1

Physical Assessment

Jennylyn C. Guadalupe, RN

Health History – provides the examiner with complete health profile that guides all aspects of the physical examination. It begins with questions that focus on problems a symptom of concern to the patient.

Chief Complaint - reason for seeking care

2

Purposes of Physical Examination

The nurse uses physical assessment for the following reasons:

To gather baseline data about the client’s health To supplement, confirm or refute data obtained in the

nursing history To confirm and identify nursing diagnoses To make clinical judgments about a client’s changing

health status and management Physical examination – usually performed after the

health history is taken.

3

Preparation of Examination

Environment

Equipment

Psychological Preparation

Physical Preparation

Positioning  

4

“ ORGANIZED & SYSTEMATIC EXAMINATION” – key to appropriate Data in a least possible amount

of time

5

Order of Examination

General Survey – includes observation of general appearance and behavior, vital signs, height and weight measurement Review of systems Head to toe examination

6

INSTRUMENTS

  senses of vision, hearing, touch, and smell. Those

human senses may be augmented by special instruments or tools e.g. Stethoscope, OPTHALMOSCOPE)

7

EXAMINATION TECHNIQUE

Patient’s Positioning and Prepping SEATED: when seated, the drape should cover the patient’s lap and

legs. It can be moved to uncover parts of the body as they examined.

8

Patient’s Positioning and Prepping SUPINE: the patient lies on his or her back, with arms

at the sides and legs extended. The drape should cover the patient from chest and knees or toes. Again, you can move or reposition the drape to give appropriate exposure.

PRONE: the patient lies on his or her stomach. This position may be used for special maneuvers as part of the musculoskeletal examination. Drape the patient to cover the torso.

9

Patient’s Positioning and Prepping

DORSAL RECUMBENT: use for genital or rectal areas. The patient lies supine with knees bent and feet on the table. Place the drape in a diamond position from chest to toes. Wrap each leg with the corresponding lateral corner of the ‘diamond”. Turn back the distal corner of the drape to perform the examination.

LATERAL RECUMBENT: This is a side lying position, with legs extended or flexed. The left lateral recumbent position (patient’s left side is down) may be used in listening to heart sounds.

   

10

LITHOTOMY: generally used for pelvic examination.

SIMS: of the rectum or obtaining rectal temperature.

11

12

Assessment techniques

Inspection Palpation Percussion Auscultation

Skills in Physical Examination & The Process of Physical examination

Inspection – to detect normal characteristics or significant physical signs. To inspect body parts accurately the nurse observes the following principles: Make sure good lighting is available Position and expose body parts so that all surface can be viewed Inspect each areas from size, shape, color, symmetry, position and

abnormalities If possible, compare each area inspected with the same area of the

opposite side of the body Use additional light (for example, a penlight) to inspect body cavities

Inspection- the first fundamental process is inspection or observation. General inspection begins at the first moment of contact with the patient.

13

Inspection a. Posture and stature Ex. Person who have breathing difficulties ( Dyspnea) secondary to cardiac disease

prefer to sit and may complain of feeling “Smothered”, if forced to lie flat for even brief periods of time.

b. Body Movements Generalized disruption of voluntary or involuntary movement and asymmetry of

movement. Ex. Convulsive movements of epilepsy or tetanus or movements of patients with

rheumatic fever. - Nutrition Ex. Obesity maybe generalized as a function of excessive intake of calories or may

be specifically localized to the trunk in those with endocrine disorders ( Cushing disease).

c. Speech pattern Slurred coz of CNS disease or damage to cranial nerves, laryngeal nerve will produce

hoarseness.

14

Skills in Physical Examination & The Process of Physical examination

Palpation Palpation – assessed through touch. Ex. Superficial blood vessels, lympnodes, the thyroid, the

organs of the abdomen and pelvis, and the rectum. It should be noted that when the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds.

15

Palpation

16

Light palpation

Deep palpation

Skills in Physical Examination & The Process of Physical examination

Percussion – examination by striking the body’s surface with a finger, vibration and sound are produced. This vibration is transmitted through the body tissues and the character of the sound depends on the density of the underlying tissue

Sounds: Tympany – is the drumlike sound produced by percussing the air-filled stomach.

