An Overview

 Part of a general health assessment  Used to gather data about the client  Focuses on functional abilities and responses to illness/stressor

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

Comprehensive:  Interview plus complete head-to-toe examination Focused:  “Focused” on presenting problem Ongoing:  Performed as needed to assess status  Evaluates client outcomes

 Head-to-toe ◦ Starts at the head ◦ Progresses “down” the body ◦ System-related data found throughout: Heart sounds - chest Pulses - periphery

 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

 Theoretical knowledge A and P, techniques  Self-knowledge Skill and comfort level Willingness to seek help  Knowledge about client situation Purpose of examination Client diagnosis

 Privacy is key Draping Use of curtains  Noise control TV/radio off  Enable visualization Adequate lighting Flashlight if needed

Promote client comfort:  Develop rapport  Explain the procedure  Respect cultural differences  Use proper positioning

Four major skills used:  Inspection  Palpation  Percussion  Auscultation

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

 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

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

 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

Infants:  Parents hold  Attend to safety Toddlers:  Allow to explore and/or sit on parent’s lap  Invasive procedure last  Offer choices  Use praise

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

Adolescents:  Provide privacy  Concerned that they are “normal”  Use examination to teach healthy lifestyle  Screen for suicide risk Young/ Middle Adults:  Modify in presence of acute or chronic illness

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

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

Integumentary:  Skin characteristics Color Temperature Moisture Texture Turgor  Lesions  Hair  Nails

Head:  Skull and Face Size Shape Facial features  Eyes External eye Sclera Pupils Visual acuity Vision examinations  Acuity, distance, near, color, visual fields Internal structures

Head:  Ears/hearing External ear Inner ear  Tympanic membrane Hearing  Weber’s test  Rinne’s test Balance  Romberg’s test  Nose Smell  Mouth Lips Buccal mucosa Teeth Hard and soft palates

Neck:  Musculature  Trachea  Thyroid gland  Cervical lymph nodes Breasts:  Size  Shape  Nipple characteristics  Tissue  Include axillae

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

Cardiovascular– Heart:  Inspection PMI Heaves/Lifts  Palpation Thrill  Heart sounds Location: Aortic, Pulmonic, Tricuspid, Mitral Components: S1, S2, S3, S4 Murmurs

Cardiovascular– Vessels:  Central vessels Carotid arteries  Palpate pulsation * Special precautions  Auscultate for bruit Jugular veins  Peripheral vessels Blood pressure Peripheral pulses Signs of inadequate oxygenation Varicosities

 Different order for assessment skills Inspect Auscultate Percuss Palpate

Body shape/symmetry:  Posture  Gait  Spinal curvature Balance:  Romberg’s test Coordination:  Finger-thumb opposition  Movement Joint mobility:  Color change  Deformity  Crepitus Muscle strength:  Range of motion  Resistance

 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

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

Sensory Function:  Light touch  Light pain  Temperature  Vibration  Position  Sense  Stereognosis  Graphesthesia  Two-point discrimination  Point localization  Extinction

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

Other:  Kidneys (CVA tenderness)  Bladder (palpation of the abdomen)  NP/MD responsible for anus, rectum, prostate examination  NP/MD responsible for pelvic examination