Physical Assessment

by:Jennie Romero RN
 Assessment
Is the systematic and continuous:
• collection
• organization
• validation
• documentation of data.
 PURPOSE

1. To confirm patient's history

2. To observe any findings not reported in the history
3. To provide basis for effective nursing care.
4. It helps in effective decision making
5. Basis for accurate diagnosis
6. To provide effective and innovative nursing care
7. To evaluation of nursing care
 Types of Assessment

Assessment

Initial Focus Time-lapsed Emergency

Assessment Assessment Assessment Assessment
 Initial assessment - also called an admission
assessment, is performed when the client enters a health
care from a health care agency.
 Problem focus assessment - This type of assessment has
a narrower scope and a shorter time frame than the initial
assessment. In focus assessments, nurse determine
whether the problems still exists and whether the status of
the problem has changed (i.e. improved, worsened, or
resolved).
 Emergency assessment- takes place in life-threatening situations
in which the preservation of life is the top priority. Time is of the
essence rapid identification of and intervention for the client’s
health problems.
 Time lapsed reassessment- another type of assessment, takes place
after the initial assessment to evaluate any changes in the clients
functional health. Nurses perform time-lapsed reassessment when
substantial periods of time have elapsed between assessments
 TOOLS/METHODS OF PHYSICAL
ASSESSMENT

TO INSPECT
(Inspection)

TO LISTEN
(Auscultation)

TO FEEL
(Percussion/Palpation)
 INSPECTION

• “the use of the senses of vision, smell and hearing to

observe the normal condition or any deviations from
normal of various body parts.”
• 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.
 PALPATION

• Touch & feel with hands to determine:

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

• Slow and systematic

• Light to deep
• Light palpation (tenderness)
• Deep palpation (abdominal organs/masses)
 PERCUSSION

Tap 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:
Direct method: involving striking the body surface directly
with one or two fingers.
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
 Sound Intensit Pitch Length Quality Example of
y origin

Resonance Loud Low Long Hollow Normal

(heard over part
air and part solid
lung

Hyper-resonance Very Low Long Booming Lung with

(heard over loud
mostly air
emphysem
a
Tympany (heard Loud High Moderat Drum like Puffed-out
over air) e cheek,
gastric
bubble
Dullness (heard Mediu Medium Moderat Thud like Diaphragm
over more solid m e
tissue
, pleural
effusion
Flatness (heard Soft High short Flat Muscle,
over very dense
tissue
Bone,
Thigh
 AUSCULTATION

“To listen for various breath, heart, and bowel sounds”

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: the use of sound augmentation

device such as a stethoscope in the detection of body
sounds.
Physical assessment
 Basic Guidelines for physical
Assessment
1. Obtain a nursing history and survey
2. Maintain privacy.
3. Explain the procedure
4. Always inspect, palpate, percuss, and then auscultate except
abdominal start with auscultate
5. Compare symmetrical sides
6. If abnormality (Symptom analysis )
7. Client teaching
8. Allow time for client’s questions.
"Remember: the most important guideline for adequate physical
assessment is conscious, continuous practice of physical assessment
skills".
 Assessment Sequencing

• General survey

• Level of consciousness and mental status.

• Mood or affect.
• Personal hygiene.
• Skin color.
• Posture and position.
• Mobility.
• Ability to hear and speak.
 Survey

• Height & Weight

• Vital signs: Temperature, Pulse, Respiration &
Blood Pressure
• Recognize transcultural considerations
• Note S/S (signs/symptoms) of distress/pain
 Cerebellar Function Assessment
• Posture and gait – steady gait with arm swing, balance maintained.
• Romberg test – Have pt. stand, feet together, arms side, eyes closed.
• Heel to toe gait – tandem walk
• Rapid Alternating Movements (RAM)
Hand movements- Tap finger to thumb, rapidly. Tap each finger to
thumb rapidly.
Pronate and supinate hands rapidly on knees
• Finger to nose test – Eyes closed touch finger to nose alternating
and increasing speed
• Finger to finger test - Have pt. touch his fingertip to your fingertip,
alter position.
• Heel to shin test – While supine or sitting, have pt run heel of one foot
over the shin of opposite leg
 Skin, Hair, Nails

Inspect for:
Lesions
•Macule
•Patch
•Wheal Nodule
•Vesicle
•Pustule
•Cyst
•Scale
•Crust
•Excoriation
•Scar
•Keloid
•Fissure/Ulcer
Skin Color
• Pallor
• Cyanosis
• Erythema
• Purpura
• Ecchymosis
• Petechia
• Jaundice

