1

Chapter 5Chapter 5

PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT

2

HEALTH ASSESSMENTHEALTH ASSESSMENT Physical Examination Physical Examination

3

PurposesPurposes• Ascertain client’s level of health & Ascertain client’s level of health &

physiological functionphysiological function

• Identify important factorsIdentify important factors

• Confirm alterations, disease or inability to Confirm alterations, disease or inability to perform ADLsperform ADLs

• Identify need for additional testing / Identify need for additional testing / examinationexamination

• Aid in evaluating outcome of treatment / Aid in evaluating outcome of treatment / therapytherapy

4

Subjective and Objective DataSubjective and Objective Data

• Subjective DataSubjective Data..

History – what the patient tells/communicates to History – what the patient tells/communicates to youyou

• Objective Data.Objective Data.

Exam – what you discover through your physical Exam – what you discover through your physical assessmentassessment

5

Possible Client Position During Possible Client Position During an Examinationan Examination

6

7

Positions for physical Positions for physical ExaminationExamination

• Assessment positions e.g.: (Standing position, Supine position, Sitting position, Dorsal recumbent position, Sims position, Prone position, Knee chest position, and Lithotomy position)

• Each position has it's specialty for parts of examination

8

Sitting positionSitting position

• Areas Assessed: Head and neck, back, posterior thorax and lungs, anterior thorax , breasts, axillae, heart, vital signs, and upper extremities

• Limitations: Physically weakened client may be unable to sit

9

Supine positionSupine position

• Most normally relaxed position • Areas Assessed: Head and neck

anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, pulses

• Limitations: Not use for client SOB, you may need to raise head of bed

10

Dorsal positionDorsal position • Areas Assessed: Head and neck,

anterior thorax and lungs, breasts, axillae, heart.

• Limitations: Not used for abdominal

assessment because it promotes contracture of abdominal muscles

11

. .Lithotomy PositionLithotomy Position

• Areas Assessed: Female genitalia and genital tract.

• * Limitations:• This position is embarrassing &

uncomfortable, so examiner minimizes time that client spends in it.

• Client is kept well draped. • This position not used for Client with

severe arthritis or other joint deformity

12

Sims’ positionSims’ position• Areas Assessed: Rectum and

vagina.• * Limitations: Joint deformities

may prevent client’s ability to Bend hip and knee

Prone positionProne position : :• * Areas Assessed: Musculoskeletal

system. • * Limitations: don’t use this

position for client with respiratory difficulties

13

Knee-chest positionKnee-chest position

Areas Assessed: Rectum.Limitations: This position is

embarrassing and uncomfortable. Don’t use this position for Clients with arthritis or other joint deformities.

• When palpation assess for Crepitus (crackling sensation & noise caused by rubbing of bone fragments).

• * If a joint appears swollen and inflamed, detect warmth in the tissues.

14

Equipment Preparation For a Equipment Preparation For a Health Assessment Health Assessment

15

16

Indications for the Physical ExamIndications for the Physical Exam

• Routine screeningRoutine screening

• Eligibility prerequisite for health Eligibility prerequisite for health insurance, military service, job, sports, insurance, military service, job, sports, schoolschool

• Admission to a hospital or long term care Admission to a hospital or long term care facilityfacility

17

STEPS OF ASSESSMENTSTEPS OF ASSESSMENT• ThinkThink

• OrganizeOrganize

Don’t forget…Nutrition / Height & WeightDon’t forget…Nutrition / Height & Weight

• Environment:Environment:

• Accommodate special needs (cultural Accommodate special needs (cultural sensitivity)sensitivity)

• Equipment - clean surface & clean equipment Equipment - clean surface & clean equipment Room - quiet, warm & well litRoom - quiet, warm & well lit

• Maintain privacyMaintain privacy

• Observe & ListenObserve & Listen

18

DON’T FORGET……DON’T FORGET……

• REVIEWING GENERAL REVIEWING GENERAL INFORMATIONINFORMATION

• INTRODUCTION TO CLIENTINTRODUCTION TO CLIENT• OBTAINING THE HEALTH OBTAINING THE HEALTH

HISTORYHISTORY• PAIN ASSESSMENTPAIN ASSESSMENT• THIS IS KEY TO THIS IS KEY TO HOLISTICHOLISTIC

APPROACHAPPROACH

19

Five Assessment Techniques Five Assessment Techniques During During A Physical ExaminationA Physical Examination• InspectionInspection

