PHYSICAL EXAMINATION

Afnan .Y. Toonsi

THORAX AND LUNG

Posterior thorax

Inspection: Inspect the Shape and symmetry Inspect the Spinal alignment for deformities

Normally chest is symmetric and spine is vertically aligned

To assess for lateral deviation of the spine (scoliosis):

- Observe the standing client from behind- Have the client bend forward at the waist and

observe - Normally spinal column is straight, right and left

shoulders and hips are at the same height.

Chest deformities:- Pigeon, Funnel, Barrel, Kyphosis, Scoliosis

Palpation: Assess the temperature and integrity of all chest

skin Palpate for bulges, tenderness, or abnormal

movements Palpate for respiratory excursion (expansion)

Normally the thumbs separate 3 to 5 cm during deep inspiration

Palpation: (cont.) Palpate for vocal (tactile) fremitus Place your hand on the posterior chest Ask the patient to repeat numbers as “one,two,three”

Normally there is a bilateral symmetry of vocal fremitus.

Decreased or absent fremitus associated with pneumothorax

Increased fremitus associated with pneumonia

Percussion:Percussion of the thorax is performed to determine

whether underlying lung tissue is filled with air, liquid, or solid material and to determine the positions and boundaries of certain organs.

Ask the client to bend head and fold the arms forward across the chest.

percuss in ICS at about 5 cm interval in systematic sequence

Normally , percussion notes resonance over the lung and flatness over the ribs

Areas of dullness or flatness over the lung associated with consolidation of lung tissue or mass.

Percussion :(cont.) percuss for diaphragmatic excursion (movement

of the diaphragm during maximal inspiration and expiration)

A-Ask the client to take deep breath and hold it while you percuss downward along the scapular line until dullness is produced at the level the diaphragm , mark this point .

B-Ask the client to take a few normal breath and expel last breath completely and hold it while you percuss upward from the marked point .

C-Measure the distance between 2 marks Excursion is 3 to 5 cm bilaterally in women and

5 to 6 cm in men.

Auscultation: Use systematic zigzag as in percussion .

Ask the client to take slow, deep breaths through the mouth and listen to breath sound during complete inspiration and expiration.

Compare findings at each side

Anterior ThoraxInspection: Inspect the breathing pattern (rate & rhythm) Inspect the costal angle Normally , costal angle is less than 90 degree.

Palpation: Palpate the anterior chest for respiratory

excursion. Palpate for tactile fremitus . Normally, same as posterior vocal fremitus,

fremitus decrease over heart and breast tissue.

Done by using two hands that are placed simultaneously on the corresponding area of each side of the chest

Percussion: Percuss the anterior chest begin above the

clavicles in the supraclvicular space and proceed downward to the diaphragm.

Normally, percussion notes resonance down to 6th rib at the level of the diaphragm but flat over bone or muscle, dull over heart and liver, and tympanic over the stomach

Auscultation:Normal breathing sounds:

Abnormal breathing sounds

Type Location characteristics

Vesicular Base of the lung Inspiration lasts longer than expiration

Broncho-vesicular

1st & 2nd ICS Equal inspiratory and expiratory

phases

Bronchial Over the trachea Expiration last longer than inspiration

Name Cause Description

Crackles Fluid & mucus Rolling hair together

Gurgles(rhonchi)

narrowing Sound with a snoring quality

Friction rub Rubbing Grating sound

wheeze Constricted bronchus

Squeaky musical sound

CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

LOCATING THE ANATOMIC SITES OF THE PRECORDUIM

Inspection, palpation & auscultation:

1- Inspect and palpate the aortic, pulmonic, tricuspid, apical area for pulsations, lifts or heaves.

2- Inspect and palpate the epigastric area at base of sternum for abdominal aortic pulsations.

3- Auscultate the heart in 4 anatomic area .( the aortic, pulmonic, tricuspid, apical area ).

Normally:

- no pulsation except in epigastric area, no lift or heave

- S1 louder at the apex of the heart, S2 louder at the base

- S3 in children and young adults

- S4 in many older adults

Carotid arteries: Palpate the carotid artery with cautions.

Palpate only one carotid artery and avoid exerting too much pressure and massaging area

Auscultate the carotid artery for presence of bruit, if present gently palpate the artery to determine the presence of thrill

Jugular veins: Inspect the jugular veins for distention while

the client is placed in semi-fowler's position with head supported on a small pillow.

Normally, veins not visible ( right side of heart is functioning normally ).

Assessing the peripheral vascular system:

Peripheral pulses: Palpate the peripheral pulses on both sides

o Peripheral veins Inspect the peripheral veins in the arms and legs

for presence of superficial veins when limbs are dependent and limbs are elevated .

Normally , in dependent position , presence of distention and nodular bulges.

When limbs elevated , veins collapse .

Assess the peripheral leg veins for signs of phlebitis.

