Faculty of Nursing-IUG

Chapter (4)Physical Assessment Techniques

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Indications for the Physical Exam

Routine screeningRoutine screening

Eligibility prerequisite for health insurance, military Eligibility prerequisite for health insurance, military

service, job, sports, schoolservice, job, sports, school

Admission to a hospital or long term care facilityAdmission to a hospital or long term care facility

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STEPS OF ASSESSMENTThinkThink

OrganizeOrganize

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

Environment:Environment:

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

Equipment - clean surface & clean equipment Room - quiet, Equipment - clean surface & clean equipment Room - quiet,

warm & well litwarm & well lit

Maintain privacyMaintain privacy

Observe & ListenObserve & Listen

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DON’T FORGET

REVIEWING GENERAL INFORMATIONREVIEWING GENERAL INFORMATION

INTRODUCTION TO CLIENTINTRODUCTION TO CLIENT

OBTAINING THE HEALTH HISTORYOBTAINING THE HEALTH HISTORY

PAIN ASSESSMENTPAIN ASSESSMENT

THIS IS KEY TO THIS IS KEY TO HOLISTICHOLISTIC APPROACH APPROACH

Physical Assessment

There are four techniques to use in performing

physical assessment: 1.Inspection

2. Palpation

3. Percussion

4. Auscultation

Note: there are five addition skill known as

olfaction

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1. Inspection: Inspection is defined as “the use of the senses of

vision, smell and hearing to observe the normal condition or any deviations from normal of various body parts.”

The nurse inspects or looks body parts to detect

normal characteristics or significant physical sings.

Inspection helps to know normal characteristics

before trying to distinguish abnormal findings in

different ages.

The quality of an inspection depends on the nurse's

willingness to spend time doing a thorough job.7

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Inspection

Use vision, hearing & smellUse vision, hearing & smell

Always firstAlways first

Look for symmetryLook for symmetry

Use good lightingUse good lighting

Use good exposureUse good exposure

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Principles of Accurate Inspection

Good lightening either day light or artificial light is suitable.Good lightening either day light or 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 client “not cold not hot". warm room for examination of the client “not cold not hot".

Observe for color, size, location, texture, symmetry, odors, and Observe for color, size, location, texture, symmetry, odors, and

sounds.sounds.

Compare each area inspected with the opposite side of body if Compare each area inspected with the opposite side of body if

possible.possible.

Use pen light to inspect body cavitiesUse pen light to inspect body cavities..

PalpationTouch & feel with hands to determine:Touch & feel with hands to determine:

Texture – use fingertipsTexture – use fingertips (roughness, smoothness). Temperature – use back of handTemperature – use back of hand (warm, hot, cold). MoistureMoisture (dry, wet, or moist). Organ location and sizeOrgan location and size Consistency of structureConsistency of structure (solid, fluid, filled)

Slow and systematicSlow and systematic

Light to deepLight to deepLight palpation (tenderness)Light palpation (tenderness)Deep palpation (abdominal organs/masses)Deep palpation (abdominal organs/masses)

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Principles for Accurate Palpation Examiner finger nails should be short.Examiner finger nails should be short.

Use sensitive part of the hand.Use sensitive part of the 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

Tell client to take slow deep breath to enhance muscle relaxation.Tell client to take slow deep breath to enhance muscle relaxation.

Examine condition of the abdominal organsExamine condition of the abdominal organs Depressed areas must be approximately “2cm” Depressed areas must be approximately “2cm”

Assess turger of skin measured by lightly grasping the body part Assess turger of skin measured by lightly grasping the body part

with finger tips.with finger tips.

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Light palpation

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Deep palpation

PercussionTap a portion of the body to elicit tenderness that varies

with the density of underlying structures.

Percussion denotes location, size and density of

underlying structures, percussion requires dexterity. Methods of percussion: Methods of percussion:

Direct method:Direct method: involving striking the body surface directly with one or two fingers.

Indirect method:Indirect method: performed by placing the middle finger of the examiner’s non dominant hand “pleximeter hand” firmly against the body surface with palm and fingers remaining off the skin, and the tip of the middle finger of the dominant hand “plexor” strikes the base of the distal joint of the pleximeter. Use a quick & sharp stroke

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Percussion

Description of sounds Sound produced by the body is characterized by

intensity, frequency, duration and quality. Intensity, or loudness, associated with physiologic

sound is low; thus, the use of the stethoscope is needed.

Frequency, or pitch, of physiologic sound is in reality “noise” in that most sounds consist of a frequency spectrum as opposed to the single-frequency sounds that we associate with music or the tuning fork.

Duration relates to the time elapsed from the beginning of the sound till the end of the sound.

Quality of sound relates to overtones that allow one to distinguish between different sounds.

