Physical Assessment

Purposes of physical examination

 To gather baseline data about the
clients health.

 To identify and manage a variety of

patient problems (actual and
potential)
– Evaluate the effectiveness of nursing
care

– Enhance the nurse-patient relationship

– Make clinical judgments

Types of assessment

1) A comprehensive or complete health

assessment

2) An interval or abbreviated assessment

3) A problem-focused assessment

4) An assessment for special populations

1) A comprehensive or complete health
assessment

 A comprehensive or complete health assessment usually

begins with obtaining a thorough health history and
physical exam.
 This type of assessment is usually performed in acute
care settings upon admission, once The patient is stable,
or when a new patient presents to an outpatient clinic.
2) An interval or abbreviated assessment at this time

 an interval or abbreviated assessment is

usually performed at subsequent visits in an
outpatient setting, at change of shift, when
returning from tests, or upon transfer to patient
unit from another in-house unit.
 The advantage of an abbreviated assessment is
that it allows nurse to assess the patient in a
shorter period of time.
3) Problem-focused assessment
 The third type of assessment that nurse may
perform is a problem-focused assessment.
 The problem-focused assessment is usually
indicated after a comprehensive assessment has
identified a potential health problem.
4) Assessment for special populations

 These special populations include:

– Pregnant patients.

– Infants.

– Children.

– The elderly.
 Health History
o Purpose of obtaining a health history is to provide
nurse with a description of the patient’s symptoms.
o A complete history will serve as a guide to help
identify potential illnesses or disease.
o obtain information about many other factors that
impact the patient’s physical status including
spiritual needs, cultural, and functional living status.
Basic components of health history
1) Chief complaint
2) Present health status
3) Past health history
4) Family history
5) Current lifestyle
6) Psychosocial status
7) Medical history
8) Surgical history
1) Chief Complain
 So, tell me why you have come here today?

 Tell me what your biggest complaint is

right now?
2) Present Health Status
 Use PQRST to assess each symptom and to
evaluate any changes to treatment.
 Provocative or Palliative: What makes the
symptoms) better or worse?
 Quality: Describe the symptoms).
 Region or Radiation: Where in the body does
the symptom occur? Is there radiation or
extension of the symptom(s) to another area of
the body?
 Severity: On a scale of 1-10, (10 being the
worst) how bad is the symptoms)?
 Timing: Does it occur in association with
something else? (i.e. eating, exertion,
movement)
3) Past Health History
 The past health history should have
information about the patient’s childhood
illnesses and immunizations, accidents or
traumatic injuries, hospitalizations, allergies,
and chronic illnesses.
 4) Family history
 To identify diseases that may be genetic in origin.
 Asks about the age and health status, or the age and
cause of death, of first-order relatives (parents,
spouse, children) and second-order relatives
(grandparents, cousins).
 In general, it is necessary to include the following
diseases: cancer, hypertension, heart disease,
diabetes, asthma, alcoholism, and obesity.
 Physical Examination:


Subjective data - Said by the client

Objective data - Observed by the
nurse
Preparing for the assessment
 Explain when, where and why the assessment will take
place.
 Help the client prepare (empty bladder, change clothes).
 Prepare the environment (lighting, temperature,
equipment, privacy.
Positioning
 Positions used during nursing assessment, medical
examinations, and during diagnostic procedures:
– Dorsal recumbent

– Supine

– Sims

– Prone

– Lithotomy
Assessment Techniques
1- Inspection - critical observation
– Take time to “observe” with eyes, ears, nose
– Use good lighting
– Look at color, shape, symmetry, position
– Odors from skin, breath, wound

Inspection is done alone and in combination with

other assessment techniques
Assessment Techniques
2- Palpation - light and deep touch

– Back of hand to assess skin temperature

– Fingers to assess moisture, areas of tenderness

– Assess size, shape, and consistency of lesions

Assessment Techniques
3- Percussion - sounds produced by touching body
surface
– Produces different notes depending on underlying mass
(dull, resonant, Hyper resonance, flat, tympani)
– Used to determine size and shape of underlying structures
by establishing their borders and indicates if tissue is air-
filled, fluid-filled, or solid .
Percussion Tones

 Dull
 Resonant
 Hyper Resonance
 Flat
 Tympani
Assessment Techniques

4- Auscultation is usually performed last,

except when
 examining the abdomen. The abdomen
should be auscultated before percussion or
palpation to prevent production of false bowel
sounds.
Assessment Techniques
 Auscultation - listening to sounds produced by the body
 Direct auscultation – sounds are audible without stethoscope

 Indirect auscultation – uses stethoscope

 Describe sound characteristics (frequency, pitch

intensity, duration, quality)
 Sounds

1- Tympany sounds like a drum and is heard over air

pockets (such as pneumoperitoneum).

