Physical assessment

Introduction

A physical assessment involves four basic techniques: inspection, palpation, percussion, and
auscultation. Correct performance of these techniques helps elicit valuable information about a
patient's condition.

Inspection requires the use of vision to observe details of the patient's appearance, behavior, and
movement. Use of special lighting and various pieces of equipment—such as an otoscope, a tongue
blade, and an ophthalmoscope may help you enhance your vision or examine an otherwise hidden area.
Inspection begins during the first patient contact and continues throughout the assessment.

Palpation usually follows inspection, except when examining the abdomen or assessing infants and
children. Palpation involves touching the body to determine the size, shape, and position of structures;
detect and evaluate temperature, pulsations, and other movement; and elicit tenderness. The four
palpation techniques are light palpation, deep palpation, light ballottement, and deep ballottement.

Ballottement evaluates a flowing or movable structure. Performing ballottement involves applying

pressure against the structure you're assessing and then waiting to feel it rebound. For example, this
technique is useful for checking the position of an organ or a fetus.

Percussion involves a quick, sharp tapping of the fingers or hands against a body surface to produce
sounds, detect tenderness, or assess reflexes. Percussing for sound helps locate organ borders, identify
organ shape, and position, and determine whether an organ is solid or filled with fluid or gas. Organs
and tissues produce sounds of varying loudness, pitch, and duration depending on their density. For
example, air-filled cavities (such as the lungs) produce markedly different sounds from those produced
by the liver and other dense organs and tissues. Percussion techniques include indirect percussion,
direct percussion, and blunt percussion.

Auscultation involves listening to various sounds of the body, particularly those produced by the heart,
lungs, vessels, stomach, and intestines. Most auscultated sounds result from the movement of air or
fluid through these structures.

You'll usually perform auscultation after the other assessment techniques. When examining the
abdomen, however, you should perform auscultation after inspection but before percussion and
palpation, which can alter bowel sounds. When assessing infants or young children, you also should
perform auscultation before percussion and palpation because they may start to cry when palpated or
percussed. Auscultation is most successful when performed in a quiet environment with a properly
fitted stethoscope.
Assessment techniques
• Gather and prepare the equipment and supplies.
• Perform hand hygiene.
• Confirm the patient's identity.
• Provide privacy.
• Explain the procedure.
• Ask the patient to undress and then drape the patient.
• Make sure that the room is warm and adequately lit.
• Warm your hands and stethoscope.
• Perform hand hygiene.
• Put on gloves, if needed.
1) Inspection
• Use your eyes to observe the patient. Focus on areas related to the patient's reason for seeking
care.
• To inspect a specific body area, expose it sufficiently; survey the entire area; identify its color,
shape, texture, size, and movement; and note unusual and expected findings.
2) Palpation
• Tell the patient what to expect and encourage relaxation.
• Provide just enough pressure to assess the tissue beneath one or both hands. Then release the
pressure and gently move to the next area.
• For light palpation, indent the skin ½" (1.3 cm).
• For deep palpation, indent the skin ¾" to 1½" (2 to 4 cm).
• For light ballottement, apply light, rapid pressure, keeping your hand on the skin.
• For deep ballottement, apply abrupt, deep pressure and then release it. Maintain fingertip
contact.
• For bimanual palpation, trap an organ between both hands or stabilize the organ with one hand
and palpate it with the other.
3) Percussion
• Decide which percussion technique to use.
• For indirect percussion, tap the middle finger of your nondominant hand with the middle finger
of your dominant hand.
• For direct percussion, tap your hand or finger against the body surface.
• For blunt percussion, strike your fist's ulnar surface against the body surface (or against your
other hand, resting on the body surface).
4) Auscultation
• Decide whether to use the stethoscope diaphragm or bell.
• Place the diaphragm or bell over the appropriate area. Place the earpieces in your ears.
• Determine the characteristics of the sounds and the frequency of recurrence.
Completing the procedure
• Remove and discard your gloves, if worn.
• Perform hand hygiene.
• Disinfect your stethoscope.
• Perform hand hygiene.
• Document the procedure.
Special Considerations
• Avoid palpating or percussing an area of the body known to be tender at the start of your
examination. Instead, work around the area and then gently palpate or percuss it at the end of
the examination. This progression minimizes the patient's discomfort and apprehension.
• Perform a variation on deep palpation to pinpoint an inflamed area deep within the patient's
body: Press firmly with one hand over the area you suspect is involved. Then lift your hand away
quickly. If the patient reports that pain increases when you release the pressure, you've
identified rebound tenderness.
Clinical alert:
Suspect peritonitis if you elicit rebound tenderness when examining the abdomen.
• If you can't palpate because the patient fears pain, try distracting the patient with conversation.
Then perform auscultation, and gently press your stethoscope into the affected area to try to
elicit tenderness.
Complications
Palpation can cause an enlarged spleen or infected appendix to rupture

