1. Chapter 5 PHYSICAL ASSESSMENT
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2. HEALTH ASSESSMENT Physical Examination

3. Purposes Ascertain client’s level of health & physiological function
Identify important factors
Confirm alterations, disease or inability to perform ADLs
Identify need for additional testing / examination
Aid in evaluating outcome of treatment / therapy

4. Subjective and Objective Data
Subjective Data.
History – what the patient tells/communicates to you
Objective Data.
Exam – what you discover through your physical assessment

5. Possible Client Position During an Examination

7. Positions for physical Examination
Assessment positions e.g.: (Standing position, Supine position, Sitting position, Dorsal recumbent position, Sims position, Prone position, Knee chest position, and Lithotomy position)
Each position has it's specialty for parts of examination

8. Sitting position
Areas Assessed: Head and neck, back, posterior thorax and lungs, anterior thorax , breasts, axillae, heart, vital signs, and upper extremities
Limitations: Physically weakened client may be unable to sit

9. Supine position Most normally relaxed position
Areas Assessed: Head and neck anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, pulses
Limitations: Not use for client SOB, you may need to raise head of bed

10. Dorsal position
Areas Assessed: Head and neck, anterior thorax and lungs, breasts, axillae, heart.
Limitations: Not used for abdominal assessment because it promotes contracture of abdominal muscles

11. . Lithotomy Position
Areas Assessed: Female genitalia and genital tract.
* Limitations:
This position is embarrassing & uncomfortable, so examiner minimizes time that client spends in it.
Client is kept well draped.
This position not used for Client with severe arthritis or other joint deformity

12. Sims’ position
Areas Assessed: Rectum and vagina.
* Limitations: Joint deformities may prevent client’s ability to Bend hip and knee
Prone position:
* Areas Assessed: Musculoskeletal system.
* Limitations: don’t use this position for client with respiratory difficulties

13. Knee-chest position Areas Assessed: Rectum.
Limitations: This position is embarrassing and uncomfortable. Don’t use this position for Clients with arthritis or other joint deformities.
When palpation assess for Crepitus (crackling sensation & noise caused by rubbing of bone fragments).
* If a joint appears swollen and inflamed, detect warmth in the tissues.

14. Equipment Preparation For a Health Assessment

16. Indications for the Physical Exam
Routine screening
Eligibility prerequisite for health insurance, military service, job, sports, school
Admission to a hospital or long term care facility

17. STEPS OF ASSESSMENT Think Organize
Don’t forget…Nutrition / Height & Weight
Environment:
Accommodate special needs (cultural sensitivity)
Equipment - clean surface & clean equipment Room - quiet, warm & well lit
Maintain privacy
Observe & Listen

18. DON’T FORGET…… REVIEWING GENERAL INFORMATION INTRODUCTION TO CLIENT
OBTAINING THE HEALTH HISTORY
PAIN ASSESSMENT
THIS IS KEY TO HOLISTIC APPROACH

19. Five Assessment Techniques During A Physical Examination
Inspection
Palpation
Percussion
Auscultation
Olfaction

21. Inspection Use vision& smell Always first Look for symmetry
Use good lighting
Use good exposure

23. Principles of Accurate Inspection
Good lightening either day light or artificial light is suitable.
Expose body parts being observed only.
look before touching.
warm room for examination of the client “not cold not hot".
Observe for color, size, location, texture, symmetry, odors, and sounds.
Compare each area inspected with the opposite side of body if possible.
Use pen light to inspect body cavities.

24. Palpation Touch & feel with hands to determine:
Texture – use fingertips
Temperature – use back of hand
Moisture
Organ location and size
Slow and systematic
Light to deep
Light palpation (tenderness)
Deep palpation (abdominal organs/masses)
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25. Light palpation

26. Deep palpation

27. Principles for Accurate Palpation
Examiner finger nails should be short.
Use sensitive part your hand.
Light Palpation precedes deep palpation.
Start with light then deep palpation
Tender area are palpated last
Client must relax during palpation.
Tell client to take slow deep breath to enhance muscle relaxation.
Examine condition of the abdominal organs
Depressed areas must be approximately “2cm”
Assess turger of skin measured by lightly grasping the body part with finger tips.

