Professional Documents
Culture Documents
Physical Assessment
Physical Assessment
This RLE will enable the students to develop beginning skills in physical assessment which is an important
part of the nursing process.
Introduction:
Assessment is an important part of the nursing process because it provides data from which the nurse can
make the nursing diagnosis and plan, implement and evaluate nursing care. A complete physical assessment is
performed for:
1. Routine screening to promote preventive health care;
2. Determination of eligibility for health insurance, military service or a new job.
3. Admission to a hospital or long-term care agency.
I.
II.
III.
1.
Sitting Position
A seated position, back unsupported and legs hanging freely; allows the
nurse to assess the head, thorax, breasts, upper and lower extremities,
vital signs, reflexes.
2.
Supine Position
The client lies on his back with legs stretched out together; used for the
examination of the breasts, anterior thorax, axillae and peripheral
pulses; the most comfortable position for most patient since it is the
most normally relaxed position.
3.
Dorsal Recumbent
The client lies on his back with knees flexed, legs separated, hips
externally rotated and soles of feet flat on the table; used to examine
abdomen, genitalia, and rectum.
4.
Lithotomy Position
The client lies on her back with the buttocks placed at the edge of the
table, knees are flexed, and feet are supported in stirrups; used for the
examination of the female genitalia, genital track, and rectum.
5.
Sims Position
Side-lying position with lower arm behind the body, upper arm placed
forward with elbow flexed and arm resting on a pillow; lower knee is
flexed slightly and upper knee is flexed sharply on the abdomen; used
for the digital examination if the rectum and the vagina.
6.
Knee-Chest or
Genupectoral Position
With the head turned to one side, the client rests on his
knees and chest, with his lower legs, perpendicular to his thighs, arms
are [placed on his head or flexed at the elbow; used for instrument
examination of the rectum.
IV.
1.
Order of Examination
2.
Preparation of
Environment
3.
Peparation of
Equipment
4.
Physical Preparation
of the Client
5.
Psychological Preparation
V.
penlight
weighing scale
stethoscope
sphygmomanometer and cuff
thermometer
tongue depressor
wristwatch with second hand
cardboard
Shellens chart per section
d.
e.
2. Palpation
Palpation is the examination of the body using the sense of touch. The
nurse uses different parts of the hand to detect characteristics such as
texture,
temperature, vibration, position, size, consistency, and mobility
of organs or masses, and tenderness
of pain. For example, the nurse
uses the pads or balls of the fingers to detect the
pulsation, texture,
shape, size, and consistency; the dorsum of the hand to detect
vibration;
the fingertips to palpate small section of the body, such as the cervical
lymph node, because they cam make fine tactile discriminations; and
the fingers can be
used in a grasping movement to assess skin turgor.
3. Percussion Percussion is the technique of tapping a [part area of the body with the
fingertips or percussion hammer in order to elicit the character and
density of the underlying
tissues. It helps in determining whether the
underlying tissues are air filled, fluid-filled, or solid.
There are two (2) methods of percussion; the direct and indirect
percussion. In direct percussion, the nurse strikes or taps the body
surface directly with the index or middle finger of the non-dominant
hand (called the pleximeter) firmly against the body surface, keeping
the palm and the remaining fingers off the skin in order not do damp the
sound. The tip of the middle finger of the dominant hand (called plexor)
strikes the distal interphalangeal joint. In both methods, the strikes are
rapid, and the movement is from the wrist.
Percussion elicits five types of sounds:
a.
b.
c.
d.
e.
4.
VI.
Auscultation
Physical Measurements
1.
Height
the nurse measures height with a measuring stick (or tape measure)
attached to weight scale or to a wall. The client removes his shoes and stands erect, with
heels together. Buttocks and head against the measuring stick. The nurse raises the Lshaped sliding arm on the weighing scale until it rests on top of the clients head, or place
a small flat object, such as a ruler, on the clients. With this object placed level
horizontally at 90 degree angle to the measuring stick, the nurse measures height in
inches or cms.
2.
Weight
To measure the weight, the client is made to stand on a platform, and
the weight is read from a digital display panel or a balancing arm. Make sure the client
wears light clothing only and no shoes.
