Assessing Health: Physical Examination Metro Community College Nancy Pares, RN, MSN Nursing Programs

1. Assessing Health: Physical ExaminationMetro Community CollegeNancy Pares, RN, MSNNursing Programs

2. Health Assessment: Performinga Physical Examination An Overview

3. The Nursing Physical Examination • Part of a general health assessment • Used to gather data about the client • Focuses on functional abilities and responses to illness/stressor

4. Purposes The nurse performs a physical examination to: • Establish baseline data • Identify nursing diagnoses, collaborative problems, or wellness diagnoses • Monitor the status of an identified problem • Screen for health problems

5. Types of Physical Examinations Comprehensive: • Interview plus complete head-to-toe examination Focused: • “Focused” on presenting problem Ongoing: • Performed as needed to assess status • Evaluates client outcomes

6. Organizing the Examination • Head-to-toe • Starts at the head • Progresses “down” the body • System-related data found throughout: • Heart sounds - chest • Pulses - periphery

7. Organizing the Examination • Body systems • Gathers system-related data all at once • May be done in a predetermined order that mimics head-to-toe: • Neurological • Cardiovascular • Respiratory • Gastrointestinal

8. Preparing Yourself:What the Nurse Needs • Knowledge about client situation • Purpose of examination • Client diagnosis • Theoretical knowledge • A and P, techniques • Self-knowledge • Skill and comfort level • Willingness to seek help

9. Preparing the Environment • Enable visualization • Adequate lighting • Flashlight if needed • Privacy is key • Draping • Use of curtains • Noise control • TV/radio off

10. Preparing the Client Promote client comfort: • Develop rapport • Explain the procedure • Respect cultural differences • Use proper positioning

11. Physical Assessment Skills Four major skills used: • Inspection • Palpation • Percussion • Auscultation

12. Inspection • Use of sight to gather data • Used throughout physical examination • Tools to enhance inspection • Otoscope • Ophthalmoscope • Penlight • Examples: Skin color, gait, general appearance, behavior

13. Palpation • Use of touch to gather data • Begin with light pressure, moving to deep palpation • Use caution with deep palpation • Parts of the hands used: • Fingertips: Tactile discrimination • Dorsum: Temperature determination • Palm: General area of pulsation • Grasping (fingers and thumb): Mass evaluation • Examples: Edema, moisture, anatomical landmarks, masses

14. Percussion • Tapping on skin to elicit sound • Direct • Indirect • Useful for assessing abdomen, lungs, underlying structures • Examples: Distended bladder

15. Auscultation • Use of hearing to gather assessment data • Direct auscultation: • Listening without an instrument • Indirect auscultation: • Use of a stethoscope to listen • Diaphragm - high-pitched sounds • Bell – low-pitched sounds • Examples: Heart sounds, lung sounds

16. Age Modifications for the Physical Examination Toddlers: • Allow to explore and/or sit on parent’s lap • Invasive procedure last • Offer choices • Use praise Infants: • Parents hold • Attend to safety

17. Age Modifications for the Physical Examination School-Aged Children: • Show approval and develop rapport • Allow independence • Teach about workings of the body Preschoolers: • Use doll for demonstration • Still may want parental contact • Allow child to help with examination

18. Age Modifications for the Physical Examination Young/ Middle Adults: • Modify in presence of acute or chronic illness Adolescents: • Provide privacy • Concerned that they are “normal” • Use examination to teach healthy lifestyle • Screen for suicide risk

19. Age Modifications for the Physical Examination Older Adults: • May need special positioning related to mobility • Adapt examination to vision and hearing changes • Assess for change in physical ability • Assess for ability to perform activities of daily living • Provide periods of rest as needed

20. Basic Components of a Comprehensive Examination:The General Survey • Appearance/behavior • Grooming/hygiene • Body type/posture • Mental state • Speech • Vital signs • Height/weight • Begins at first contact • Overall impression of client • Deviations lead to focused assessments

21. Basic Assessments: Skin, Head Integumentary: • Skin characteristics • Color • Temperature • Moisture • Texture • Turgor • Lesions • Hair • Nails

22. Basic Assessments: Skin, Head • Eyes • External eye • Sclera • Pupils • Visual acuity • Vision examinations • Acuity, distance, near, color, visual fields • Internal structures Head: • Skull and Face • Size • Shape • Facial features

23. Basic Assessments: Ears, Nose, Mouth • Nose • Smell • Mouth • Lips • Buccal mucosa • Teeth • Hard and soft palates Head: • Ears/hearing • External ear • Inner ear • Tympanic membrane • Hearing • Weber’s test • Rinne’s test • Balance • Romberg’s test

24. Basic Assessments: Neck, Breasts Breasts: • Size • Shape • Nipple characteristics • Tissue • Include axillae Neck: • Musculature • Trachea • Thyroid gland • Cervical lymph nodes

25. Basic Assessments: Lungs Breath Sounds: • Bronchial • Bronchovesicular • Vesicular • Adventitious • Diminished or misplaced • Abnormal vocal sounds Chest and Lungs: • Describe size and shape of chest • Relate findings to landmarks

26. Basic Assessments: Heart, Vessels • Heart sounds Location: • Aortic, Pulmonic, Tricuspid, Mitral Components: • S1, S2, S3, S4 Murmurs Cardiovascular–Heart: • Inspection • PMI • Heaves/Lifts • Palpation • Thrill

27. Basic Assessments: Heart, Vessels • Peripheral vessels • Blood pressure • Peripheral pulses • Signs of inadequate oxygenation • Varicosities Cardiovascular–Vessels: • Central vessels • Carotid arteries • Palpate pulsation * Special precautions • Auscultate for bruit • Jugular veins

28. Basic Assessments: Abdomen • Different order for assessment skills • Inspect • Auscultate • Percuss • Palpate

29. Basic Assessments: Bones, Muscles, Joints Joint mobility: • Color change • Deformity • Crepitus Muscle strength: • Range of motion • Resistance Body shape/symmetry: • Posture • Gait • Spinal curvature Balance: • Romberg’s test Coordination: • Finger-thumb opposition • Movement

30. Basic Assessments: Neurological • Staff RN Uses Focused Neuro Assessment: Cerebral Functioning: • Level of consciousness • Arousal - response to stimuli • Orientation - time, place, person • Mental status/cognitive function • Behavior, appearance, response to stimuli, speech, memory, communication, judgment

31. Basic Assessments: Neurological Motor/Cerebellar Function: • Movement/coordination • Tone • Posture • Equilibrium • Proprioception Reflexes: • Automatic responses • Responses on a graded scale • 0 = No response • 4 = Clonus • Example: deep tendon reflexes

32. Basic Assessments: Neurological • Stereognosis • Graphesthesia • Two-point discrimination • Point localization • Extinction Sensory Function: • Light touch • Light pain • Temperature • Vibration • Position • Sense

33. Genitourinary Assessment Male: • Includes reproductive information • External genitalia: penis, urethral opening, scrotum, lymph nodes, pubic hair • Examine for the presence of a hernia Female: • Female external genitalia: labia, clitoris, urethral opening, vaginal orifice, pubic hair, lymph nodes

34. Genitourinary Assessment Other: • Kidneys (CVA tenderness) • Bladder (palpation of the abdomen) • NP/MD responsible for anus, rectum, prostate examination • NP/MD responsible for pelvic examination