Physical assessment is taking an educated, systematic look at all aspects of an individual’s health status utilizing knowledge, skills and tools of health history and physical exam.
- To collect data- information about the client’s health, including physiological, psychological, sociocultural and spiritual aspects
- To establish actual and potential problems
- To establish the nurse-client relationship
Method: The history is done first, then the physical examination focuses on finding data associated with the history.
- Health History- obtained through interview and record review.
- Physical exam- accomplished by tools and techniques
** A complete assessment is not necessarily carried out each time. A comprehensive assessment is part of a health screening examination. On admission, you will do an admission assessment (not necessarily including everything presented here) and document it on the admission form. You will do a daily shift assessment (patient systems review). And, if client has a specific problem, you may assess only that part of the body (focused).
Information is organized into objective and subjective data:
- Subjective: Apparent only to person affected; includes client’s perceptions, feelings, thoughts, and expectations. It cannot be directly observed and can be discovered only asking questions.
- Objective: Detectable by an observer or can be tested against an acceptable standard; tangible, observable facts; includes observation of client behavior, medical records, lab and diagnostic tests, data collected by physical exam.
** To obtain data for the nursing health history, you must utilize good interview techniques and communications skills. Record accurately. DO NOT ASSUME.
D. Frameworks for Health Assessment
There are two main frameworks utilized in health assessment:
Head to Toe- systematic collection of data starting with the head and working downward.
- Functional Health Assessment- Gordon’s 11 functional health patterns that address the behaviors a person uses to maintain health.
- PERSON is the ACC-ADN framework for assessment. It is similar to Gordon's functional health patterns.
- If possible, review the chart before seeing the client. Review the medical history and progress notes; significant x-ray, imaging and lab findings.
- Secure the environment. It should be private, quiet and uninterrupted. The environment should be well lighted; have all the necessary equipment on hand.
- Greeting Client- Use appropriate title; introduce self (both names and explain role). Explain the purpose and nature of the assessment.
- Manner- Relaxed, not hurried; may sit or stand
- Comfort- Inquire how client is feeling; is it convenient; watch for signs of discomfort such as poor positioning; evidence of pain or anxiety.
- Opening- “What brings you to the hospital?” (Chief complaint). Then, tell me about it. Watch out for closed end questions.
- Follow client leads- Many will talk; others will not. Listen actively for important symptoms, emotions, events and relationships. Guide the client into telling more about these areas. Be empathetic and caring
- Be professional- nonjudgmental, concerned and informed. Reactions that betray distrust, disapproval, impatience (nonverbal behaviors) block communication.
- Confidentiality- Assure clients that the information you collect will be shared only with the health care team.
- Show Cultural sensitivity -Be aware of any preconceived biases. If language is a problem, try to get an official translator. Also, be aware that certain physical findings or conditions are associated with certain races or cultures.
Health History Collection:
- Biographical Data: Name, Age, Sex, etc.
- Chief Complaint: Answer to “What brought you to the hospital?” This should be told in the client’ s own words and establishes the purpose of the contact. Client should be encouraged to discuss symptoms specific to the complaint.
- History of the Present Illness (HPI): A clear, chronological account of the events that led the client to seek care (onset, s/s, occurrence of symptoms, and response to treatment).
- Family History: Reveals risk factors for disease- focus on diabetes mellitus, heart disease, HTN; TB; cancer.
- Review of Systems: (subj. information) Purpose is to reveal data r/t present illness; to identify other problems that might be missed. Checklists are often used.
- Personal Profile: Personal habits (EOTH, drugs, tobacco); diet; ADL’s (bathing, toileting, transfer, eating, dressing).
- Social History: Family members, occupation, spiritual beliefs, economic status.
The General Survey:
Overall state of the client. Begin your observations of the client from the first moment you see him and continue throughout the examination. Focus on:
- Level of consciousness (LOC): awake, alert, or drowsy, lethargic, stuporous, comatose, coma. Is the client arousable or non-responsive? If the client is stuporous, comatose, or in a coma, you need to define the level of consciousness by describing the client's response to environmental stimuli, such as noise, spoken word, verbal commands, touch, pain.
- Age: appears stated age or > or <.
