 3 quick taps and listen carefully.

28. Types of sounds SoundQuality of sound Where it is heard Source TympanyDrumlike soundOver enclosed air Puffed-out cheek, air in bowel ResonanceHollow soundOver areas of part air and solid Normal lung Hyper resonance Booming soundOver air(child’s lungs) N (adult) Lung with emphysema DullnessThudlike soundOver solid areaLiver, spleen FlatnessFlat soundOver dense tissue Thigh Muscle, bone, over tumor

29. 4.Auscultation  A method used to “listen” to the body sounds.  Various body systems like heart, lungs, and abdominal organs have characterized sounds  Bowel, breath, heart, and blood movement sound are heard using a stethoscope  It is important to know the normal sound to distinguish from abnormal sound

30. Types of auscultation 1. Direct auscultation : * Uses the ear alone to listen, such as when listening to the grating of a moving joint. * Sounds are audible without stethoscope 2. Indirect auscultation: sounds are audible with stethoscope 3. Bell for low pitched sound and diaphragm for high pitched sound

31. Question? 31