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2
Fundamental physicalassessment techniques
A look at physical assessment 
Physical assessment is generally the vitally important second step in theassessment process, following your history. Your history will guide youregarding the nature of the physical assessment that you need to carry out. During the physical assessment you’ll use a systematic approachto build on your history, using the key assessment skills of inspection,palpation, percussion and auscultation. As you proceed through theexamination, you may well also have the opportunity to engage in somehealth promotion, for example regarding the value of exercise. Morethan anything else, successful assessment requires critical thinking.Don’t just look at findings in isolation. Look at your findings as a whole,and consider how one particular finding fits into the bigger picture.
Collecting the tools
Before starting a physical assessment, ensure the necessary tools areto hand. These will vary depending on the nature of the assessmentthat you are about to carry out, but will most commonly include a
In this chapter, you’ll learn:
♦
skills for performing an initial observation of thepatient
♦
ways to prepare your patient for an assessment
♦
techniques for performing inspection, palpation,percussion and auscultation.
 Just the facts
Performinga physicalassessmentgives me theopportunity to usecritical thinking.
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34FUNDAMENTAL PHYSICAL ASSESSMENT TECHNIQUES
stethoscope, gloves and a pen torch. Neurological examinations, inparticular, require additional equipment.
Two heads are better than one
 You’ll need a stethoscope with both a diaphragm and a bell toauscultate sounds of varying pitches. (See
Choosing the right  stethoscope
below.)
All the better to see you with . . .
 You may well need a pen torch to illuminate the inside of thepatient’s nose and mouth, to evaluate pupillary reactions, to casttangential (sideways) light on the neck to view jugular venouspressure or to more clearly see any ‘lumps and bumps’.
Remember that the bell of astethoscope is used to hear low-pitchedsounds and thediaphragm is used to hear high-pitchedsounds. Be
l
l and
l
ow both contain theletter
l
.
Memory jogger 
Choosing the right stethoscope
Use a stethoscope with a diaphragm and a bell. The diaphragm has a flat, thin,plastic surface that picks up high-pitched sounds such as breath sounds. Thebell has a smaller, concave, open end that picks up low-pitched sounds, suchas some abnormal heart sounds and some vascular sounds. A good qualitystethoscope generally gives clearer sound.
Only one head . . .
Some stethoscopes appear to have a single head (just a diaphragm). These arecardiac (or cardiology) stethoscope. The single head works as a bell with lightpressure and a diaphragm with firm pressure.
. . . or two diaphragms . . .
Some stethoscopes seem to have a large and a small diaphragm. Don’t mistake the small diaphragm for an unusual looking bell. These stethoscopes work like acardiac stethoscope, but offer the choice of two sizes of end-piece. The largerone is able to cover a larger surface area, and the smaller end-piece is for usewith infants and small children, or to assess small areas such as the apices of thelungs which sit under the hollow just above the clavicle.
. . . or just seems tiny.
Some stethoscopes have a head that looks much smaller than normal. Theseare paediatric stethoscopes, especially designed for use with infants and smallchildren.
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35
Beginning the examination
 The first part of the physical assessment concerns forming yourinitial impressions of the patient and obtaining baseline data. Inthe acute or emergency care situation, always remember ABCDE(Resuscitation Council UK 2006) as the priority for any patientassessment. Initial assessment focuses sequentially on ABC – airway,breathing and circulation. Once these have been deemed stable,or have been stabilised, remaining elements of the assessment canproceed (Mackway-Jones
et al.
2005). The next priority is then D (fordisability), which includes assessing level of consciousness; the AVPUtool will be helpful here. (See
 Interpreting level of consciousness and vital  signs 
, page 38.) Pupil reaction and blood glucose monitoring may alsobe indicated at this point; in some cases a full Glasgow Coma Score will be required. Finally E (for exposure) includes viewing the exposedbody if required, and assessing temperature and skin condition/rashes.
The mnemonic SOME TEAMS might be a helpful checklist to remind you about some key points as you make yourinitial general observation of the patient.
S
ymmetry – Are face and body symmetrical?
O
lder or younger – Does the patient look notably older oryounger than his/her given age?
M
ental acuity – Is the patient alert, confused, agitated orinattentive?
E 
xpression – Does the patient appear distressed, in painor anxious?
T
runk – Does the patient seem a normal weight, thin orobese? Is the chest a normal shape?
E 
xtremities – Are there any problems with the nails/hands.Are there any joint abnormalities or swelling?
 A
ppearance – Is the patient clean and well groomed?
M
ovement – Are posture, gait and coordination seeminglynormal?
S
peech – Is speech relaxed, clear, strong, understandableand appropriate? Does it indicate any signs of stress?
Memory jogger 
BEGINNING THE EXAMINATION
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