• PalpationPalpation

• PercussionPercussion

• AuscultationAuscultation

• OlfactionOlfaction

20

21

InspectionInspection

• Use vision& smellUse vision& smell

• Always firstAlways first

• Look for symmetryLook for symmetry

• Use good lightingUse good lighting

• Use good exposureUse good exposure

22

23

Principles of Accurate InspectionPrinciples of Accurate Inspection• Good lightening either day light or Good lightening either day light or

artificial light is suitable.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 warm room for examination of the

client “not cold not hot". client “not cold not hot". • Observe for color, size, location, Observe for color, size, location,

texture, symmetry, odors, and sounds.texture, symmetry, odors, and sounds.• Compare each area inspected with the Compare each area inspected with the

opposite side of body if possible.opposite side of body if possible.• Use pen light to inspect body cavities.Use pen light to inspect body cavities.

24

PalpationPalpation

• Touch & feel with hands to determine:Touch & feel with hands to determine: Texture – use fingertipsTexture – use fingertips Temperature – use back of handTemperature – use back of hand MoistureMoisture Organ location and sizeOrgan 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)

25

Light palpationLight palpation

26

Deep palpationDeep palpation

27

Principles for Accurate PalpationPrinciples 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 Tell client to take slow deep breath to

enhance muscle relaxation.enhance muscle relaxation.• Examine condition of the abdominal organsExamine condition of the abdominal organs• Depressed areas must be approximately Depressed areas must be approximately

“2cm” “2cm” • Assess Assess turgerturger of skin measured by lightly of skin measured by lightly

grasping the body part with finger tips.grasping the body part with finger tips.

28

PercussionPercussion

29

PercussionPercussion

• Tapping of body part to assess tenderness, Tapping of body part to assess tenderness, Size, location, densitySize, location, density

• Direct: Direct: with one or two fingers e.g. with one or two fingers e.g. SinusesSinuses

• Indirect: Indirect: middle finger of left handmiddle finger of left hand against the body surface with palm and against the body surface with palm and fingers remaining off the skin,fingers remaining off the skin, and the and the tip of the middle fingertip of the middle finger of the right of the right

hand strikes the base of the distal jointhand strikes the base of the distal joint.. Use a quick & sharp strokeUse a quick & sharp stroke

30

Five Percussion Sounds Produced in Five Percussion Sounds Produced in Different Body RegionsDifferent 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, tumorFlat – no air (thigh muscle, bone, tumor))

31

AuscultationAuscultation

32

AuscultationAuscultation

• Listening to body soundsListening to body sounds

• Movement of air (lungs)Movement of air (lungs)

• Blood flow (heart)Blood flow (heart)

• Fluid & gas movement Fluid & gas movement (bowels)(bowels)

• Remember the sound Remember the sound changes in the abdomen…changes in the abdomen…

33

HOW TO BEGIN…HOW TO BEGIN…

• Positions for physical exam Positions 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 Hold diaphragm firmly against client’s skin (NOT THROUGH CLOTHING!!)(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

34

Olfaction Olfaction

Another skill that used during assessment. Another skill that used during assessment.

Certain alteration in body function creates Certain alteration in body function creates

characteristic body odors.characteristic body odors.

Smelling can detect abnormalities that Smelling can detect abnormalities that

unrecognized by other means.unrecognized by other means.

35

Assessment of Characteristic OdorsAssessment 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 Bad odor from skin, (e.g. under arms and beneath

breasts) means poor hygiene, excess perspiration breasts) means poor hygiene, excess perspiration (bromidrosis)(foul smelling perspiration).(bromidrosis)(foul smelling perspiration).

• Feces odorFeces odor from woundfrom wound site means site means wound abscesswound abscess, but , but this odor this odor from vomitusfrom vomitus this means this means bowel obstructionbowel obstruction, , and if the odor from rectal area this means fecal and if the odor from rectal area this means fecal incontinence.incontinence.

