Fundamentals of Nursing

Unit XV

General Physical Examination

(Student‟s Hand Out)

Introduction to the general physical examination

General survey
The Integument
Breast and Axillae

B G I S Ariyarathne
Tutor Trainee
Teaching and Supervision Batch 2017
Post Basic College Of nursing
Colombo
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 General Physical Examination

Session outcomes
 Recognize the idea of general physical examination
 Combine knowledge, skills, attitudes while performing a general physical
examination
 Utilize the learned knowledge of assessing general appearance and mental status
of the patient/ client into practical setting
 Distinguish normal and deviated findings of integument/ breast /axillae
assessment in physical examination
Health Assessment
Assessing a client‟s health status is a major component of nursing care.
It has two aspects
1. History taking
2. Physical examination
This lesson is focused on introduction to general physical examination; purposes of
physical examination, methods used for physical examination, role of the nurse in
physical examination, general survey, the Integument, breast and axillae.

Introduction to the physical examination

Definition

Physical examination is a systematic approach of collecting objective data about

clients‟ health status. It becomes one of the many important components of
understanding a patient‟s needs and problems.

It requires the nurse to apply special techniques, use equipment and knowledge base,
to physically expose each region of clients‟ body and examine it by looking, listening,
touching, or smelling.

Physical examination can be any of three types

1. Complete assessment – Head to toe assessment (e.g. on admission)
2. Examination of the body system (e. g. Cardiovascular system)
3. Examination of body area (e. g. the lungs when difficulty in breathing is
observed

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Procedure can vary with
1. Age of the individual
2. Severity of illness
3. Location of the examination

 Frequently nurses assess a specific body area instead of the entire body relation
to the client complaints. e.g.:
Situation Physical Examination
Complain of abdominal Inspect, auscultate, and palpate the abdomen and
pain assess vital sign

Purposes of the physical examination

 To make clinical diagnoses and treatments

 To make nursing diagnosis and plan of care
 To supplement, confirm, or refute data obtained in the nursing
history
 To understand any changes in the condition of diseases
 To obtain data about client‟s functional ability
 To identify areas for health promotion and disease prevention

General considerations
 Consider about client‟s age, ethnicity, cultural background, educational level,
social background, level of the illness
 wash hand in the presence of the patient before beginning the physical
examination
 A new patient warrants a complete examination, regardless of chief complaint
 The sequence of comprehensive examination should maximize the patient‟s
comfort
Methods used in General physical Examination
Four primary methods are used in the physical examination.

Inspection Palpation Percussion Auscultation

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Inspection
Visual observation of the body is called „inspection‟. It is the observation with the
naked eyes to determine the structure and function of the body
 It begins during the first contact with client and continues throughout the
assessment
 It provides information about body parts‟: color, size, location, movement,
texture, symmetry, rash ,scar

Principles of accurate inspection

 Good lightening either day light or artificial light is suitable
 Expose body parts being observed only
 Look before touching
 Warm room for examination of the client “ not cold not hot”
 Observe for color, size, location, texture, symmetry,
 Use auditory sense along with vision to detect abnormalities e.g. bad breath
indicates poor hygiene
 Compare each area inspected with the opposite side of body if possible
 Use pen light to inspect body cavities e.g. oral
Palpation
 Palpation is the use of hands and fingers to feel different body parts for data
collection.
 The nurse uses pads of the fingers and palms to touch and feel the patient‟s
body parts with his hands to examine: size, texture, location tenderness, body
temperature, lumps or masses
 Degree of the pressure applied depending on age, tenderness of the are and the
depth of the palpation need

Types of palpation
1. Light palpation
 Using the flat part of the right hand or the pads of the fingers, not the fingertips
 The fingers should be together
 Depress the skin 1 to 2 cm with finger pads, usually the lightest touch possible.