- State of health: appears healthy or looks ill (chronic/acute illness). Posture and gait.
- Nutritional status: Appears well developed, well nourished (WD/WN). Obese; slender, emaciated, cachectic.
- Personal hygiene: clean and neat; choice of clothing; body odors.
- Signs of distress: Grimacing; anxious, labored breathing.
- Facial expression, mood, affect, and manner: pleasant, anxious, angry, sad, apathetic; manic, depressed.
- Mental status: Orientation- person, place, time (x3)
- Height/weight (BMI) and vital signs.
The Physical Exam
The following techniques are used in physical examination of each specific area of the body.
- Inspection- visual examination; must be systematic; Describe what you see not what you see not what you think. (Ex: swollen joints, not arthritis).
- Palpation- examination using the sense of touch. Used to determine temperature, position (location), size, texture (masses, fluids), vibration (joints), tenderness/pain, rate(pulse). Light (.5-1”) then deep (1.5-2”).
- Percussion- method by which the body is struck indirectly to elicit sounds. Sounds produced: flatness (bone); dullness (liver); resonance (lungs); hyper resonance (emphysema/lung); tympani (abdomen). May be performed directly or indirectly.
- Auscultation- Listening to sounds in body; direct (use of ear) or indirect with a stethoscope. The diaphragm (flat) is used for high-pitched sounds (breath, normal heart sounds, bowel sounds). The bell is used for low-pitched sounds (abnormal heart sounds, bruit). Tubing should be short; earpieces pointed toward nose.
**Physical exam always in order of: inspection, palpation, percussion, auscultation except on the abdomen; then inspection auscultation before palpation and percussion.
B. The Integument
Assessed by inspection and palpation.
- Color: Pallor (decrease blood supply); cyanosis (bluish tint- decreased oxygenation); jaundice (yellow- due to increased bilirubin); erythematous (inflammation or rashes).
- Moisture: Excessive sweating (diaphoresis); excessive dryness (elderly).
- Temperature: Hypothermia (fever); coolness- decreased circulation.
- Turgor: Elasticity r/t hydration- assess on back of hand. Poor turgor: skin remains tented >3 sec.
- Lesions/Rashes: Should be described in terms of size, color, type (primary or secondary) and location.
- Primary lesions (appear initially):
- Macule: flat up to 1 cm in size- freckle.
- Papule: elevated, solid; <1cm- pimple, wart
- Nodule: solid mass, deeper than papule.
- Vesicle: fluid filled, defined-blister; chickenpox.
- Bulla: large, elevated, fluid filled- hives.
- Pustule: pus filled, <1cm- acne, impetigo.
- Wheal: irregularly shaped fluid collection- hive
Plaque: raised solid lesion.
- Secondary Lesion (results from change in primary)
- Scale: dried fragments of cells- dandruff, psoriasis
- Scar: formation of fibrous tissue after healing
- Fissure: linear crack-athlete’s foot
- Ulcer: excavation of epidermis- stasis ulcer
- Crust: dried serum- impetigo
- Keloid: hypertrophied scar
- Hair: Assesses for distribution (hirsutism); texture, infestation; fullness or loss (alopecia).
- Nails: Assessed for shaped (clubbing) color (blanch test); texture (infection)
- Clubbing- angle between nail and nail bed is 180 degrees or > (normal is 160); indicates circ/resp. problem. Seen in patients with prolonged/chronic hypoxia.
- Capillary Refill- blanch test- when nail is pressed color should return promptly (< 3 sec); may indicate circulatory or respiratory problem.
Head and Face
Assessed by inspection and palpation.
- Inspect size (normocephalic); symmetry; note any deformities.
Eyes and Vision
Assessment can include external structures, ocular movement, visual fields, visual acuity and fundus.
- Eyelids: inspect for ability to blink; position (ptosis); lesions (hordeolum- stye).
- Conjunctiva: palpebral (lid)- color (pink) or lesions.
- Sclera: color- white, not red or yellow
- Cornea: assess for opacity or scratch
- Pupil: inspect for size, shape, reaction to light and accommodation. PERRLA normally, both are black, round, equal in size and react to light and accommodation. Chart is used to measure size (1-10mm). Test pupillary reaction to light: have client look at distant object (room should be dim); look for direct and consensual. Accommodation refers to pupillary change for near and distance (look far off then at finger. Eyes should converge and pupils contract).
