Physical Assessment

Indications for the Physical

Exam
1. Routine screening

2. Eligibility prerequisite for health

insurance, military service, job, sports,
school

3. Admission to a hospital or long term care

facility
Physical Exam and Health
Assessment
 A complete health assessment includes both
nursing history and physical exam

 Information gathered in both the health

history and physical exam serves provides a
baseline of the client’s functional abilities
Skills of Physical Assessment
 Inspection

 Palpation

 Percussion

 Auscultation

 Olfaction
Utilization of Assessment
Skills
 We utilize our assessment skills to:
 Gather a database (baseline)
 Confirm and identify nursing diagnoses
 Make clinical judgments about a client’s changing
health status
 Evaluate the effectiveness of nursing care
Preparation of Client and
Environment
 Exam room needs to be well lit and and noises
limited or eliminated
 Equipment should be within reach and working
properly
 Client should be prepared with appropriate draping
 Client’s dignity, privacy, and comfort should be
maintained
 Client should be given appropriate explanations and
directions before and during exam
Organization of Exam
 Exam should follow organized and systematic
format
 Why?

 All physical and emotional findings should be

recorded as soon as possible
 Why?
Helpful Guidelines for
Examination
 Compare both sides for symmetry
 If client is seriously ill, first assess systems of the body
more at risk for being abnormal
 If client becomes fatigued, offer rest periods of rest
 Record results of exam in specific anatomical and
scientific terms
 Use common, accepted abbreviations, keep notes
brief and concise
 Record quickly to avoid keeping client waiting
 May use standardized form to record findings in the
same sequence that it was gathered
Types of Examinations
 Head to Toe exam
 A complete physical
 Often done on an initial visit to hospital or doctor’s office- serves
as a baseline
 Head to toe exam includes an assessment of systems
 Systems assessment
 Used more on a day to day basis w/ hospital clients
 Focus is on a particular system that may be affected by pathology
 Systems assessment
 Guides questioning
 Provides clues of related pathology
 Example: Pneumonia- exam lungs, breath sounds and any other
system affected by poor oxygenation