2. Deep palpation
 Used to determine organ size as well as the presence of abdominal masses The
flat portion of the right hand is placed on the abdomen
 Depress the skin 4 to 5 cm with firm, deep pressure.
 Pressure should be applied to the abdomen gently but steadily
 The patient should be instructed to breathe quietly through the mouth and to
keep arms at the sides

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Principles for accurate palpation
 Examiner finger nails should be short
 Use sensitive part of the hand
 Start with light then deep palpation
 Tender area are palpated last
 Tell client to take slow deep breath to enhance muscle relaxation
 Examine condition of the abdominal organs
 Assess turgor of skin measured by lightly grasping the body part with finger tips
Activity1: Identify and name the two types of palpation

a)……………………………… b) ……………………………
Percussion
 A methods of “ tapping” of body parts during physical examination with fingers
to evaluate the size, consistency, borders and presence of fluid in body organs
 Percussion of a body part produces a sound that indicates the type of tissue
within the organ
 It is particularly important in examining the chest and abdomen

Methods of percussion
Direct method
 Using one or two fingers, tap directly on the body part.
 Ask the patient to tell which areas are painful and watch his/her face for signs of
discomfort.
 Direct percussion is commonly used to assess an adult patient's sinuses for
tenderness.

Indirect method
 Press the distal part of the middle finger of
non-dominant hand firmly on the body part
(left hand).
 Keep the rest of hand off the body surface.
 Flex the wrist of dominant hand.
 Using the middle finger of dominant hand, tap quickly and directly over the
point where other middle finger touches the patient's skin. The motion of the
striking finger should come from the wrist and not from the elbow
 Deliver 2 - 3 quick taps and listen carefully.
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Another method: tap middle finger with the rubber head of a reflex hammer

Activity 2: Identify and label diagram

a)……………………………………………………… b)………………………………………………………
……… …

Sounds produced by percussion

Five percussion sounds produced in different body regions

Sound Example
Flatness Bone or muscle
Dullness Heart, liver, spleen
Resonance Normal lung sound( air filled –hollow)
Hyperresonance Emphysematous
Tympany Air filled stomach (drumlike)
Auscultation
 A method used to “listen” to the body sounds.
 Various body systems like heart, lungs, and abdominal organs have
characterized sounds
 Bowel, breath, heart, and blood movement sound are heard using a stethoscope
 It is important to know the normal sound to distinguish from abnormal sound

Types of auscultation
Direct auscultation:
 Uses the ear alone to listen, such as when listening to the grating of a moving
joint.
 Sounds are audible without stethoscope
Indirect auscultation:
Sounds are audible with stethoscope. E. g. heart sounds, bowel sounds

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Bell side Diaphragm
How to begin……
Positions for physical exam
Using a stethoscope:
 Longer the tube – more sound has to travel (Ideal 30 -35cm)
 Hold diaphragm firmly against client‟s skin (Not through clothing)
 If using bell – less pressure
 Bell for low pitched sound (blood movements) and diaphragm for high pitched
sound (lungs)
Warm in your hands first!
Listen / Concentrate on the sounds

Auscultated sounds are described according to their, pitch, intensity, duration and
quality
Pitch- Frequency of vibration e.g. Low heart sound- bronchial sound
Intensity- Loudness or softness of the sound e.g. Normal breath sounds soft, bronchial
sounds heard from trachea
Duration-Its length
Quality-Subjective description of a sound e.g. whistling

Role of the nurse in physical examination

A).Preparing the environment

 Need separate area with screens, keep the door close, relatives are not allowed
 Adequate lighting
 Comfortable bed or Examination bed
 The room should be warm enough to be comfortable

B). Preparing the client

Mental preparation Physical preparation

-Reduce anxiety and fear,
Nurse should explain the procedure
*When and where it will take place
*Why it is important
*What will happen during the examination
-Reassure during the examination by
explanation at each step
-Nurse should remain with the female patient
during the examination
-Keep the patient clean
-Shave the part if necessary
-Empty the bladder prior to examination
-Loosen the garments and change into hospital
dress
-Keep the patient in a comfortable position.
Consider about age, energy level and physical
condition. Several body area can be assessed in
one position thus minimize the number of position
changes
Drape the patient with extra sheets and expose
only the need areas it provides warmth.
They are made of paper, cloth or bed linen