Neurologic assessment
• Perform hand hygiene.
• Confirm the resident's identity.
• Provide privacy.
• Explain the procedure.

Assessing level of consciousness (LOC) and orientation

• Assess the resident's LOC.
• Assess the resident's ability to understand and follow one-step commands that require a motor
response.
• If the resident doesn't respond to commands, use a central stimulus. Check motor responses
bilaterally.

Examining pupils and eye movement

• Ask the resident to open the eyes. If the resident doesn't respond, lift the upper eyelids gently.
Inspect pupils for size and shape and compare them for equality.
• Darken the room slightly.
• Test each pupil's direct response to light and consensual response by holding a penlight 20″ (51
cm) from each eye, directing the light from the side.
• Brighten the room.
• Ask a conscious resident to open the eyes. Observe the eyelids for ptosis; check extraocular
movements.
• Test accommodation by placing your finger about 4″ (10 cm) from the bridge of the resident's
nose. Ask the resident to look at a fixed object in the distance and then at your finger. Expect
the eyes to converge and the pupils to constrict.
• Test peripheral field by bringing a pencil or other object in from the side and having the resident
state when the object enters the field of vision.
• Test the corneal reflex by touching a wisp of cotton ball to the cornea. Expect an immediate
blink reflex. Repeat for the other eye.
Evaluating motor function
• If the resident is conscious, test grip strength in both hands at the same time. Extend your hands
with your index and middle fingers extended outward, ask the resident to squeeze your fingers
as hard as possible, and compare the strength of each hand.
• Test arm strength by having the resident close the eyes and hold the arms straight out in front
with palms up. Observe whether either arm drifts downward or pronates.
• Test leg strength by having the resident raise the legs against gentle downward pressure from
your hand, one at a time.
• Flex and extend the extremities on both sides to evaluate muscle tone.
• Test the plantar reflex.

Evaluating sensory function

• To test for pain sensation, have the resident close the eyes and touch various areas of the
resident's body with a safety pin, alternating between the sharp and dull ends.
• Test the resident's sense of light touch using a wisp of cotton while the resident's eyes remain
closed. Ask the resident to respond to the sensation. Compare responses on opposite sides of
the body.
• To test vibratory sense, apply a tuning fork over different bony prominences while the resident
keeps the eyes closed. Ask the resident to tell you when the sensation stops. Touch the fork to
stop it.
• Assess position sense by grasping the resident's big toe, holding it by its sides between your
thumb and index finger and then pulling it away from the other toes. Show the resident up and
down as you move the toe clearly upward and downward. Then have the resident close the eyes
and tell you whether you're moving the toe up or down as you move the large toe in an arc.
Repeat several times on each side.
• To test stereognosis, have the resident close the eyes. Place a familiar object in the resident's
hand and ask the resident to identify it.
• If motor impairment prevents the resident from identifying the object in this manner, draw a
number in the palm using the blunt end of a pen or pencil and have the resident identify it.
• Test point localization by touching one of the resident's limbs while the resident has the eyes
closed. Then ask the resident to identify the location of the touch.
• Test two-point discrimination by touching the resident simultaneously in two contralateral areas
with an opened paper clip. Find the minimal distance at which the resident can discriminate one
point from two points.