28. Percussion

29. Percussion
Tapping of body part to assess tenderness, Size, location, density
Direct: with one or two fingers e.g. Sinuses
Indirect: middle finger of left hand against the body surface with palm and fingers remaining off the skin,
and the tip of the middle finger of the right hand strikes the base of the distal joint.
Use a quick & sharp stroke

30. Five Percussion Sounds Produced in Different Body Regions
Resonant – normal lung
Hyper resonant – infant lung, emphysema
Tympany – air filled (stomach)
Dull – organ (liver, spleen)
Flat – no air (thigh muscle, bone, tumor)

31. Auscultation

32. Auscultation Listening to body sounds Movement of air (lungs)
Blood flow (heart)
Fluid & gas movement (bowels)
Remember the sound changes in the abdomen…

33. HOW TO BEGIN… Positions for physical exam Using a stethoscope:
longer the tube – more sound has to travel
Hold diaphragm firmly against client’s skin (NOT THROUGH CLOTHING!!)
If using bell – less pressure
Warm in your hands first!
Listen / Concentrate on the sounds

34. Olfaction
Another skill that used during assessment. Certain alteration in body function creates characteristic body odors.
Smelling can detect abnormalities that unrecognized by other means.

35. Assessment of Characteristic Odors
Alcohol odor from oral mouth ingestion of alcohol.
Ammonia from urine means urinary tract infection.
Bad odor from skin, (e.g. under arms and beneath breasts) means poor hygiene, excess perspiration (bromidrosis)(foul smelling perspiration).
Feces odor from wound site means wound abscess, but this odor from vomitus this means bowel obstruction, and if the odor from rectal area this means fecal incontinence.
Foul smelling stool in infant means mal absorption syndrome.

36. Assessment of Characteristic Odors…cont
Halitosis from oral cavity means poor dental hygiene.
Sweat, fruity ketenes from mouth DKA
Musty odor from organ with cast part means infection inside cast.
Fetid odor from tracheotomy or mucous secretions means infection

37. Basic Guidelines for Physical Assessment
Obtain a nursing history.
Maintain Privacy.
Explain the procedure and purpose of each examined part of the client.
Follow a planned order of examination for each body system.

38. Basic Guidelines for Physical Assessment cont..
Inspect, palpate, percuss, and then auscultate, except in the abdomen auscultate then percuss to avoid alteration in the bowel sounds
Compare symmetrical sides of the body and organs.
Assess both structure and function of each body part and organ e.g. (the appearance and condition of the ear as well as its hearing function)

39. Basic Guidelines for Physical Assessment cont..
If there is abnormality assess for further data. e.g. radiation of pain, effect on eating? bowels? ADLs?
Assess self physical assessment (e.g. exam of the breast, testicular exam, foot care for the diabetic)
Allow time for client questions
“Remember: the most important guideline for adequate physical assessment is, continuous practice of physical assessment skills”
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40. Variation in Physical Assessment of the Pediatric Client
Sequence of physical assessment depends on the development level of the client.
Establishment of rapport with the child and significant others is the most essential step in physical assessment data.
Reduce fearing of child prior to beginning the examination.
You may require physical restraint of the client with help of another adult.

41. Variation in Physical Assessment of the Pediatric Client…cont
Assistance from the child’s significant caregiver may facilitate examination.
Assessment approach of the child based on child's response.
Uncooperative attitude toward the examiner is a normal finding in children from birth to early adolescence.

42. Variations for Physical Assessment of the Geriatric Client
Remember normal variation related to aging.
Divide the physical assessment into parts in order to avoid fatigue.
Provide room with comfortable temperature.
Allow sufficient time for client to respond to directions.
If possible assess the elderly clients in a setting position.
Give him/her fulltime to understand you.

43. THANK YOU