VII.
B. Measurements
1.
2.
Head
a.
b.
c.
d.
e.
f.
g.
h.
2.
3.
4.
5.
6.
7.
8.
skull
scalp
hair
face
eyes
ears
nose
mouth
neck
anterior thorax
posterior thorax
abdomen
upper extremities
lower extremities
breasts
General Appearance
1.
2.
Signs of Distress
3.
Posture
4.
Body movements
5.
6.
Type of Clothing
Technique
Normal Findings
Palpation
=======
size, shape or contour
symmetry and curvature
A. Head
1. Skull
2. Scalp
Inspection
3. Hair
Palpation
======
areas of tenderness
no areas of tenderness
Inspection
=======
Inspect for the color
distribution,. thickness,
lubrication/appearance
Palpation
======
palpate for texture
coarse or fine
Note:
Terminal Hair: is the long, thick and coarse hair of the body which is easily visible on the
scalp, axilla and the public area
Vellus Hair: is the soft, small, tiny hair that covers the whole body except for the palms and the soles.
Body Parts
Technique
Normal findings
4. Face
Inspection
========
5. Eyes
Inspection
========
observe for placement,
symmetry, protrusion,
and clarity and lacrimation
6. Eyebrows
Inspection
========
Observe for the color,
symmetry, quantity of hair
distribution and placement
or parallelism.
7. Eyelashes
Inspection
========
Observe for the color,
distribution and direction.
8. Eyelids
Inspection
========
As the client to close eyes
Observe for position and
symmetry, then ask him to
open eyes again
Palpation
=======
10. Sclera
11. Sclera
12. Pupils
Inspection
=======
Ask client to look up and
Pull the lower lid down.
Observe for color and
appearance.
Inspection
=======
Note color and clarity
Inspection
=======
Note clarity and texture
Inspection
=======
Note size, shape,
symmetry
Reaction to light and
*accommodation
Testing for
Eye
Movement
Inspection
========
Note size, color, and
symmetry
Inspection
========
Stand directly in front of
the
Client of the client and
hold
The finger at about one ft.
in from of the clients
eyes.
Able to move eyes in full rang
Ask client to refrain from
Moving his head and
Motion or able to move in all
follow
The direction of the
Direction.
examiner
Fingers with his eyes only.
Move the finger in a slow
orderly manner through
the cardinal fields of gaze.
Testing for
Inspection
=======
Note parallelism,
symmetry size, position,
color and appearance.
Palpation
Palpate for the firmness of
the cartilage of the
auricles.
Ear Canal
Hearing
Acuity
Inspection
=======
By using a penlight
examine the ear canal by
pilling the pinna up and
back for adults, down
and back for children.
Inspect for color,
appearance, presence of
cerumen, foreign bodies
and presence of cilia.
Inspection
=======
Whisper from the clients Able to hear a whisper spoken 2 feet
ear at a distance of 2 feet
away.
(one ear at a time and then
at the back of the client for
both ears.
Instruct the client not to
move his head and to
repeat the words that you
will say.
Nose
Inspection
=======
Note placement,
symmetry and patency
NOTE: Ask client to close one nostril at a time and ask if he has
any difficulty in breathing while one nostril is covered.
Internal
Nares
Septum
Inspection
=======
Note appearance, color of
mucus membrane,
presence of cilia.
Inspection
Observe appearance
straight
16. Mouth
Lips
Inspection
=======
Observe for color, shape,
symmetry, lip margin,
appearance.
NOTE: Ask client to open his mouth wide and to move his
tongue if necessary for better visualization of the following parts.
Ask him to say Ah-h and depress the tongue at the side to see the
throat. A penlight maybe necessary.
Gums
Teeth
Tongue
Frenulum
Cheeks
(buccal
mucosa)
Palate
Soft
palate
Hard
palate
Inspection pinkish,
=========
Observe for color,
Appearance, discharge and
swelling or retraction
Inspection
========
Note number, color
alignment, general
condition, breath odor
Inspection
=======
Inspect for size, color
surface, appearance and
movement
Inspection
Midline, straight and thin
========
position and appearance
Inspection
========
Pinkish, smooth and moist
Note color and appearance
Inspection
========
note color and appearance
Inspection
========
Uvula
Tonsils
Voice
16. Neck
17.