2- Resonance is a hollow sound heard over areas where

there is a solid structure and some air (like the lungs).
3- Hyper resonance is a booming sound heard over air
such as in patients with emphysema in their lungs.

4- Dullness is usually heard over solid organs or masses.

5- Flatness is heard over dense tissues including muscle

and bone
General Survey
 General appearance, gait, nutrition status
(NOT to be confused with nutrition history),
state of dress, body build, obvious disability,
speech patterns, affect (mood), hygiene,
body odor, posture, race, gender, height,
weight, vital signs
 Height up to age 2 is recumbent
– Add head circumference if child is less than 2
years old
 Integumentary System
– Integument includes skin, hair, and nails
 Inspect: skin color and uniformity of color,
moisture, hair pattern, rashes, lesions, pallor,
edema
 Palpate: temperature, turgor, lesions, edema .
 Percussion and auscultation: rarely used on skin
 Terminology: pallor, cyanosis, edema,
ecchymosis, macule, papule, jaundice, vitiligo,
hirsutism, alopecia, etc.
 Integumentary System
 Hair - texture, distribution, scalp
 Nails - inspect and palpate
– Why palpate?
– Cyanosis - is it true or d/t cold?
– Blanch test (aka capillary refill): delayed return of
color indicates poor arterial circulation
– Clubbing - loss of normal angle between nail and nail
bed d/t chronic oxygen deprivation
 HEENT
 Head - inspection and palpation
– Size, shape, symmetry
 Eyes - inspection and palpation
– Inspect and palpate lids, lashes, inspect eye position
and symmetry and position, symmetry and size of
pupils
– Visual acuity with Snellen chart
» 20/20 - first number (numerator) is distance from chart
» Second number is distance at which a normal eye could have
read that line (OU, OD, OS)
» Always record if tested cc (with correction)
Eyes
 Visual acuity (Snellen for distance)

 Visual fields - assess peripheral vision

 EOMs - checks 6 ocular movements; tests CN 3, 4, and 6

 Pupil response to light and accommodation

– Pupils constrict o light, and also to accommodate for near vision (dilate for
dimness and distance)

 Corneal light reflex - checks eye alignment

 Fundoscopic exam - ophthalmoscope

Ears
 Inspection and palpation

– Inspect size, shape, position, discharge, lesions

– Palpate for tenderness, any lesions

 Gross hearing acuity: normal voice, Internal ear

(behind tympanic membrane)
Nose and Sinuses
 Inspection, palpation, percussion
 Inspect color of mucosa, presence of discharge
– There is a nasal speculum – most people don’t like it
– Assess for patency
 Palpate for tenderness
 Percuss for tenderness over frontal and maxillary
sinuses .
Mouth and Throat
 Inspection, palpation, auscultation
 Inspect and palpate lips, tongue, oral cavity,
tonsils, pharynx (color, moisture), teeth, breath,
presence of exudate, erythema, lesions, palate
– Enlarged tonsils are graded
» Grade 1 – wnl
» Grade 2 – tonsils b/w pillars and uvula
» Grade 3 – tonsils touching uvula
» Grade 4 – tonsils touching each other (kissing tonsils)
Throat and Neck
 Inspect and palpate neck for trachea
(should be at midline), thyroid, lymph
nodes .
 Auscultate carotids for bruits (bell)
– If bruit is heard, palpate for carotid
– Palpate one side at a time
 Perform ROM on neck (active and passive)
Thorax and Lungs
 Changes in respiratory status can happen very
slowly, or very quickly, so respiratory status is
assessed carefully, and frequently .