Completing the procedure

• Obtain the resident's temperature, pulse rate, respiratory rate, and blood pressure.
• Perform hand hygiene.
• Document the procedure.
Neurovascular assessment
Introduction
A neurovascular assessment is a procedure that assists in determining the neurologic and vascular
integrity of a patient's extremity. The major components of a neurovascular assessment include
assessing the patient's extremities for pain, pallor, and perfusion (capillary refill), pressure, pulses,
paresthesia, paralysis, and skin temperature. Neurovascular assessment is essential for identifying
neurovascular disorders and preventing secondary ischemic injury in a patient
with musculoskeletal injury, trauma or surgery to an extremity, a cast, restrictive bandages, traction, or
limb restraint. Early detection of a compromised extremity from neurovascular impairment enables
prompt treatment that can help to prevent permanent debilitating damage. Neurovascular assessment
is necessary whenever a patient has a suspected or observed neurovascular condition. The frequency
with which neurovascular assessment is necessary depends on the patient's condition.
Clinical alert:

Note whether the patient complains of severe pain that worsens with movement and is unrelieved by
pain medication because such pain may be an early sign of compartment syndrome. Notify the
practitioner immediately if you notice these symptoms.19 Acute compartment syndrome, a rare but
serious complication, can occur following extremity injury. The patient may complain of extreme pain in
the extremity that occurs when pressure within the muscles builds to dangerous levels. This pressure
may decrease blood flow and tissue oxygenation that, without quick correction, can lead to permanent
nerve damage and loss of the affected limb. Compartment syndrome is most common in the lower leg
and in the forearm, but it can also occur in the hand, foot, thigh, and upper arm. Because necrosis and
nerve injury can occur after 6 hours of ischemia, perform frequent neurovascular assessments and be
alert for complaints of increased pain or decreased effectiveness of analgesics.
Neurovascular assessment
• Review the patient's medical record for risk factors for neurovascular compromise.
• Perform hand hygiene.
• Confirm the patient's identity.
• Provide privacy.
• Explain the procedure.
• Screen for and assess the patient's pain using facility-defined criteria.
• Ask the patient about changes in sensation in the affected extremity.
• Raise the bed to waist level.
• Perform hand hygiene.
• Put on necessary personal protective equipment.
• Palpate the affected extremity for pulses proximal and distal to the injury. Compare findings
bilaterally. Record pulse presence and volume (strength). Use a Doppler ultrasound device (if
available) if you can't palpate a pulse using the pads of two fingers.
• Use a marking pen to place an "X" over the pulse site if the pulse is weak or difficult to palpate.
Notify the practitioner immediately if you're unable to locate a pulse.
• Assess capillary refill time in the affected extremity.
• Assess the extremities for swelling and note patient complaints of pressure.
• Unless contraindicated, check for range of motion and strength of the joints above and below
the patient's affected extremity. Compare both extremities for symmetry and movement. Note
any paralysis or complaints of pain upon passive extension. Report paralysis immediately to the
practitioner.
• In an alert, communicative patient, assess the affected extremity for sensation by touching
areas above and below the injury with your fingertips or a cotton swab, evaluating for normal,
impaired, or absent responses.
• Assess the affected extremity for discoloration compared to the opposite extremity.
• Assess the skin for excessive warmth or coolness above or below the injury compared to the
opposite extremity.
• Assist the patient to a comfortable position.
• Treat the patient's pain, as needed, and ordered.
• Notify the practitioner of any abnormal findings immediately.
• Return the bed to the lowest position.
• Remove and discard your personal protective equipment.
• Perform hand hygiene.
• Reassess and respond to the patient's pain.
• Perform hand hygiene.
• Document the procedure.
Special Considerations

• Assess the neurovascular status of any extremity with a cast for signs of compromise. Note any
inability to assess pulses due to the presence of casts or splints.
• If the patient's extremity is immobilized, check distal pulses, circulation, sensation, and mobility.
Stretch the patient's fingers or toes to elicit associated pain.