- Extraocular Movement- evaluation of the movement of the eyes while the head remains still.
- 8 cardinal fields of gaze, which are controlled by three cranial nerves (CN 3 oculomotor, 4 trochlear, 6 abducens). Watch for nystagmus.
- Visual Fields: How much a person can see at the periphery.
- Visual Acuity: Degree to which a person can discern an image. Normal is 20/20.
- near vision: (general screening) have client read a paper;
- far vision: (general screening) read something across the room. Do one eye; then the other. Test wearing corrective lenses.
- Using Snellen Chart, have client stand 20’ from chart (numerator is 20). Take three readings, right, left, both eyes. Record the smallest line person is able to read. The denominator is the number next to the line on the chart that the person is able to read.
- 20/200 client can read only very large # which a person with normal vision could read at 200’. The larger the denominator, the worse the vision.
- Internal Structures: Requires use of an ophthalmoscope to visualize the fundus (back part of internal eye).
Exam includes inspection/palpation of external parts; inspection of canal and drum with otoscope and auditory acuity.
- Auricle: Inspect for position (pinna level with corner of eye), compare each side; lesions.
- Canal- look for drainage. Tympanic membrane (eardrum) requires use of otoscope.
- Auditory acuity: gross hearing may be assessed by client’s response to voice. Test one ear at a time, covering the other. Start with a whisper. Use 2 syllable words such as “baseball.” A tuning fork may be used to perform tests such as Rinne and Weber.
The Nose and Sinuses
- External nose: inspect for any deviations in shape, size, color, flaring or discharge. Check for patency Check for sense of smell (olfactory nerve- CN I).
- Frontal/Maxillary sinuses- palpate for tenderness.
The Mouth and Oropharynx
- Lips: inspect for color, lesions (cancer or herpes).
- Oral Mucosa: Using tongue blade, inspect for color, lesions; should be uniformly pink.
- Teeth (# and dentition); gums (bleeding, retraction).
- Tongue: Inspect for position (center), color, and texture.
- Tonsils: Lie between posterior and anterior tonsillar pillars. Normal: does not elevate above the tonsillar pillars. Should be pink and smooth; note size, hypertrophy; exudates. Should have gag reflex.
- Palpate for lymph nodesnormally cannot feel any lymph nodes; document any enlarged or painful nodes.
- Jugular venous distentionrefers to distention of the Jugular vein and is an indication of increased central venous pressure as found in Rt. heart failure or fluid overload. Patient should be at 30-45 degree angle and note the level of neck vein distention
The Thorax and Lungs
- Anterior imaginary lines: Midsternal, midclavicular, anterior axillary.
- Posterior imaginary lines: L or R scapular, vertebral.
- Lateral: Posterior axillary, midaxillary and anterior axillary.
- 2nd and 5th intercostals space (ICS).
- To identify the 2nd ICS: Palpate the clavicle and follow it to the sternum; note the suprasternal notch and angle of Louis. Place 3 fingers under the suprasternal notch and palpate the bony ridge below your fingers (angle of Louis); move finger laterally to find the 2nd rib. (The 2nd rib is the first one felt since the 1st rib is beneath the clavicle). The 2nd ICS is the space beneath the 2nd rib.
- Inspect shape and look for deformities.
- Note the anteroposterior diameter compared with transverse (1:2)- AP diameter is < transverse diameter. A barrel chest is associated with pulmonary emphysema or normal aging.
- Note any retraction of the interspaces during inspiration- found in emphysema, tracheal or laryngeal obstruction. Seen in newborns.
- Palpate – respiratory excursion. Place hands over lower thorax (10th rib) with thumbs adjacent to spine should separate 1 ½” – method of determining equal expansion of the lungs
- Percussion- advanced technique. Range: resonance (hollow); hyperresonance (booming); dullness (masses, fluid).
- Inspect/ count respiratory rate (15-20/min) and note rhythm. Note respiratory effort; use of neck muscles or abdominal breathing. Observe intercostals spaces for retraction (obstruction) or bulging (emphysema).
- Palpation- may palpate for masses or crackling feeling (crepitus subcutaneous air).
