physical examination

PHYSICAL

EXAMINATION

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Objectives of Health Assessment

Describe prehospital physical examination techniques

Describe examination equipment

Describe the general approach to the physical examination

Outline the steps of the comprehensive physical examination

www.drjayeshpatidar.blogspot.in

Objectives

Detail the components of the mental status examination

Identify abnormal findings in the mental status examination

Outline steps in the general patient survey

Distinguish between normal and abnormal findings in the general survey

Objectives

Describe examination techniques for

specific body regions

Identify normal and abnormal findings in

the body region examination

Describe examination techniques specific

to children and older adults

Health Assessment

Component of Health assessment

Health History

Physical assessment

Purposes

Establish a nurse- client relationship.

Gather data about the client‟s general health

status, integrating physiologic, psychological,

cognitive, socio cultural, development and

spiritual dimensions.

Identify client‟s strengths.

Identify actual and potential health problem.

Establish a base for the nursing process.

To evaluate the physiological outcome of care.

Techniques of Physical Examination

Health History

Health history is a collection of subjective

and objective data that provide a detailed

profile of the client‟s health status.

History Taking

IDENTIFICATION DATA OF THE PATIENT

Patient's name:-

Age: - Sex-

Hospital Name:-

File No./MLC No.:-

Source providing history:-

Date/ Time of admission-

OPD No.:-

IPD No.:-

Bed No.:-

Doctor‟s Unit:-

Provisional Diagnosis-

Surgery done/Date of Surgery:-

Name of the Surgery:-

Residential Address-

Mother Tongue:-

Marital Status-

Educational Status: -

Occupation-

Monthly income

DETAILS OF ADMISSION:-

Arrived via wheel chair / stretcher /

ambulatory: -

LOC – Conscious / Semiconscious /

Unconscious

From admitting room / emergency room.''

home / any others:-

ORIENTATION TO THE UNIT:-

Use of telephone / TV / call lights:-

Visiting hours:-

No Smoking:-

Patient is informed that hospital is not

responsible for the personal belongings: -

Yes/No

Valuable handed over to (Write relationship

With patient)

Written consent:-

BASELINE DATA

Weight:- Height:- Abdominal Girth:-

Temperature: - Oral: -

Axilla: - Rectal:-

Respiration:-

Pulse: -

Blood Pressure:-

REASON FOR ADMISSION

(Onset, duration, earlier treatments)

ALLERGIES AND MEDICATIONS

Drugs / Foods / dyes / Others:-

Sign and symptoms:-

Alcohol/ Tobacco/Cigarette/Drug Abuse:-

Amount of intake/Day:

Duration of intake (Since when) and

frequency of intake (How often in a day?):-

LEISURE ACTIVITIES /RECREATIONAL

ACTIVITIES (IN HOSPITAL)

PATIENTS ROUTINES HABITS (IN

HOSPITAL)

FAMILY INFORMATION

-Name of Family Members

-Relationship with patient

-Type of Family

-Education

-Occupation

-Marital Status

-Health Status

Family Income per Year:

Family interpersonal relationship / Any

Family Disharmony:-

Family History of illness: (Hypertension,

DM, Cancer, Arthritis, etc

ENVIRONMENTAL BACKGROUND

1) HOUSING

Type of house:-

Lighting :-

Ventilation:-

Water facilities:-

Sanitation:-

2) PETS/ANIMALS

3) FOOD HYGIENE PRACTICES:

4) PERSONAL HYGIENE PRACTICES:

5) COMMUNITY RESOURCES

a) Transport: -

b) Health facilities:-

c) Educational Facilities :-

PAST MEDICAL HISTORY

Hypertension, DM, Cancer, Respiratory,

Arthritis, stroke and others:

PAST SURGICAL HISTORY

PRESENT MEDICAL HISTORY;-

CURRENT MEDICATION:-

Current Medication

Dose/Frequency

Last Dose Taken

LABORATORY/OTHER INVESTIGATION:-

Investigations Name

Normal Findings

Patient’s Findings

SPECIAL ASSISTIVE DEVICES

Wheel Chair / Braces / Crutches /

Walkers / others:-

Contact lenses / Hearing aid / Prosthesis /

Glasses:-

Dentures:- Total / Partial

PSYCHOSOCIAL HISTORY

Any recent stress?