Areas of pain/itching
 Palpate for
• Moisture
• Temperature
• Texture
• Turgor
• Capillary refilling
• Elevation or depression

Describe:
• Shape
• Distribution
• Associated smptoms
 Head, Face and Neck

I. Head and Face

• Inspect and Palpate skull for contour; Tenderness, swelling
• Hair for color and distribution.
• Inspect for facial features and symmetry.
• Inspect bony structures of face for size, symmetry, and intactness.
Symmetry and Condition of Facial Features
• Inspect bony structures of face for size, symmetry, and
intactness(Eyebrows, Eyelid)
• Evaluate sensitivity of forehead, cheeks, and chin to light touch.
• Complete an assessment of cranial nerves.
• Inspect skin for color and lesions.
Facial Asymmetry
II. Inspection of the Neck
Assess Trachea for:
• Position
• Appearance with swallowing
• note areas of swelling or masses
Assess Thyroid
• size,symmetry, tenderness and
nodules
Palpate for Enlargement and
Tenderness of Lymph Nodes
• Anterior Cervical
• Posterior Cervical
• Auricular
• Supraclavicular

normally nodes are

not palpable
 Eyes
Inspection of Periorbital
Area:
• Discoloration
• Orbital Hematoma
(black eye)
• Gross deformity
• Immediate referral
• Lacerations
• Inspection: Conjunctiva
• Appearance should be
transparent (covers sclera)
• Subconjunctival Hematoma –
leakage of the superficial blood
vessels beneath the sclera
• Examination
• Inferior portion – gently pull
down on the eyelid, patient
looks up
• Upper portion – gently lift
upper eyelid, patient looks
down
• Inspection: Pupils
• Normally equal in size and
shape
• Anisocoria – unequal pupil
sizes
• Benign congenital condition
• Secondary to Brain Trauma
• Teardrop pupil
• Serious underlying
pathology (corneal
laceration, ruptured globe)
• Assess pupil:
Direct and consensual
reaction, corneal light
reflex,
accommodation.
• Inspect symmetry of
eye movement.
 Ear
• Ears:
• Inspect external ear and auditory canal.
• Alignment, position, size, shape, symmetry, skin color, intactness.
• Discharge or lesions.
• Palpate external ear and mastoid areas for tenderness, edema, or
nodules.
• If indicated, perform whisper test to evaluate gross hearing.
• Perform Rinne’s and Weber’s tests.
• Ears:
• Otoscopic examination: Inspect characteristics of external canal,
cerumen, and eardrum (landmarks)
 Nose

• Assess nasal structure and

septum.
• Assess nose for patency,
symmetry, and discharge.
• If indicated, evaluate
sense of smell.
 Mouth and Oropharynx

• Lips should be symmetrical, pink, smooth, and moist.

• There should be no growths, lumps, or discoloration of the
tissue.
Abnormal Findings
• If the lips are asymmetrical, cyanotic, cherry red, pale, or
dry.
• Assess oropharynx for odor, anterior and posterior pillars,
uvula, tonsils, and posterior pharynx
• If indicated, grade tonsils.
• Assess tongue for symmetry, movement, color, and
surface characteristics.
• If indicated, palpate tongue and gums, evaluate gag reflex, and
test temporomandibular joint for movement.
 Mouth – A & P
 Hard palate – made out of bone (whitish color)
 Soft palate – made out of muscle (more pink in color)
 Uvula – hangs from middle of soft palate
 Tongue – striated muscle assist with mastication and swallowing.
Papillae on dorsal surface of tongue hold neurons responsible
for taste
Thorax
Lungs
Heart
Thorax and Lungs
 Breath Sounds

• Bronchial: Heard over the trachea and mainstem bronchi (2nd-4th

intercostal spaces either side of the sternum anteriorly and 3rd-6th
intercostal spaces along the vertebrae posteriorly). The sounds are
described as tubular and harsh. Also known as tracheal breath
sounds.

• Bronchovesicular: Heard over the major bronchi below the clavicles

in the upper of the chest anteriorly. The sounds are described as
medium-pitched and continuous throughout inspiration and expiration.