Patient Teaching

Teach the patient and family about the underlying condition and the care plan, including the purpose of
and need for frequent neurovascular assessments. Discuss lifestyle changes the patient should make to
enhance circulation. Teach the patient appropriate positioning to enhance blood flow and venous
return. Discuss signs and symptoms of impaired circulation that the patient should immediately report.

Complications

Failure to assess and properly recognize changes in the patient's neurovascular status can lead to
ischemic injury and tissue death.

Documentation

Document the date and time you performed the neurovascular assessment and your assessment
findings. Record the name of the practitioner you notified of any abnormal assessment findings, the
date and time of the notification, any prescribed interventions, and the patient's response to those
interventions. Document teaching provided to the patient and family (if applicable), their understanding
of that teaching, and any need for follow-up teaching.
Respiration assessment
Introduction
Controlled by the respiratory center in the lateral medulla oblongata, respiration is the exchange of
oxygen and carbon dioxide between the atmosphere and body cells. The diaphragm and chest muscles
perform external respiration, delivering oxygen to the lower respiratory tract and alveoli.

Four measures of respiration (rate, rhythm, depth, and sound) reflect the body's metabolic state,
diaphragm and chest-muscle condition, and airway patency. Respiratory rate is recorded as the number
of cycles (with one cycle comprising inspiration and expiration) per minute; rhythm, as the regularity of
these cycles; depth, as the volume of air inhaled and exhaled with each respiration; and sound, as the
audible deviation from normal, effortless breathing. The normal respiratory rate for an average adult is
12 to 18 breaths/minute. However, knowing a patient's normal baseline respiratory rate allows
detection of changes in the patient's condition. The best time to assess a patient's respirations is
immediately after taking the pulse rate, although the patient's breathing should be observed with each
patient contact.

Respiration assessment

• Gather and prepare the equipment and supplies.

• Perform hand hygiene.
• Confirm the patient's identity.
• Provide privacy.
• Explain the procedure.
• Perform hand hygiene.
• Put on personal protective equipment, as necessary.
• Place your fingertips over the patient's radial artery.
• Count respirations by observing the rise and fall of the patient's chest during breathing.
• Count for 30 seconds and multiply by two to determine the respiratory rate. Count for 60
seconds, if breathing is irregular.
• Be alert for stertor, stridor, wheezing, and expiratory grunting.
• Observe chest movements for depth of respirations.
• Listen to breathing.
• Auscultate breath sounds with a stethoscope.
• Observe for accessory muscle use.
• Remove and discard gloves and other personal protective equipment if worn.
• Perform hand hygiene.
• Clean and disinfect your stethoscope.
• Perform hand hygiene.
• Document the procedure.
IDENTIFYING RESPIRATORY PATTERNS
Type Characteristics
Apnea Absence of breathing; may
be temporary or periodic
Bradypnea Slow, regular respirations
of equal depth
Cheyne-Stokes Gradual increase in
respiratory rate and tidal
volume, then gradual
decrease to complete
apnea, which may last
several seconds before
gradual increase again as
cycle repeats
Eupnea Normal rate and rhythm
Kussmaul Rapid (over 20
breaths/minute), deep
(resembling sighs), labored
respirations without pause
Tachypnea Rapid respirations: rate
increase corresponds to
increase in body
temperature—about four
breaths/minute for every
1° F (0.6° C) above normal
Pattern Possible causes
• Mechanical airway obstruction
• Conditions that affect the brain's
respiratory center
• Normal pattern during sleep
• Conditions that affect the brain's
respiratory center, such as tumors,
metabolic disorders, and respiratory
decompensation
• Use of opiates, alcohol, or both
• Increased intracranial pressure
• Severe heart failure
• Kidney failure
• Meningitis
• Drug overdose
• Cerebral anoxia
• Normal respiration
• Kidney failure
• Metabolic acidosis, particularly diabetic
ketoacidosis
• Pneumonia
• Compensatory respiratory alkalosis
• Respiratory insufficiency
• Lesions in the brain's respiratory center
• Salicylate poisoning
 UNDERSTANDING BREATH SOUNDS
The four types of breath sounds you'll hear over normal lungs are:
• tracheal heard over the trachea; harsh and discontinuous
• bronchial usually heard over the fourth intercostal space, between the sternum and the midclavicular line;
loud, high-pitched, and discontinuous; loudest when the patient exhales
• bronchovesicular—heard when the patient inhales or exhales; medium-pitched and continuous; best heard
over the upper third of the sternum and between the scapulae
• vesicular heard over the rest of the lungs; soft and low-pitched; prolonged during inspiration and shortened
during expiration.
Considered abnormal no matter where you hear them over the lungs, adventitious breath sounds include:
• crackles: intermittent, nonmusical, brief crackling sounds caused by collapsed or fluid-filled alveoli popping
open; heard primarily during inspiration; classified as fine or coarse; usually don't clear with coughing unless
caused by secretions
• wheezes: high-pitched sounds heard first during expiration; result from blocked airflow; also heard during
inspiration when airflow is severely blocked
• rhonchi: low-pitched snoring, rattling sounds that occur primarily during exhalation; usually due to fluid or
secretions in the large bronchial airways; may change or disappear with coughing
• stridor: loud, high-pitched crowing sound that occurs during inspiration; typically audible without a
stethoscope; caused by obstruction of the upper airway; requires immediate intervention
• pleural friction rub: low-pitched grating, rubbing sound heard during inhalation and exhalation; results from
pleural inflammation that causes the two layers of the pleura to rub together; may result in pain in the areas
where the sound is heard.