Who is with the patient in the hospital?

Does the patient have anybody who will

give financial support if needed?

Who will care for the patient at home?

Calm: Yes / No

Anxious: Yes / No

Skills of Physical Assessment

Inspection

Palpation

Percussion

Auscultation

Olfaction

Inspection

Visual assessment of the patient and

surroundings

Findings that may be significant:

– Patient hygiene

– Clothing

– Eye gaze

– Body language

– Body position

– Skin color

– Odor.

Nurse observe body part

Pay attention to client, watching all

movement & looking carefully at any body

It help to know physical characteristics.

Quality of inspection depend on the

nurse‟s willingness to spend time during a

If the emergency response was to the

patient's home, make a visual inspection

– Cleanliness

– Prescription medicines

– Illegal drug

– Weapons

– Signs of alcohol use

Principles

Make sure good lighting is available.

Position and expose body parts so that all

surface can be viewed.

Inspect each area of size, shape,

colour,symmetry, position and abnormalities.

If possible, compare each area inspected with

the same area on the opposite side of the body.

Use additional light to inspect body cavities.

Do not hurry inspection. Pay attention to detail.

Palpation

A technique in which the hands and fingers are used to gather information by touch.

Palmar surface of fingers and finger pads are used to palpate for– Texture

– Masses

– Fluid

--And assess skin temperature

Client should be relax and positioned comfortably because muscle tension during palpation impair its effectiveness.

Asking the patient to take deep & slow breath.www.drjayeshpatidar.blogspot.in

Types of Palpation

Light palpation

Deep palpation

Bimanual palpation

Light Palpation

The nurse apply tactile pressure slowly,

gentely and deliberately.

The nurse‟s hand is placed on the part to

be examined and depressed about 1-2cm.

Deep Palpation

It is done after light palpation.

It is used to detect abdominal masses.

Technique is similar to light palpation

except that the finger are held at a greater

angle to the body surface and the skin is

depressed about 4-5 cm.

Bimanual Palpation

It involve using both hand to trap a

structure between them. This technique

can be used to evaluate spleen, kidney,

breast, uterus and ovary.

Sensing hand – Relax & place lightly over

the skin.

Active hand – Apply pressure to the

sensing hand.

Deep Bimanual Palpation

Percussion

Percussion involve tapping the body with the

fingertips to evaluate the size, border and

consistency of body organs and to

discover fluid in body cavity.

Percussion

Used to evaluate

for presence of air

or fluid in body

tissues

– Sound waves

heard as

percussion tones

(resonance)

Methods of Percussion

Mediate or Indirect Percussion

Immediate Percussion

Fist Percussion

Mediate or Indirect Percussion

It can be performed by using the finger

on one hand as a plexor (Striking finger)

and the middle finger of the other hand as

a pleximeter (the finger being struck).

Used mainly to evaluate the abdomen or

thorax.

Immediate Percussion

Used mainly to evaluate the sinus or an

infant thorax.

It can be performed by striking the surface

directly with the fingers of the hand.

Fist Percussion

Used to evaluate the back and kidney for

tenderness.

It involves placing one hand flat against

the body surface and striking the back of

the hand with a clenched fist of the other

Sounds Produced by Percussion

Sound : Tympany

Intensity : Loud

Pitch : High

Duration : Moderate

Quality : Drumlike

Common location : Air containing space,

enclosed area, gastric air bubble, Puffed out cheek

Sound : Resonance

Intensity : Moderate to Loud

Pitch : Low

Duration : Long

Quality : Hollow

Common location : Normal lungs

Sound : Hyper Resonance

Intensity : Very Loud

Pitch : Very Low

Duration : Longer than resonance

Quality : Booming

Common location : Emphysematous lungs

Sound : Dullness

Intensity : Soft to moderate

Pitch : High

Duration : Moderate

Quality : Thudlike

Common location : Liver

Sound : Flatness

Intensity : Soft

Pitch : High

Duration : Short

Quality : Flat

Common location : Muscle

Auscultation

Auscultation is listening to sound produce by the body.