• Vesicular: Heard over the peripheral lung. Described as soft and low-
pitched. Best heard on inspiration.
 Adventitious Breath Sounds

• Crackles (Rales)
• Discontinuous, intermittent, nonmusical, brief sounds
• Simulated by rolling hair near the ear between two fingers
• Heard more commonly with inspiration
• Classified as fine or coarse
• Wheeze
• Continuous, high pitched, musical sound, longer than crackles
• Hissing quality, heard > with expiration, however, can be heard on
inspiration
• Produced when air flows through narrowed airways
• Rhonchi
• Similar to wheezes
• Low pitched, snoring quality, continuous, gurgling sound
• Best heard on expiration over bronchi and trachea
• Implies obstruction of larger airways by secretions

Pleural Rub
• Discontinuous or continuous brushing sounds
• Heard during both inspiratory and expiratory phases
• Occurs when pleural surfaces are inflamed and rub against each
other
• Stridor
• Harsh, high-pitched audible sound
• Indicates a progressive narrowing of the airway, requiring
immediate attention
• Diminished
• Inability to hear equal, bilateral breath sounds
• Associated with pneumothorax, pleural effusion

Always document respiratory rate, depth, effort, and sounds and fields
of auscultation.
 Respiratory Patterns
• Rate
• Eupnea 12 – 20 bpm normal
• Tachypnea > 24, rapid, shallow
• Bradypnea < 10
• Apnea = No respirations for 10 sec. or more
• Pattern - it is the breathing rhythm.
• Normal respirations are regular and even.
• Cheyne – stokes
• resp wax & wane in reg pattern with periods of apnea
• Biot’s or ataxisic
• Similar to cheyne –stokes but pattern irreg
• Kussmaul's
• Rapid, deep and labored
• Sputum
• Sample
• Color
• Mucoid, yellow/green, rust/blood tinged, black, pink
• Odor
• Amount
• Consistency
 Cardiovascular (Chest)
• Inspection:
• Side to side, at right angle and
downward over precordium where
vibrations are visible.
• Point of Maximal Impulse (PMI)
Apical Impulse – located at 5th
intercostal (IC) space at
midclavicular line (MCL) – mitral
area and Jugular Vein Distention
• Inspect skin, nailbeds and
extremities
• Inspect for edema
• Observe chest for scars, symmetry,
movement and deformity
• Palpate
• fingers and most sensitive part of palm of hand to detect any precordial
motion or thrills.
• Palpate pulses
• Palpate and grade Edema if present
• Percussion
• estimate heart size, most accurately done by chest x-ray
• Auscultation
• evaluates heart rate, rhythm, cardiac cycle and valvular function.
• Auscultate anterior chest for breath sounds.
• Auscultate heart for rate, rhythm, S1/S2 (location, intensity, frequency,
timing, and splitting), S3, S4, or murmurs.
• Lightly palpate all quadrants for tenderness, guarding, and
masses.
• If indicated:
• Deeply palpate midline epigastric area for aortic pulsation (AP).
• Percuss all quadrants and epigastric region for tone.
• Percuss upper and lower liver borders, and estimate liver span.
• Percuss left midaxillary line for splenic dullness.
 Percussion sounds

Sound Inten Pitch Lengt Qualit Exampl

sity h y e of
origin
Resonance Loud Low Long Hollow Normal
(heard over lung
part air and
part solid
Hyper- Very Low Long Boomi Lung
resonance loud ng with
(heard over emphys
mostly air ema
 Skin, Hair, Nails

Inspect for:
Lesions
•Macule
•Patch
•Wheal Nodule
•Vesicle
•Pustule
•Cyst
•Scale
•Crust
•Excoriation
•Scar
•Keloid
•Fissure/Ulcer
Skin Color
• Pallor
• Cyanosis
• Erythema
• Purpura
• Ecchymosis
• Petechia
• Jaundice

Areas of pain/itching
Skin Color
• Pallor
• Cyanosis
• Erythema
• Purpura
• Ecchymosis
• Petechia
• Jaundice

Areas of pain/itching
 Palpate for
• Moisture
• Temperature
• Texture
• Turgor
• Capillary refilling
• Elevation or depression

Describe:
• Shape
• Distribution
• Associated smptoms
 Genitourinary
FEMALE
• History:
• pain, bleeding, discharge, masses
• Physical assessment
• Breast examination
• Abdominal examination
• Examination of the external genitalia
• Pelvic examination
• Bimanual examination
• Rectovaginal examination
MALE
• Examination of the external genitalia
• Examination for inguinal hernia
• Examination of the rectum and prostate