Auscultation: To assess breath sounds that occurs as a result of the movement of air through the trachea, bronchi and alveoli. Use of diaphragm; have client breath through mouth, more deeply than usual. Avoid hyperventilation. Remember the right lung is divided into 3 lobes, the left into 2 lobes. Try to visualize each lobe. Apex is at the top; base at the bottom. Sounds are compared side-to-side, top to bottom; anterior and posterior. The middle lobe is best assessed on the right side under the arm.
Normal Breath Sounds: depending on where you listen, sounds may be different. Sounds may be decreased when client fails to breath deeply or is obese.
- Vesicular- inspiration > expiration; soft, low, heard in periphery and base of lungs.
- Bronchovesicular- inspiration = expiration; medium pitch, heard between scapula and anteriorly close to sternum.
- Bronchial- expiration > inspiration; loud and harsh; heard over trachea. Abnormal when heard elsewhere (pneumonia, tumor).
Adventitious (abnormal) breath sounds occur when air passes through narrowed airways filled with fluid or mucus; superimposed over normal breath sounds.
Crackles- fine, high pitched crackling sound; best heard on inspiration at the base caused by reinflation of the alveoli.
Rhonchi- low pitched, gurgling; moaning, snoring quality; heard between scapula and lateral to sternum; clear with coughing.
Wheeze- high pitched, squeaky; best heard on expiration; heard anywhere.
Documentation: Clear, if normal breath sounds are heard in all areas. Document: Clear breath sounds throughout all lung fields. Otherwise, state the abnormal sounds you have heard and where you heard it.
Function can be assessed to a large degree by findings in the history: shortness of breath (SOB), edema of ankles/legs, pain, pulse rate and rhythm; vital signs, signs and symptoms of oxygen deficit.
Location: Heart lies behind and to the left of the sternum. The upper portion or atria (BASE) lies to the back; the ventricles (APEX) points forward, the apex of the left ventricle actually touches the anterior chest wall near the left midclavicular line at or near the 5th left ICS. Known as point of maximal impulse (PMI) and is where apical beat is assessed. Impulse is a good index of heart size.
Landmarks for assessment: The precordium is the area on the anterior chest overlying the heart. Hearts sounds are heard throughout the precordium, but there are 4 major areas for examining heart sounds. Each area corresponds to one of the hearts 4 valves.
- Aortic area- 2nd ICS to right of sternum (closure of the aortic valve loudest here).
- Pulmonic area- 2nd ICS to left of sternum (closure of the pulmonic valve loudest here).
- Tricuspid- 5th ICS left of sternal border (closure of tricuspid valve).
- Mitral- 5th ICS left of the sternum just medial to MCL (closure of mitral valve). When cardiac output is increased as in anemia, anxiety, HTN, fever, the impulse may have greater force- inspect for lift or heave.
Techniques of Assessment:
- Inspection- look for lift at apex.
- Auscultation- Client should be assessed in supine position with head up to 45 deg.; examiner stands at right side. Use diaphragm for basic sounds; bell for murmurs and extra sounds.
- Identify the heart rate, rhythm; bell for murmurs aortic, pulmonic, mitral.
- Review of A&P: Blood flows from R. atrium to R. ventricle through the atrioventricular valve, the tricuspid. Blood flows from L. atrium to L. ventricle through the mitral valve. Blood passes from R. ventricle to pulmonary artery through the pulmonic valve and from the left ventricle to aorta through the aortic valve (semilunar valves). Events on the left side of the heart slightly precede those on the right.
- There are 2 basic normal heart sounds and several abnormal ones. Normal:
- S-1 (produced by closure of the atrioventricular valves, mitral and tricuspid)- at mitral area and tricuspid area S1 is louder than S2. The sound is a dull, low pitched “lub.”
- S-2 (produced by closure of aortic and pulmonic valve) is higher pitched, shorter and is the “dub” sound. Heard best at the base (aortic and pulmonic areas) where S-2 is louder than S-1
- Systole begins with the 1st sound. As ventricles start to contract, pressure within exceeds the atria, shutting the mitral and tricuspid valves. Blood is forced into the great vessels.