Normally, limbs not tender , symmetric in size

Peripheral perfusion: Inspect the skin of the hand and feet for color,

temperature, edema and skin changes. Assess the adequacy of arterial flow if arterial

insufficiency is suspected by two method : Buerger's test ( arterial adequacy test ): Put the client in supine position, raise one leg or

arm about 30 cm above heart level, move foot or hand briskly up and down about 1 minutes, then sit up and dangle the leg or arm .

Observe the time elapsed until return of original color and vein filling . Original color normally return in 10 seconds and vein filling in about 15 seconds.

Capillary refill test Documentation .

BREAST AND AXILLAE Inspection: Inspect the breast for size, symmetry, contour or

shape while the client is in a sitting position.

Inspect the skin of the breast for localized discoloration or hyperpigmentaion, retraction, localized hypervascular area, swelling or edema.

Emphasize any retraction by having the client :

Raise the arms above the head .

Push the hand together with elbows flexed.

Press the hand down on hip.

Inspect the areolas for size, shape, symmetry, color, surface characteristic and any masses or lesion.

Inspect the nipples for size, shape, color, position, discharge and lesion.

Palpation: Palpate the axillary ,subclavicular and

suparclavicular lymph nodes. Assess axillary lymph nodes while client sits with arms abducted and supported on the nurse forearm.

Palpate the breast for masses ,tenderness and any discharge from nipple.

Put the client in supine position . Instruct the client to abduct the arm and place

her hand behind her head and then place small pillow under client shoulder.

Use the palmar surface of the middle three fingertips .

Choose one of three pattern for palpation :

a. Hand of the clock or spokes on wheel.

b. Concentric circles pattern .

c. Vertical strips pattern .

Palpate the areola and the nipples for masses or discharge by compressing

(amount, color, consistency ,odor ). Teach the client the technique of breast self

examination. Documentation.

ASSESSING THE ABDOMEN

Inspection: Inspect the abdomen for skin integrity.

Inspect the abdomen for contour and symmetry .

a-Observe abdominal contour while standing at the client side when the client is supine.

b-Ask the client to take a deep breath and hold it.

c-Assess the symmetry of contour while standing at the foot of the bed.

d-If distention is present ,measure the abdominal girth at the level of umbilicus.

Observe abdominal movements associated with respiration, peristalsis or aortic pulsations.

observe the vascular pattern.

Auscultaion: Auscultate the abdomen for bowel sound and

vascular sound Listen for active bowel sounds every 5 to 20

seconds Normal bowel sounds are described as audible,

absent, hypoactive or hyperactive

For vascular sounds use the bell over the aorta, renal arteries, iliac arteries, and femoral arteries

Listen for bruits. Normally absence of arterial bruits Loud bruit over aortic area indicate aneurysm

Percussion of the abdomen:

Percuss in the 4 quadrant starting from the right lower quadrant proceeding to the left lower quadrant.

Percussion of the liver: Percuss the liver to determine its size ( 6 to 12

cm) at midclavicular line or( 4 to 8 cm ) at the midsternal line.

Palpation: Perform light palpation first for tenderness or

muscle guarding.

Light palpation:

Hold the palm of your hand parallel to the abdomen .

Depress the abdomen wall about 1 cm in depth

Move the finger pads in slightly circular motion .

Note any tenderness, ask the client to tell you about them and look for patient facial expression .

Deep palpation:

Perform deep palpation over all 4 quadrant.

Press the distal half of the palmer surface of fingers of one hand into abdominal wall .

Depress the abdominal wall about 4 to 5 cm .

Normally, tenderness may be present near xiphoid process, over cecum and over sigmoid colon.

Check for rebound tenderness at the areas of pain which indicates peritoneal inflammation

Palpation of the liver: Palpate the liver to detect enlargement and

tenderness

Stand on the client right side .

Place your left hand on posterior thorax about 11th and 12th rib .

Place your right hand parallel to the rectus muscle with fingers pointing toward the rib cage.

During exhalation palpate with a depth of 4 to 5 cm

Maintain your hand position & ask the client to inhale deeply, while the client inhale, feel the liver border move against your hand.

Palpation of the bladder: Palpate the area above pubic symphysis if the

client has a history of urinary retention

Normally, not palpable .

Documentation.

MUSCULOSKELETAL SYSTEM

Muscles: Inspect the muscles for size .

Inspect the muscles and tendons for contracture.

Inspect the muscles for tremor. Inspect any tremors of hand and arm by having the client hold the arm out in front of the body.

Palpate muscles at rest to determine muscles tonicity .

Palpate muscles for flaccidity ( weakness or laxness ), spasticity ( sudden involuntary muscle contraction ) and smoothness of movement.

Test muscles strength.

Sternocleidomastoid:

Trapezius:

Biceps:

Deltoid :

Triceps:

Wrist & fingers:

Grip strength:

Hip adduction: Hip muscles:

Hamstrings:

Hip abduction: Quadriceps:

Dorsiflexion:

Bones: Inspect the skeleton for normal

structure and deformity.