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Clients Position and Body Area Assessed

Activity 2: Identify the correct position and fill in the blanks

Position Description Area assessed caution

Back lying position with Head, neck, Patient with
knees fixed and hips axillae, lungs, cardiopulmon
externally rotated breast, heart, ary problems
Small pillow under the extremities,
head, soles of feet on the vital signs,
surface vagina
…………………
Back lying position with Head, neck, Patient with
legs extended, with or axillae, Cardiovascula
without pillow anterior r and
thorax, lungs, respiratory
breast, heart, problems
………………… extremities,
vital signs,
A seated position, back Head, neck, Elderly and
unsupported and legs axillae, lungs, weak clients
hanging freely breast, heart,
extremities,
vital signs,
………………… reflexes, lower
extremities
Back lying position with Female Elderly, often
feet supported in strips, reproductive embarrassing
the hips should be in line tract
with the table
…………………
Side lying position with Rectum, Elderly,
lowermost arm behind vagina people with
the body. Uppermost leg limited joint
flex at hip and knee, movement
upper arm flexed at
………………… shoulder and elbow
Lies on the abdomen Posterior Patient with
with head turned to the thorax, hip Cardiovascula
side with or without joint r and
pillow respiratory
problems,
………………… elderly

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C). Preparation of the instruments

The entire instrument required should be clean, good in working order, and readily
accessible. Equipment is frequently set up on a tray, ready for use.
Activity 2: Identify articles need for specific examination and fill in the blanks
Specific Articles
examination
Eye …………………,Snellen
chart, wisp of cotton

Ear Head mirror, table lamp,

torch, Tuning fork
……………………..

Nose …………………., head

mirror, ENT forcep

Throat …………………….,
laryngeal mirror, torch,
gauze,

Chest and …………………………,

abdomen
Measuring tape
Vagina ……………………….,
Gloves, bow lubricant l
with sterile swabs,
antiseptic lotion,
Rectal ………………………..,
lubricant, gloves

Neurological …………………………,
wisp of cotton, hot or
cold water

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 D). Documentation
Documentation is very essential. Nurses can Document findings in the clients record
using forms or checklist or write nurse‟s notes in the BHT. It must be documented
clearly and narratively.
E. g.:

Nurses notes: 6 years old boy, BP 90/60mmHg, Tem. 99.4 0F, Wt. 20 Kg
Patients‟ mother states that patient has had a severe sore throat and headache for the
past 3 days. No cough, no fever, no ear pain. Brother sick too. No other complains
O/E
ENT: Ears: normal, no discharges
Pharynges: red
Neck: no nodes
Lungs: clear
Axillae: No nodes

Components of the general physical examination

The physical examination is subdivided into the following regional/anatomic

components: general survey; vital signs; head, eyes, ear, nose, throat (HEENT); neck;
chest; cardiovascular; back; abdomen; extremities; neurologic; musculoskeletal; skin;
breast; genitourinary; rectal; lymph nodes.
Each component exam consists of maneuvers employing the techniques of inspection,
percussion, palpation, and auscultation.

General survey
Physical examination begins with general survey. Observe client‟s general appearance
and mental status and measure vital signs, height and weight.

Appearance and mental status

Assess,
-Body build, posture, and gait
-Hygiene, grooming,
-Speech/ behavior appropriate to development level
-Facial characteristics
Must be assess in relation to culture, educational level, socioeconomic status and
current circumstance
E.g.: person who has met with personal loss may appear with depress mood

Vital signs
Use to compare future measurements and detect actual or potential health problems
.Measure Body temperature, pulse, respiration, BP, Oxygen saturation, pain

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Height and weight
In adult ratio of weight to height general measure of health and nutrition. A very
common method for identify risk of non- communicable diseases such as diabetes,
cardiovascular diseases is measuring body mass index.
BMI= Body weight (Kg)

Height (m2)

Normal Overweight Obese Severely obese Morbidly obese

BMI 18.5- BMI 25-29.9 BMI 30-34.9 BMI 35-39.9 BMI>40
24.9

*Under weight BMI<18.5 kg/m2

Taking Weight Measurement

 Have client remove shoes and as much other clothing as practical and possible
 Ask client to remove anything in pockets
 Ask client if he or she knows about how much they weigh
 Assists you in setting the weight on the scale in a general area; also avoids
embarrassment if you misjudge a person at a too-heavy weight
 It is relaible, if possible to use same weight scale to measure same person‟s
weight next time.