- When the ventricles have emptied themselves, the pressure in the aorta and pulmonary arteries force the semilunar valves shut (aortic/pulmonic), which is the 2nd sound and diastole (ventricular relaxation) begins.
Other heart sounds
- S-3 – rapid filling of the ventricle with blood; heard following S-2. Can be normal in young adults and children; pathologic in elderly.
- S-4 – atrial contraction and thought to result from stiffened left ventricle; directly precedes S-1. Heard in elderly.
- Extra sounds: snaps and clicks are associated with valves: aortic and mitral stenosis, prosthetic valves.
- Murmurs: S1 or S2 is a swishing or blowing sounds caused by
- Forward flow through a stenotic (narrowed) valve
- Increased flow through a normal valve
- Backward flow through a valve that fails to close (insufficiency).
Murmurs should be identified as systolic (S-1) or diastolic (S-2). Murmurs are common in children and occur often in the elderly. Try to identify grade of murmur: Grade I (barely audible) to Grade VI (loud and may be heard with the stethoscope not quite on the chest or barely touching the chest).
Documentation: Normally, you should be able to note that S-1, S-2 heard without extra sounds.
Peripheral Vascular System
- Assessment of BP, peripheral pulses, jugular and peripheral vessels; and inspection of skin tissues to determine perfusion to the extremities.
- Inspect neck for pulsations and jugular veins for distention. JVD refers to jugular venous distention- index of function of the right atrium.
- Advanced practitioners would auscultate the carotid artery for a bruit (blowing or swishing sound) and palpate a thrill (a vibrating sensation).
- Inspect and palpate skin of hands, feet and legs for color, temperature and edema. Unilateral coolness may be associated with decreased blood flow and should be correlated with pulse in that extremity.
- Arterial insufficiency- cool extremity, dec. or absent pulse, color changes.
- Venous insufficiency- normal temperature, normal pulses, color changes; skin changes.
- Deep vein thrombosis (DVT)- Homan’s sign: Knee flexed- pain in calf with dorsiflexion of foot. Not performed if pt. is dx’d with thrombus.
- Edema- fluid accumulation in the tissues; assess by pressing firmly with the thumb- usually over shin or medial malleolus of foot. Graded on scale of 1+ - 4+.
Description: Done by dividing the abdomen into quadrants or into 9 sections.
- Quadrants- imaginary lines crossing at the umbilicus. RUQ, LUQ, LLQ, RLQ.
- 9 sections- terms most often used are epigastric, umbilical, right and left inguinal, suprapubic.
Visualize contents of each quadrant:
- RUQ: liver, gall bladder, duodenum, colon, kidney, head of pancreas.
- LUQ: stomach, spleen, colon, kidney, pancreas.
- RLQ: appendix, ovary, urethra, colon, uterus.
- LLQ: sigmoid colon, ovary, urethra, uterus.
Techniques of examination: Use of inspection, auscultation, palpation, and percussion. General guidelines:
- Client should not have full bladder. Should be supine with pillow under head; relaxed, flat. Arms at sides, not overhead.
- Expose only abdomen from costal margin to pubis.
- Warm hands and stethoscope.
- Ask client to point to any area of discomfort.
- Skin- look for scars (describe and note location); rashes, lesions, striate, vascularities.
- Contour- is it flat, rounded; protuberant; scaphoid (concave); distended- the 6 F’s: flatus, fetus, fat, fluid, feces, and fetal growth.
- Pulsations- if found, usually the abdominal aorta.
Auscultation: To assess bowel sounds, vascular sound; in pregnancy, FHT’s are heard.
- Frequency of bowels sounds approx 5-20/min; listen 3-5/min. before reporting that they are absent.
- Describe what you hear as: audible- diminished- hypoactive- absent- hyperactive, borborygmi.
Percussion: To identify organ size and detect fluid, gas or masses.
Palpation: To detect tenderness, distention, ascities, flatus), presence of masses, bladder distention;
- Light palpation- use fingertips with fingers together in a light dipping motion (1/2- 1” deep).
- Deep palpation- advanced skill.
The Musculoskeletal System
Approach: The completeness of the exam depends to a certain extent on the needs and problems of the client.
- Muscles are inspected for strength, tone, size and symmetry. Muscle strength is graded on a 0-5 scale. Impaired strength is called paresis; hemi paresis refers to weakness on one half of the body.