Through auscultation the nurse note the following characteristics of sound.

Frequency or the number of oscillation generated per second by a vibrating object.

Loudness – Loud or soft

Quality – Blowing or Gurgling

Duration – Length of time that sound vibration last. Short / medium / long.

Auscultation

Best performed in a quiet environment

Requires a stethoscope– Body sounds produced by movement of fluids or

gases in patient's organs or tissues

Note:– Intensity

– Pitch

– Duration

– Quality

Stethoscope

Used to evaluate sounds created by

cardiovascular, respiratory,

and gastrointestinal systems

Position stethoscope between

index and middle fingers

Olfaction

While assessing a client, the nurse

should be familiar with the nature and

source of body odors.

Preparation for Examination

Infection control : If patient have any

open skin lesions and any drainage. Nurse

has to maintained infection control and

avoid infection.

- use gloves

- use apron

- use mask

- use gown

Environment

Privacy

Well equipped examination room

Adequate lighting

Sound proofed room

Comfort environment

Examination table

Equipment

All necessary equipments for procedure.

Physical preparation

Bladder and Bowel elimination

Draped properly

Dressed properly

Positioning

Psychological preparation

Explain procedure

If both are opposite sex then third person

is necessary.

Observe facial expression

Client should free from anxious feeling.

Clarify client doubt.

General examination

1.Gender and race :

Example – Skin cancer is 20% higher in

white than black people. Prostate cancer

is higher in African American than white

American.

2. Age : old age people and children's are

more prone to get infection.

3. Signs of distress :

Pain, Difficulty in breathing

4. Body type : Thin, Fat

5. Posture : Standing. Upright position,

Knee flexed

6. Gait : Co-ordination proper or not, person

normally walk with the arms swinging

freely at the sides, with the head and face

leading the body.

7. Body movement :

- Movement are purposefully.

- If any part is immobile.

8. Hygiene and grooming :

- Personal hygiene maintain or not.

- Cosmetic used or not

9. Dress : culture, life style, socio economic

status. It should be appropriate according

to weather condition.

10. Body odor :

- Unpleasant odor

- Poor hygiene

- Bad breath

- Poor oral hygiene

11. Affect and mood :

- Feeling‟s to other

- Emotionally expression

- Mood appropriate as per situation

12. Speech :

Pressure, tone, speed.

13. Client abuse : any problem during

growing and serious health problem during

childhood.

14. Substance abuse :

- Drugs

- Alcohol

- Smoking

- Ganja

Vital signs

Temperature

Pulse rate

Respiratory rate

Blood pressure

Temperature Measurement

Oral temperature

Hold thermometer

firmly under tongue

Tell child to “kiss”

Caution to avoid

biting www.drjayeshpatidar.blogspot.in

Axillary Temperature

Hold arm down

firmly

Should be

approximately 1 F

less than core

Rectal Temperature

Risk of perforation

Avoid in

uncooperative, or

immuno-suppressed

patient

Stabilize

thermometerwww.drjayeshpatidar.blogspot.in

Rhythm

Quality

Consider ECG monitoring

Respirations

Adult rate

– 16-24 breaths per minute

Observe

Feel for chest movement

Auscultate

Blood PressureLocations

Blood Pressure Cuff

Sphygmomanometer

Measures systolic

and diastolic blood

pressure

Manual or electronic

Anthropometry

Height

Weight

Abdominal girth

Mid arm circumference

Height and Build

Descriptions include:

– Average, tall, short, lanky ( long & thin ),

muscular

May also be affected by age and lifestyle

Weight

Observe general appearance

– Obese to emaciated

Recent changes may be key finding

– Recent weight loss or gain

Head to toe Examination

Hair type :

Terminal Hair : long, thick, found on axilla

and pubic area.

Vellus Hair : small, soft, found all over

body except palm or sole.