Palpate the bone to locate any area of edema and tenderness.

Joints: Inspect the joint for swelling,

Palpate each joint for tenderness, smoothness of movement, swelling and presence of nodules.

Assess joint range of motion. The amount of joint movement can be measured by goniometer ,device that measure the angle of joint in degree.

Documentation.

ASSESSING THE NEUROLOGICAL SYSTEM

Language: If the client displays difficulty speaking: Ask the client to name common objects. Ask the clients to respond to simple commands

as raise your arm

Orientation: Determine the client orientation to time , place

and person by questioning .

Memory: Ask the client about difficulty with memory If problem apparent, 3 categories of memory

are tested:

Immediate recall, recent memory and remote memory

To assess immediate recall:

Ask the client to repeat series of three digit e.g. 7-4-3 ,spoken slowly and gradually increases no of digit e.g. 7-4-3-5-6-2 and ask client repeat correctly

The average person can repeat 5-8 digits in sequence

To assess recent memory :

Ask the client to recall the recent events of day such as how to got the clinic.

To assess remote memory :

Ask client to describe previous illness or surgery, birthday or anniversary.

Attention span and calculation:

Test the ability to concentrate and maintain attention. Ask the client to count back from 100 or ask client to subtract 7 or 3 progressively from 100 .

Level of consciousness:

Apply the Glasgow coma scale .

Assessment totaling 15 point indicate the client is alert and completely oriented .

Comatose client score 7 or less.

Cranial nerves:

Name: Type: Function Assessment Method

I Olfactory sensory

Smell Identifying aromas

II Optic sensory

Vision Snellen chart

III Oculomotor motor (EOM ,)movement of sphincter of pupil, movement of ciliary muscles of lens.

Assess six ocular movement

IV Trochlear motor Moves eyeball downward & laterally

Assess six ocular movement

V Trigeminal -Opthalmic

branch -Maxillary

Branch

-Mandibular

branch

Sensory

Sensory

Motor &

sensory

Sensation of cornea, skin of face & nasal mucosa Sensation of skin of face, tongue & teeth

Muscles of mastication

- Blink reflex- Test light sensation

- Ask client to clench teeth

VI Abducens Motor EOM, moves eyeball laterally

Assess directions of gaze

Cranial nerves

Cranial nerve

Name Type Function Assessment method

VII Facial Motor & sensory

Facial expression taste

-Ask client to smile, frown, etc-Identifying tastes

VIII auditory sensory Equilibrium and hearing

-Romberg test-tuning fork

IX Glosso-pharyngeal

Motor and sensory

Swallowing ability tongue movement

-Swallow-move tongue

X vagus Motor and sensory

Sensation of pharynx and larynx, swallowing vocal cord movement

Assess speech for hoarseness

XI Accessory motor Head movement shrugging of shoulder

Shrug shoulder against resistance

XII hypoglossal

motor Tongue movement

Protrude tongue

Cranial nerves (cont.)

Reflexes Biceps

Triceps

Brachioradialis

Patellar

Achilles

Plantar

Motor function: Balance Tests:

1. Walking Gait:

2. Romberg Test:

Ask the client to stand with feet together and arm resting at the side first with eye close and open .

3. Standing on one foot with eyes closed

4. Heel-Toe Walking:

Ask the client to walk a straight line, placing the heel of one foot directly in front of toe of the other foot

5. Toe or Heel Walking:

6. Finger to Nose test:

7. Alternating supination and pronation of hands on knees:

8. Finger to nose and to the nurse’s finger

9. Fingers to fingers:

10. Fingers to thumb:

Fine motor tests for lower extremities:

1. Heel down opposite shin

2. Toe to the nurse’s finger

Sensory function:

Light – touch sensation (by cotton)

Pain sensation (tongue depressor)

Temperature sensation

Kinesthetic sensation

Tactile discrimination

One and two point discrimination

Sterognosis ( ability to recognize object by touching them).

Documentation.

ASSESSING THE FEMALE GENITALS & INGUINAL AREA

Inspect the distribution, amount and characteristics of pubic hair .

Inspect the skin of the pubic area for parasites , inflammation, swelling and lesion .

Inspect the clitoris, urethral orifice and vaginal orifice when separating the labia minor.

Palpate the inguinal lymph nodes in a rotary motion, noting any enlargement or tenderness.

Document findings.

ASSESSING RECTUM & ANUS

Inspect the anus and surrounding tissue for color, integrity and skin lesion ask the client to bear down . Bearing down create slight pressure on the skin and allow you to see rectal fissure, rectal prolapse, polyps & internal hemorrhoids.

Palpate the rectum for anal sphincter tonicity , nodules, masses and tenderness.

Lubricate your gloved finger and ask the client to bear down

Insert your finger and palpate for a distance of 6 to 10 cm

Documentation .