- Bones for normalcy and form.
- Joints for ROM, tenderness, swelling, crepitating and nodules.
- Total body- compare one side with the other- should be symmetrical; note any gross deformities.
- Posture- head balanced midway between shoulders, shoulders aligned with hips, hips over ankles.
- Back Contour- normally, the cervical spine is concave, the thoracic spine is convex, the lumbar spine concave. Note any deformities: Kyphosis- convex curvature of the thoracic spine; Scoliosis- lateral deviation of spine; Lordosis- exaggerated concavity of lumbar spine.
- Gait- normal is balanced, coordinated walking movements.
- Extremities-compare side-to-side, compare length, muscle condition. Look for atrophy (wasting away); hypertrophy (increase in size). Note contractures.
- Range of motion- establish for each joint as needed. Describe as adduction, abduction, ext. and int. rotation, flexion and extension. In terms of foot; dorsiflexion is foot up; plantar flexion is foot down. Look for joint swelling/inflammation.
- Tone- slight residual tension- assessed by slight resistance to passive stretch.
- Muscle Strength- level of active movement against resistance- grips or push/pull of elbow.
The Neurological System:
Includes (1) mental status; (2) level of consciousness; (3) cranial nerves; (4) motor system; (5) sensory system; (6) reflexes. Most of this is advanced work but you should have a general idea of what it covers.
Level of consciousness—a continuum from alert to coma. Note if your patient is awake? Alert?
Drowsy, Lethargic? Responds to verbal stimuli? Comatose? Coma? Reacts to painful stimuli?
- Glasgow coma scale—uses objective numeral scale for measurement of consciousness in a patient in a coma or who is comatose. Measures eye opening, verbal response and motor response. The higher the score, the more normal the level of functioning.
Mental Status: reveals general cerebral function including cognitive (intellectual) and affective (emotional) function.
- Cognitive function: Determine orientation- to person, place and time (0x3). Other measures of cognitive function- intact memory, judgment, abstract thinking and knowledge, calculation. Are the client’s thought processes logical, coherent and relevant?
- Speech/language: Should be clearly articulated, not slurred. Aphasia- defects in word formation or choice of words.
- Mood and behavior: Attentive to examiner, cooperative, not distracted, irritable or hostile. Appearance reflects how client feels about self- personal hygiene, choice of clothing- appropriate to setting.
||eye movements, PERRLA, eyelids; III, IV, VI assessed together
||III, IV, VI assessed together
||facial sensations, corneal reflex
||III, IV, VI assessed together
||taste, smile, frown, close eyes tightly
||Gag reflex, swallowing, taste
||Swallowing; the vagus nerve is sometimes called the "wandering nerve" because it wanders through the body. It is a parasympathetic nerve therefore has a cholinergic effect. Stimulation of the vagus nerve can cause increased gastric secretion, bradycardia. Giving an enema or taking a rectal temperature can stimulate the vagus nerve.
||XI Spinal accessory
||Shrug shoulders, turn head against resistance
||Stick out tongue, move tongue side to side
Reflexes: Automatic response to stimulus- common one is knee jerk; biceps; triceps; reported in plusses. Babinski- normal: toes down going (plantar flexion). Babinski positive: dorsiflexion of great toe with fanning of other toes indicates upper motor neuron disease.
Motor Function: Motor pathways, corticospinal, extra pyramidal & cerebella maintain our equilibrium; mediate muscle tone and voluntary movements.
- Note gait and posture- erect; balanced, coordinated gain, arm swinging.
- Inspect muscles for tremor (involuntary); flaccidity (weakness); Spasticity (sudden involuntary contraction); contraction (rigidity).
- Compare strength bilaterally. ('Squeeze my hands')
- move all extremilties (MAE); pull and push against resistance,
Sensory Function: Sensory pathways, lateral spinothalamic, anterior spinothalamic, & posterior column, conveys crude and fine touch, pain and temperature and position and vibration.
- Simple assessment of client’s sensory ability: Does client complain of any numbness, tingling or any unusual feeling in an extremity (parestheses). Assess ability to feel light touch by touching lower extremities lightly; compare side to side.
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