Colour:

Distribution:

Quantity:

Shiny:

Curly:

Using dye:

Alopecia

Bittle hair

With puberty hair colour, distribution and

amount change.

Hirsutism

Lubrication of hair

Unusual scalp

Lesions

Trauma

Dandruff

Reaction with shampoo

Using chemical for pediculosis treatment

Using chemical to color

Fore Head

Lesions

Head injury

Visual activity:

Visual field:

Eye movement:

Eye structure:

Shape:

Symmetry:

Reactive to light

Redness and swelling

Eye chart reading ( snellen‟s chart )

Discharges:

Eye alignment:

Eye brows:

Eye lids:

Use of glasses or contact lenses:

Corneal reflex

Lacrimal function

Ophthalmoscope used to see any abnormalities in eyes

Structure:

Symmetry:

Obstruction:

Position and alignment:

Shape:

Discharge:

Inflammation:

Hearing AID:

Otoscope is used to see internal ear

structure

Hearing activity:

Weber‟s test:

Rinne test:

Shape:

Lesions:

Inflammation:

Deformity:

Edema:

Mucus colour:

Patency of Nair:

Epistaxis:

Discharge:

Polyp‟s:

Pen light and nasal speculum is used to

see nose

Frontal sinus

Maxillary sinus

Colour:

-Cherry :carbon-monoxide poisoning

-Pallor: Anemia

-Cyanosed: Respiratory or cardiac problem

Dryness

Smoothness

Crack lips With mouth closed the nurse

view the lips from end to end.

Remove lipstick before examination of lips.

Arrangement:

Dental hygiene:

Loose teeth:

Colour of teeth:

Halitosis:

Dentures

Upper molar should rest directly on the

lower molar with upper incisors slightly

overriding the lower incisors.

Dental caries – discoloration of the enamel

Colour:

Edema:

Gingivitis:

Ulcer:

Healthy gums are pink, smooth and moist.

Spongy gums bleed easily ( vit-c

deficiency )

Oral mucosa

Color: Pinkish red

moist/dry:

Ulcer:

Lesion:

Leuckoplakia: thick white patches because

of smoking and alcohol.

Tongue

The client first relax the mouth and sticks the tongue out halfway.

Slightly rough on the top surface and smooth along the lateral margin.

Under surface of the tongue and floor of the mouth are highly vascular.

Observe for cyst, lesions, swelling and nodule on the back side of tongue.

Examination of tongue : Protrude the tongue, grasp the tip and gently pulls it to one side.

Movement:

Shape:

Ulcer:

Lesions:

Protrude of tongue:

Taste of tongue:

Colour:

Moist:

Glossitis:

Palate

Extend the Head backward and open the mouth

and inspect hard palate & soft palate

Hard palate: Anterior part of palate

Shape: Dome shape

Colour: Whitish

Soft palate: Posterior part of palate

Shape: „C” shape

Colour: Light pink

Pharynx

Procedure : Extend his neck slightly, open

the mouth widely and say „ah‟. Place

tongue depressor on the middle third of

tongue. Use penlight for inspection.

Inspect for edema, ulcer, inflammation,

lesions.

Gag reflex

Dysphagia

Examine the anatomical position of neck.

Function of sternocleidomastoid muscle :

the nurse ask the client to flex the neck

with the chin to the chest.

Function of the trapezius muscles :

movement of the head sideway so that the

ear moves toward the shoulder.

Neck should move freely without any pain.

Movement of neck :

Stiff ness:

Swelling:

Neck muscle:

Lymph nodes : With the client‟s chin raised and head tilted slightly, the nurse first inspect the area where lymph nodes are distributed.

Inspect for size, shape, inflammation and mobility.

Thyroid gland

It lies anterior lower neck, in front of neck and

both side of trachea.

Inspect for visible mass of thyroid gland,

symmetry and fullness at the base of neck.

Give water then see for bulging of the gland.

Palpation : Client flex the neck forward and

laterally toward the side being examined. The

client hold a cup of water and take a sip to

swallow.

Anterior Part : using the pads of the index

and middle finger, the nurse palpate the

left lobe with the right hand and right lobe

with left hand.