Taking Height Measurement

 Pull the arm of the scale above the height estimate the person to be
 Have the client remove their shoes, step onto the scale
 with back to the scale,stand up straight with heels together and head level.
 Have the client take a deep breath in, hold the breath and look straight ahead.

The Integument
 Integument includes the skin, hair, and nails
 Examination begins with an inspection using good lightning, preferably indirect
natural day light
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  Consider nurses‟ responsibility during physical examination

Examination of Integument –Head to toe

Scalp-Dandruff, Hair- Dryness, Eyebrows-loos Eye-Jaundice,

Lesions, brittleness, hair, pallor, redness,
Excoriations oiliness, asymmetrical, periorbital
thickness, color,
lesions, scar, edema
Lumps, Bruises nits
Eye lash-Nits
Lice

Upper extremities- Nose- skin tag, polyp

Scars, rashes, sores, Lips- Edema, dry, lesion,

lesions, bruises, and cyanosis, pallor, angular
edema stomatitis

Nails- clubbing, cyanosis,

infections, Face- Acne, lesions, edema

Brittle nail, beau‟s Ear- lesions, tags, nodules

Thorax, Abdomen and

Back:

Discoloration, Scars, rashes,

Pubic area-lesions,
sores, lesions, bruises, and
skin tags, warts, lice
edema

Lower extremities

Color, Scars, rashes, sores,

lesions, bruises, and
discoloration, varicose veins

Foot –fissure, edema

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Skin
Assessment involves inspection, olfactory senses and palpation. The entire skin
surface may be assessed at one time or as each aspect of the body is assessed.

Assessment Normal Deviation

Inspect skin color Vary Pallor, cyanosis, Jaundice,
light to deep brown erythema, vitiligo( hypo-
pigmentation)
Assess edema: : location, No edema Edema
color, temperature, shape, Edema Scale
degree to pitted when pressed 2mm 4mm 6mm 8mm

by a finger
(edema scale)
0= none, 1+= trace,
+2=moderate
+3= deep, +4= very deep
Observe and palpate skin Moisture in skin Excessive moisture-
moisture fold and axillae hyperthermia
Excessive dryness-
dehydration

Palpate skin temperature. Uniform within Generalize hyperthermia-

Compare two hands and two normal range Fever
feet by using back of the Generalize hypothermia-
fingers Shock
Localize hyperthermia-
infection
Generalize hypothermia-
narrowing peripheral
vessels
Note skin turgor ( elasticity) Skin stays pinch or move
by lifting and pinching the Skin springs back back slowly
skin on an extremity previous state
Skin odor No special odor Foul –smelling
perspiration‟ excessive
perspiration

-Document findings

Lesions – altered normal skin appearance

Inspect, palpate and describe skin lesions according to location, color, configuration,
size, shape, type or structure

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Two kinds
1. Primary lesions: Those initially appear as react to some changes of internal or
external environment of the skin
E.g. vesicle, nodule, macule, papule, pustule

2. Secondary lesions: modification of primary lesion

E. g. Vesicle ruptures cause erosion
Ulcer, scar, fissure, atrophy, keloid

Hair
Hair assessment is carried out by inspecting and palpating
-Consider about development changes, ethnicity differences, and individual‟s hair care
practice
-Much information can be obtained by questioning the client

