Assessing Health: Physical Examination

Metro Community CollegeNancy Pares, RN, MSNNursing Programs

An Overview

Health Assessment: Performinga Physical Examination

Part of a general health assessment Used to gather data about the client Focuses on functional abilities and responses

to illness/stressor

The Nursing Physical Examination

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

Purposes

Comprehensive: Interview plus complete head-to-toe

examination

Focused: “Focused” on presenting problem

Ongoing: Performed as needed to assess status Evaluates client outcomes

Types of Physical Examinations

Head-to-toe◦ Starts at the head◦ Progresses “down” the body◦ System-related data found throughout:

• Heart sounds - chest• Pulses - periphery

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

Organizing the Examination

Theoretical knowledge• A and P, techniques

Self-knowledge• Skill and comfort

level• Willingness to seek

help

Knowledge about client situation• Purpose of

examination• Client diagnosis

Preparing Yourself:What the Nurse Needs

Privacy is key• Draping• Use of curtains

Noise control• TV/radio off

Enable visualization• Adequate lighting• Flashlight if needed

Preparing the Environment

Promote client comfort:

Develop rapport Explain the procedure Respect cultural differences Use proper positioning

Preparing the Client

Four major skills used:

Inspection Palpation Percussion Auscultation

Physical Assessment Skills

Use of sight to gather data Used throughout physical examination Tools to enhance inspection

• Otoscope• Ophthalmoscope• Penlight

Examples: Skin color, gait, general appearance, behavior

Inspection

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

Palpation

Tapping on skin to elicit sound• Direct• Indirect

Useful for assessing abdomen, lungs, underlying structures

Examples: Distended bladder

Percussion

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

Auscultation

Infants: Parents hold Attend to safety

Toddlers: Allow to explore and/or

sit on parent’s lap Invasive procedure

last Offer choices Use praise

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

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

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

Age Modifications for the Physical Examination

Basic Components of a Comprehensive Examination:The General Survey

• Appearance/behavior• Grooming/hygiene• Body type/posture• Mental state

• Speech• Vital signs• Height/weight

Begins at first contact Overall impression of client Deviations lead to focused assessments

Basic Assessments: Skin, HeadIntegumentary: Skin characteristics

• Color• Temperature• Moisture

• Texture• Turgor

Lesions Hair Nails

Head: Skull and Face

• Size • Shape• Facial features

Eyes• External eye• Sclera• Pupils• Visual acuity• Vision examinations

Acuity, distance, near, color, visual fields

• Internal structures

Basic Assessments: Skin, Head

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

Basic Assessments: Ears, Nose, Mouth

Neck: Musculature Trachea Thyroid gland Cervical lymph

nodes

Breasts: Size Shape Nipple

characteristics Tissue Include axillae

Basic Assessments: Neck, Breasts

Basic Assessments: Lungs

Breath Sounds: Bronchial Bronchovesicular Vesicular

Adventitious Diminished or misplaced Abnormal vocal sounds

Chest and Lungs: Describe size and shape of chest Relate findings to landmarks

Cardiovascular–Heart:

Inspection• PMI• Heaves/Lifts

Palpation• Thrill

Heart soundsLocation:• Aortic, Pulmonic,

Tricuspid, Mitral

Components:• S1, S2, S3, S4

Murmurs

Basic Assessments: Heart, Vessels

Cardiovascular–Vessels:

Central vessels• Carotid arteries

Palpate pulsation * Special precautions Auscultate for bruit

• Jugular veins

Peripheral vessels• Blood pressure• Peripheral pulses• Signs of inadequate

oxygenation• Varicosities

Basic Assessments: Heart, Vessels

Different order for assessment skills• Inspect • Auscultate• Percuss• Palpate

Basic Assessments: Abdomen

Body shape/symmetry: Posture Gait Spinal curvature

Balance: Romberg’s test

Coordination: Finger-thumb opposition Movement

Joint mobility: Color change Deformity Crepitus

Muscle strength: Range of motion Resistance

Basic Assessments: Bones, Muscles, Joints

Staff RN 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

Basic Assessments: Neurological

Reflexes: Automatic responses Responses on a

graded scale• 0 = No response• 4 = Clonus

Example: deep tendon reflexes

Motor/Cerebellar Function:

Movement/coordination Tone Posture Equilibrium Proprioception

Basic Assessments: Neurological

Sensory Function: Light touch Light pain Temperature Vibration Position Sense

Stereognosis Graphesthesia Two-point

discrimination Point localization Extinction

Basic Assessments: Neurological

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

Genitourinary Assessment

Other: Kidneys (CVA tenderness) Bladder (palpation of the abdomen) NP/MD responsible for anus, rectum, prostate

examination NP/MD responsible for pelvic examination

Genitourinary Assessment