Muscular
Strength
18. Thorax
Palpation
No lumps/masses or areas of
=======
tenderness on palpation
palpate for lumps, masses
and areas of tenderness
Measure chest excursion
Chest excursion equal/symmetrical.
by placing hands on the
Thumbs move apart in equal distance
lower rib cage with
at the same time (Normally thumbs
thumbs 2 inches apart
separate 1 to 2 inches during deep
pointing toward the spine inspiration.
so a small fold of the skin
appears between the
thumbs. Ask client to take
a few deep breaths.
Elicit tactile fremitus by
Bilateral symmetry of vocal fremitus.
placing the palms of the
It is normally decreased over heart &
hands bilaterally
breast tissue. Low pitched voices of
symmetrical on the chest
male are more readily palpated than
starting from the top of the higher pitched voices of females.
chest wall going down.
Each time the hands move
down, ask the client to say
ninety-nine or one-one
with the same intensity of
voice.
Percussion
Percussion notes resonate except over
========
scapula
Use indirect percussion in
the ICS over symmetrical
areas of the chest starting
from the supra clavicular
area. Compare one side of
the chest with the other.
(Note: if the posterior thorax is used , the clients arms should be folded forward
across the chest in a sitting position)
Auscultation
==========
Clear breath sounds heard.
Auscultate the chest using (bronchovesicular and vesicular sound)
a flat disc diaphragm
observing the same zigzag
procedure used in
percussion. Ask client to
take slow, deep breaths
through mouth.
19. Heart
Inspection
No pulsations noted in the aortic,
========
pulmonic and tricuspid areas.
Inspect and
simultaneously palpate the
valves of the heart with
the client in supine
position.
(Note: The health care provider stands on the clients right side and asks client
not to talk)
Place ball of 1-2 fingers
on the 2nd ICS at the right
of the angle of Louis for
the aortic valve.
Place ball of 1-2 fingers
on the 2nd ICS at the left
of the angle of Louis for
the pulmonic valve.
Move the fingers along
the clients left sternal
border to the 5th ICS for
the tricuspid valve
Move the fingers laterally
to the left-mid clavicular
line which is slightly
below the nipple for the
apical area.
Place fingers at the base
of the sternum for the
epigastric area.
Auscultation
=========
Auscultate the heart in all
anatomic areas: aortic,
pulmonic, tricuspid, and
apical. (Counts the cardiac
rate for 1 full minute at the
eapical area)
20. Breasts
Inspection
========
Inspect the breasts for
size, symmetry and
contour, shape, color,
retraction, or dimpling
Palpation
=======
Palpate the breasts for
lumps, masses, tenderness,
and consistency of breast
tissues using palmar
surfaces of the first three
fingers. Perform palpation
in a clockwise rotary
motion, from the borders
going inward.
(Note: Client is in supine position with the hand placed under the head)
Areola
Nipples
21.
Abdomen
Inspection
========
Inspect for size, shape,
color and symmetry
Palpation
=======
Palpate for masses and
tenderness
Inspection
========
Inspect for size, shape,
position, discharges and
lesions
Palpation
=======
Compress the nipples
using thumb and index
finger to determine any
discharge
Inspection
========
22. Upper
extremities
Inspection
========
Inspect the appearance of
Inspection
=======
Convex in curvature
Inspect nails for shape and
color
Palpation
=======
Smooth in texture; prompt return of
Palpate nails for texture
usual color upon release of pressure
applies a little pressure on
the nailbed with the thumb
and then quickly realeses
the pressure
Mobility
d. wrists- flexion,
extention, radial and
ulnar flexion
e. hands and fingersflexion, extension
Equality of strength noted
Holds clients hand
in a hand shake
manner and ask
client to press hard
as possible.
Compares right and
left muscle strength
23. Lower
Extremities
Inspection
========
Inspect for symmetry, size,
length and presence of
abnormalities. Note the
pattern of hair distribution,
color and presence of
varicose veins. Inspect for
cleanliness of feet and toes
including skin lesions and
number of toes.