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Sound Intensity Pitch Duration Quality Example

Tympany Loud High Moderate Drum like Large

pneumothorax

Resonance Moderate

to loud

Low Long hollow Normal lung

Hyper-

resonance

Very loud Very

low

Longer

than

resonance

Booming Emphysematous

lung

Dullness Soft to

moderate

High Moderate Thud like Liver

Flatness Soft High Short Flat Muscle

Sounds produced by percussion

Five percussion sounds produced in different body regions

1. Resonant – normal lung1. Resonant – normal lung

2. Hyper resonant: it’s a louder and lower pitched than resonant sounds. Normally 2. Hyper resonant: it’s a louder and lower pitched than resonant sounds. Normally

heard in children and very thin adults , and abnormally in emphysema heard in children and very thin adults , and abnormally in emphysema

3. Tympany : A hollow drum-like sound produced when a gas-containing cavity 3. Tympany : A hollow drum-like sound produced when a gas-containing cavity

is tapped sharply. Tympany is heard if the chest contains free air is tapped sharply. Tympany is heard if the chest contains free air

(pneumothorax) (pneumothorax) or the abdomen is distended with gas air filled (stomach)air filled (stomach)

4. Dull or thud like sounds are normally heard over dense areas such as the heart 4. Dull or thud like sounds are normally heard over dense areas such as the heart

or liver. Dullness replaces resonance when fluid replaces air-containing lung or liver. Dullness replaces resonance when fluid replaces air-containing lung

tissues, such as occurs with pneumonia, pleural effusions, or tumorstissues, such as occurs with pneumonia, pleural effusions, or tumors

5. Flat: shown in no air areas such as thigh muscle, bone and tumor5. Flat: shown in no air areas such as thigh muscle, bone and tumor

Auscultation“To listen for various breath, heart, and bowel

sounds”

Direct or immediate Direct or immediate auscultation is accomplished by the unassisted ear that is without amplifying device. This form of auscultation often involves the application of the ear directly to a body surface where the sound is most prominent.

Mediate auscultation: Mediate auscultation: the use of sound the use of sound augmentation device such as a stethoscope augmentation device such as a stethoscope in the detection of body sounds. in the detection of body sounds.

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AuscultationListening to body soundsListening to body sounds

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

Blood flow (heart)Blood flow (heart)

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

Remember the sound changes in Remember the sound changes in

the abdomen…the abdomen…

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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 (NOT Hold diaphragm firmly against client’s skin (NOT

THROUGH CLOTHING)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

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Olfaction

Another skill that used during assessment, certain alteration is body

function create characteristic body odors, smelling can detect

abnormalities that unrecognized by other means.

Assessment of characteristic odors: Alcohol odor from oral cavity means ingestion of

alcohol. Ammonia from urine means urinary tract

infection. Body odor from skin, particularly in areas where

body parts rub together means poor hygiene, excess perspiration (bromidrosis).

Feces odor from wound site means wound abscess, but if this odor from vomitus this means bowel obstruction, and if the odor from rectal area this means fecal incontinence.

Foul–smelling stools in infant from stool means mal absorption syndrome.

Halitosis from oral cavity means poor dental and oral hygiene, gum disease.

Sweet, fruity ketones from oral cavity may be from diabetic acidosis.

Musty odor from casted body part means infection

inside cast. Fetid odor from tracheostomy or mucous secretions

means infection of bronchial tree (pseudomonas bacteria).

Basic Guidelines for physical Assessment

1. Obtain a nursing history and survey2. Maintain privacy.3. Explain the procedure4. Always inspect, palpate, percuss, and then

auscultate except abdominal start with auscultate

5. Compare symmetrical sides6. If abnormality (Symptom analysis )7. Client teaching 8. Allow time for client’s questions.

"RememberRemember: the most important guideline for

adequate physical assessment is conscious,

continuous practice of physical assessment skills".

Variation in physical assessment of the pediatric client.

Sequence of physical assessment is dependent

upon the developmental level of the client.

Allowing time for interaction with the child

prior to beginning the examination helps to

reduce fears.

In certain age groups, portions of assessment

will require physical restraint of the client with

the help of another adult.

Distraction and play should be intermingled throughout the examination to assist in maintaining rapport with the pediatric client.

Involving assistance from the child’s significant caregiver may facilitate a more meaningful examination of the younger client.

The examiner should be prepared to alter the order of the assessment and approach to the child based on the child’s response.

Protest or an uncooperative attitude toward the examiner is a normal finding in children from birth to early adolescence, throughout parts or even all the assessment process.

Variations for physical assessment of the geriatric client. Remember: normal variation related to aging may be

observed in all parts of the physical examination.

Dividing the physical assessment into parts in order to

avoid fatigue in the older client.

Provide room with comfortable temperature and no

drafts.Allow sufficient time for client to respond to directions.

If possible assess the elderly clients in a setting where

they have an opportunity to perform normal activities of

daily living in order to determine the client’s optimum

potential.