• Foul smellingFoul smelling stool in stool in infantinfant means means mal absorption mal absorption syndrome.syndrome.

36

Assessment of Characteristic Assessment of Characteristic Odors…contOdors…cont

• Halitosis from oral cavity means poor Halitosis from oral cavity means poor dental hygiene.dental hygiene.

• Sweat, fruity ketenes from mouth DKASweat, fruity ketenes from mouth DKA

• Musty odor from organ with cast part Musty odor from organ with cast part means infection inside cast.means infection inside cast.

• Fetid odor from tracheotomy or mucous Fetid odor from tracheotomy or mucous secretions means infectionsecretions means infection

37

Basic Guidelines for Physical AssessmentBasic Guidelines for Physical Assessment

• Obtain a nursing history.Obtain a nursing history.

• Maintain Privacy.Maintain Privacy.

• Explain the procedure and purpose of each Explain the procedure and purpose of each examined part of the client.examined part of the client.

• Follow a planned order of examination for Follow a planned order of examination for each body system.each body system.

38

Basic Guidelines for Physical Assessment cont..Basic Guidelines for Physical Assessment cont..

• Inspect, palpate, percuss, and then auscultateInspect, palpate, percuss, and then auscultate, , except in the except in the abdomenabdomen auscultate then percussauscultate then percuss to avoid alteration in the bowel soundsto avoid alteration in the bowel sounds

• Compare symmetrical sides of the body and Compare symmetrical sides of the body and organs.organs.

• Assess both Assess both structure and function of each structure and function of each body part and organbody part and organ e.g. (the appearance and e.g. (the appearance and condition of the ear as well as its hearing condition of the ear as well as its hearing function) function)

39

Basic Guidelines for Physical Assessment cont..Basic Guidelines for Physical Assessment cont..• If there is abnormality assess for further data. If there is abnormality assess for further data.

e.g. radiation of pain, effect on eating? bowels? e.g. radiation of pain, effect on eating? bowels? ADLs? ADLs?

• Assess self physical assessment (e.g. exam of Assess self physical assessment (e.g. exam of the breast, testicular exam, foot care for the the breast, testicular exam, foot care for the diabetic)diabetic)

• Allow time for client questions Allow time for client questions • ““Remember: the most important guideline for Remember: the most important guideline for

adequate physical assessment is, continuous adequate physical assessment is, continuous practice of physical assessment skills”practice of physical assessment skills”

40

Variation in Physical Assessment of Variation in Physical Assessment of the Pediatric Clientthe Pediatric Client

• Sequence of physical assessment depends on Sequence of physical assessment depends on the development level of the client. the development level of the client.

• Establishment of rapportEstablishment of rapport with the child and with the child and significant others is the most essential step in significant others is the most essential step in physical assessment data.physical assessment data.

• Reduce fearing of child prior to beginning Reduce fearing of child prior to beginning the examination.the examination.

• You may require You may require physical restraintphysical restraint of the of the client with help of another adult.client with help of another adult.

41

Variation in Physical Assessment of the Variation in Physical Assessment of the Pediatric Client…contPediatric Client…cont

• Assistance from the child’s significant Assistance from the child’s significant caregivercaregiver may may facilitatefacilitate examination. examination.

• Assessment approach of the child based on Assessment approach of the child based on child's response.child's response.

• UncooperativeUncooperative attitude toward the examiner is a attitude toward the examiner is a normal finding in childrennormal finding in children from birth to early from birth to early adolescence.adolescence.

42

Variations for Physical Assessment of the Variations for Physical Assessment of the Geriatric ClientGeriatric Client

• Remember normal variation related to aging.Remember normal variation related to aging.• Divide the physical assessment into parts in Divide the physical assessment into parts in

order to avoid fatigue.order to avoid fatigue.• Provide room with comfortable temperature.Provide room with comfortable temperature.• Allow sufficient time for client to respond to Allow sufficient time for client to respond to

directions.directions.• If possible assess the elderly clients in a If possible assess the elderly clients in a

setting position.setting position.• Give him/her fulltime to understand you.Give him/her fulltime to understand you.

43

THANK YOUTHANK YOU