Assessment Normal Deviation

Inspects the evenness of Evenly distributed hair Patches of the hair loss-
the growth over the scalp Alopecia
Inspect hair thickness or Thick hair Very thin hair-
thinness hypothyroidism
Inspect hair texture and Silky ,resilient hair Brittle hair-, dry hair or
oiliness excessively oily -
hypothyroidism
Note presence of No infection lies, nits and ringworm
infection
Inspect amount of body Variable Abnormal hairiness in
hair women- Hirsutism

-Hair color -faded, reddish or bleached- in protein deficiency

-Document findings

Nail
Nail plate
Lunula
Cutical
Nail root

Nails are inspected for

 nail plate shape
 angle between the nail and nail bed
 nail texture
 nail bed color

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  intactness of the tissue around the nails

Assessment Normal Deviation

Inspect fingernail plate Convex curvature angle Spoon nail,
shape to determine its of nail plate about 1600 clubbing>1800
curvature and angle
Inspect finger nail and Smooth Excessive thickness or
toenail texture thinness, presence of
groove- Beau’s
Inspect fingernail and Highly vascular and pink Bluish or purplish-reflect
toenail bed color in light skin, dark- cyanosis-
skinned may have brown vasoconstriction/abnormal
or black hemoglobin
Pallor reflect poor arterial
circulation
Inspect the tissue Intact Inflammation
surrounding nail
Perform blanch test of Promote return of pink or Delay return normal color
capillary refill. Press two usual color<2 sec Indicate circulatory
or more nails between impairment
thumb and index finger, E g. dengue fever,
look for blanching and massive bleeding
return of pink color to
nail bed

The breast and Axillae

The Breast

The breasts of men and women need to be inspect and palpate

Men- Glandular tissue, beneath the nipple
Women- Glandular tissue, large portion located upper outer quadrant of the breast
Glandular tissue > women than men

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*Tail of the Spence and upper outer quadrant are potential site for malignancy

Activity4: Identify rest of the quadrants of the breast and fill in the blanks

Tail of the spence

Upper inner quadrant

Lower outer quadrant

Quadrants of the breast

Assessment of the Breast and Axillae

Inspection:
The breasts are visualized to assess the size, shape, symmetry, color and the presence
of any dimpling, lesions, swelling, edema, visible lumps and nipple retractions. The
nipples are also assessed for the presence of any discharge, which is not normal for
either gender except when the female is pregnant or lactating.

Palpation:
The nurse performs a complete breast examination using the finger tips to determine if
any lumps are felt. The lymph nodes in the axillary areas are also palpated for any
enlargement or swelling.

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Breast palpation methods
Vertical strips
pattern

Spokes on a Circle pattern

wheel pattern

Central

Pectoral Lateral

Subscapular

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 Assignment

1. Explain the special considerations of examine the older adult

2. Describe safety precautions to be used during a general physical examination
3. Explicit special considerations of conducting physical examination below
mentioned categories
a) Pregnant mother
b) Child
c) Patients with Physical disabilities
d) Patients from different cultures
4. Interpret a leaflet about breast self- examination
N.B. Assignment to be submitted before 12thJuly 2019

References
Ariyaseeli, W. M. (2014). Fundermentals of Nursing (1st ed). Nugegoda, Sri
Lanka: Author Publisher.
Assisting with a General Physical Examination (22nd. May. 2019).
https://slideplayer.com/slide/5998434/
Burmen, A., Bruke, K., Erb,G., & Kozier, B. (2007). Fundamental of Nursing –
Concepts, Process, and Practice (7th ed). New Delhi, India: Dorling
Kindersley Pvt.Ltd.
Clement, I. ( 2013). Basic concepts of nursing procedures( 2nded). Karnataka,
India: Jaypee brothers medical publishers (P) LTD
Lillis, C., Mone, P. L., &Taylor, C. (1997). Fundamentals of nursing- the Art 7
Science of Nursing Care (3rded). Washington Square, Philadelphia:
Lippincott- Raven Publishers.
Nancy, Sr., (2017). Stephanie’s Principles and Practice of Nursing (7thed).
Indore: N.R. Publishing House

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