Posterior Part : Both hand of the nurse are

keep around the neck with two finger of

each hand on the side of trachea.

Breast

Female:

– Symmetry

– Pain:

– Lump:

– Discharge:

– Swelling:

– Trauma:

– History of breast disease:

– Surgery:

-Lump:

-Swelling:

- Gynecomastia

Thorax & Lung

Thorax size:

Thorax shape:

Chest movement:

Respiratory rate:

Rhythm:

Breathing pattern:

Breathing sound:

Chest pain with breathing:

Cough:

Productive & Nonproductive:

Hemoptysis:

Cardio vascular system

Apical pulse: To find the apical pulse the nurse locate the 5th ICS just to the left to the sternum and move the fingers laterally, just medial to the left mid- clavicular line.

Redial: Rt…………….. Lt…………….

Heart rate:

Rhythm:

Perfusion:

Edema: because of heart failure

Site of edema:

Cyanosis or Pallor: Because of MI

Fatigue: Because of decrease cardiac

output

Gastro- intestinal system

Abdomen

Shape:

Abdomen distention:

Surgical mark:

Stool frequency / Character:

Last movement :

Ostomy present:

Bowel sound

Reproductive system

Urinary complain:

Discharge:

Anuria:

Haematuria:

Dysuria:

Urinary Incontinence:

Urinary Retention:

Urine last voided:

Catheter present:

Any other:

– Opening of penis:

– Penile Discharge:

If „Yes‟ describe

Female

-Vaginal discharge:

-If „Yes‟ describe

Colour:

Rashes:

Lesion:

Surgical scar:

Abnormal growth:

Secretion:

If „Yes‟ then describe:

Musculoskeletal

Weakness / paralysis / contracture / joint

swelling / pain /other:

Extremity strength:

Wrist Extension

Flexion

Elbow Flexion

Extension

Shoulder Abduction

Adduction

Extension

Flexion

Dorsiflexion

Plantarflexion

Curvature of spine observe for:

Lordosis: Increase lumber curvature

Scoliosis: Lateral spinal curvature

Kyphosis: Exaggeration of posterior curvature of thoracic spine

Mental status

Memory:

Knowledge:

Thinking:

Judgment:

Insight:

Neurological Examination

Orientation – To place / person / time

Level of conscious - confused / alert / restless / lethargic / comatose

Co-ordination to walk:

Equilibrium test:

Sensation test: Pain

Temperature

Vibration

Romberg Testwww.drjayeshpatidar.blogspot.in

Pronator Drift Testwww.drjayeshpatidar.blogspot.in

Reflexes

Biceps:

Triceps:

Patellar:

Achilles:

Planter:

Gluteal:

Biceps

Identify biceps tendon have patient flex

elbow against resistance while you palpate

antecubital fossa

Place arm so it‟s bent ~ 90 degrees

Place one of your fingers on tendon and

strike it.

Reflex : Flexion of arm at elbow.

Triceps

Flex client‟s arm at elbow, holding arm

across chest or hold upper arm

horizontally. Strike triceps tendon just

above elbow.

Reflex : Extension at elbow.

Patellar

Have client sit with leg hanging freely over

side of table. Tap patellar tendon just

below patella.

Reflex : Extension of lower leg.

Achilles

Have client assume same position as for

patellar reflex. Slightly dorsiflex client‟s

ankle by grasping toes in palm of your

hand. Strike Achilles tendon just above

heel at ankle malleolus.

Reflex : Planter flexion of foot.

Planter:

Have client lie supine with legs straight

and feet relaxed. Take handle end of

reflex hammer and stroke lateral aspect of

sole from heel to ball of foot, curving

across ball of foot toward big toe.

Reflex : Planter flexion of all toes.

Gluteal:

Have client assume side lying position.

Spread buttocks apart and lightly stimulate

perineal area with cotton applicator.

Reflex : Contraction of anal sphincter

Thank You

physical examination

clients health

marital statushealth

health historyhealth

b health facilities

family history of illness

type of family

family income

family information

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