 Need to know angle of Louis, how to count ribs,

how to describe locations, what is under the
surface .
 Assess size and shape of thorax
– Look for deformities
– Barrel chest from asthma or COPD
 Presence of supernumery nipples
 For efficiency, you usually assess posterior chest first
 Intercostal spaces (ICS) are names according the rib
they lie beneath
– 4th rib lies superior to 4th ICS
– Posterior, you have to count spinous processes to name ribs
and ICSs
Lungs
 Inspect, Palpate, Percuss (normal note is
resonance), Auscultate (normal is clear and
equal bilaterally)

– Auscultate using diagram Assess and document

respiratory rate, rhythm, and effort
Respiratory Terminology
 Tachypnea
 Bradypnea
 Apnea
 Hyperventilation
 Hypoventilation
 Dyspnea
Respiratory Warning Signs
 Anxious expression
 Suprasternal & intercostal retractions
 Nasal flaring
 Circumoral cyanosis
 Hyperexpanded chest
– ALWAYS REMEMBER ABCs
Breath Sounds
 Auscultate using diaphragm, use a
systematic approach, compare each side to
the other, document when and where
sounds are heard
 Normal breath sounds: bronchovesicular,
bronchial, and vesicular
– Abnormal breath sounds are called adventitious
sounds
Breath Sounds
 Stridor - may be heard without stethoscope, shrill
harsh sound on inspiration d/t laryngeal obstruction
 Wheeze - may be heard with or without stethoscope
(document which), high-pitched squeaky musical
sound; usually not changed by coughing; Document
if heard on inspiration, expiration, or both; May
clear with cough
– Noise is caused by air moving through narrowed or
partially obstructed airway
– Heard in asthma
Breath Sounds
 Crackles - heard only with stethoscope (formerly
called rales): fine, medium, coarse short crackling
sounds (think hair); May clear with cough
– Most commonly heard in bases; easier to hear on
inspiration (but occurs in both inspiration and expiration)
 Gurgles - heard only with stethoscope (formerly called
rhonchi): Low pitched, coarse wheezy or whistling
sound - usually more pronounced during expiration
when air moves through thick secretions or narrowed
airways – sounds like a moan or snore; best heard on
expiration (but occur both in and out)
 Document breath sounds as clear, decreased or
 absent, compare right to left, and describe type
and location of any adventitious sounds .
Breasts and Axillae
 Inspection and palpation
– Instruct female clients to perform BSE q month
– Men have some glandular tissue beneath nipple;
women have glandular tissue throughout breast and
into axilla
– Inspect for symmetry, contour (shape), look for any
areas of hyperpigmentation, retraction or
– Palpate breasts, areolae, nipples and axillary lymph
nodes in both men and women .
 Respiratory. Cough; sputum (color, quantity);
hemoptysis, wheezing, asthma, bronchitis, pneumonia,
tuberculosis, last chest x-ray film

 Cardiac. Heart trouble, high blood pressure, rheumatic

fever, heart murmurs, chest pain or discomfort,
palpitations, dyspnea, orthopnea, edema, past
electrocardiogram or other heart test results
 Gastrointestinal. Trouble swallowing, heartburn,
appetite, nausea, vomiting, regurgitation, vomiting of
blood, indigestion, frequency of bowel movements,
color and size of stools, change in bowel habits, rectal
bleeding or black tarry stools, hemorrhoids,
constipation, diarrhea, abdominal pain, food
intolerance, excessive belching or passing of gas,
jaundice, liver or gallbladder trouble, hepatitis

 Urinary. Frequency of urination, polyuria, nocturia,

burning or pain on urination, hematuria, urgency, or
force of the urinary stream, incontinence, urinary
infections, stones
 Genital.
 Male: Hernias, discharge from or sores on the penis,
testicular pain or masses, history of sexually transmitted
diseases and their treatments, and problems.

 Female: Age at menarche; regularity, frequency, and

duration of periods; amount of bleeding; bleeding
between periods; last menstrual period; dysmenorrhea;
premenstrual tension; age at menopause; menopausal
symptoms; Discharge, itching, sores, sexually transmitted
diseases and their treatments. Number of pregnancies,
deliveries, or abortions (spontaneous and induced);
complications of pregnancy; birth control methods.
 Peripheralvascular.
 leg cramps, varicose veins, past history of
blood clots in the veins
 Musculoskeletal. Muscle or joint pains,
stiffness, arthritis, gout, backache. If
present, describe location and symptoms
(e.g., swelling, redness, pain, tenderness,
stiffness, weakness, limitation of motion or
activity)
 Neurologic. Fainting, blackouts, seizures,
weakness, paralysis, numbness or loss of
sensation, tingling or “pins and needles,”
tremors or other involuntary movements
 Hematologic/immunologic. Anemia, easy
bruising or bleeding, past transfusions and
any reactions to them, status for human
immunodeficiency virus infection,
autoimmune disorders
 Endocrine. Thyroid trouble, heat or cold
intolerance, excessive sweating, diabetes,
excessive thirst or hunger, polyuria
 Psychobiologic. Nervousness, tension,
mood, memory