Special Considerations
• When assessing respiratory status, consider the patient's personal and family history. Ask the patient about smoking. If the
patient smokes, ask for how many years and how many packs per day.
• A more detailed assessment (including palpating the chest for lymph node abnormalities, assessing tracheal position, and
percussing for signs of fluid or trapped air in the chest) may be necessary for a patient with a respiratory disease, such as
chronic obstructive pulmonary disease or asthma.
• If the patient's respiratory rate suddenly increases, assess for other signs and symptoms of respiratory distress, such as
anxiety, nasal flaring, accessory muscle use, abnormal breath sounds, grunting, and cyanosis. To detect cyanosis, look for
the characteristic bluish discoloration in the nail beds, on the lips, under the tongue, in the buccal mucosa, and in the
conjunctivae. Report your findings to the patient's practitioner.
• If the patient's respiratory rate suddenly decreases, assess for an underlying cause. Notify the patient's practitioner, as
necessary.
• If you find the patient unresponsive, shout for nearby help and activate the emergency response system via mobile device
(if appropriate). Check for absent breathing or only gasping while simultaneously checking for a pulse to minimize delay in
detecting cardiac arrest and initiating cardiopulmonary resuscitation (CPR). If the patient has a pulse but inadequate
breathing, administer one rescue breath every 5 to 6 seconds; check the patient's pulse about every 2 minutes. If breathing
is absent or if the patient is only gasping and you don't feel a pulse within 10 seconds, take these steps:
• Have a coworker retrieve the defibrillator (or automated external defibrillator [AED]) and other emergency equipment. If
you're alone, retrieve them yourself.
• Immediately begin chest compressions. Continue until the defibrillator (or AED) is ready for use. Compress an adult's chest
at a rate of 100 to 120 compressions per minute, with a compression depth of at least 2" (5 cm) for an average adult but
not to exceed a depth of 2.4" (6 cm). Avoid leaning on the chest between compressions to allow full chest wall recoil.
• After 30 compressions, open the patient's airway and deliver two breaths (with each breath about 1 second long). Continue
CPR using a ratio of 30 compressions to two breaths. When the defibrillator is ready for use, check the patient's rhythm and
defibrillate for a shockable rhythm; otherwise, continue CPR.