Resonance- is the sound elicited over air-filled lungs. Hyperresonance- is audible when one percusses over

inflated lung tissue in someone with emphysema. Dull sound- percussion of liver. Flatness- percussion of the thigh.

17

Skills in Physical Examination & The Process of Physical examination

Percussion

18

Direct percussion

Indirect percussion

Skills in Physical Examination & The Process of Physical examination

Auscultation – is listening to sound created in body organs to detect variations from normal. Some sounds can be heard with the unassisted ear, although most sounds can be heard only through a stethoscope.

Ex. Breath sound- movement of air through the trachea and bronchi, Vesicular, Brochovesicular, Bronchial

Spoken voice- movement of air past functioning vocal cords Bowel sounds- movement of air through the intestine. Murmur- movement of blood through vascular structures that provide critical

resistance to flow Heart sounds     Examples of Adventitious Breath Sounds Crackles (previously called rales) Rhonchi Wheeze Friction rub

19

20

Physical assessment

21

Assessment Sequencing

Head – to - Toe Assessment

Body Systems Assessment

22

EYES - Review of anatomy conjunctiva - mucous membrane of the eye. cornea - protective part of the eye. iris - regulates quantity of light into the eye. lens - expands/contracts in order to focus light. pupil - circular area that allows for the passage of light.

retina - receives images from light and converts them into electrical impulses sent to the brain.

vitreous humor - transparent liquid that gives the eye its shape.

aqueous humor - fluid anterior to the lens that is used in the support of the iris and refraction of the light

EYE ASSESSMENT

SUBJECTIVE DATA Vision difficulty(decrease

acuity, blurring, blind sports.

Pain Strabismus, diplopia Redness, swelling Watering, discharge History of ocular

problems Uses of glasses/contact

lenses Self care behavior.

STRUCTURE - EYE

OBJECTIVE DATA

Preparation

Equipments needed Snellens eye chart Opaque card

/occluder Penlight Applicator stick Ophthalmoscope

E Chart also known Tumbling E Chart

27

OPTHALMOSCOPE

OBJECTIVE DATA

Facial and ocular expression

Eye lids & Conjunctiva

Lacrimal system Sclera Cornea

----Prominence of eyes: alert or dull expression.

__Symmetry, presence of edema, ptosis, itching, redness, discharges, blinking, equality, growth.

___Tears, swelling, growth

___Color___Clarity

Cont’d objective data

Anterior chamber

Iris & pupils

Pupillary reflex light

__Depth, presence of blood/pus

__Irregularities in color, shape , size

__Constriction of pupil in response to light in that eye (direct light reaction);equal amount of constriction in the other eye (consensual light reaction)

cont’d objective data

Accommodation

Lens

Peripheral vision

Acuity with or without glasses

Supportive aids

__Convergence of eyes and constriction of pupils as gaze shifts from far to near object

__Transparent or opaque

__Ability to see movements & objects well on both sides of field of vision

Ability to read newsprint, clocks on wall, & recognize faces-b/side/door

Glasses, contact lenses, prosthesis.

Types of refractive errors hyperopia - image is focused behind the retina,

(farsightedness): Inability to see near objects clearly. The eye is “too short” for the lens, or certain eye muscles have weakened with age.

Myopia - image focused anterior to the retina, is also known as short sightedness, near sightedness, and short sight. It is a refractive error and it makes it difficult to see objects from afar.

Presbyopia - accommodation muscles are unable to focus,

People who have this condition will have a hard time focusing, will experience blurry vision, and will have tired eyes more often. People with presbyopia will have trouble reading in poor light conditions, they will have trouble changing their focus from near to far, and they will keep repositioning reading material in order to see things properly.

Astigmatism - uneven focusing / displaced lens,

characterized by abnormalities in the curvature of your eyes. This can cause your vision to blur at any angle.

Inflammation and infection of the eye

Blepharitis - an inflammation of the eyelids.

signs/symptoms Tenderness, reddening, sore sticky exudates Eyelids may become inverted & eyelashes fall out

treatment Antibiotics applied to eyelids oral antibiotics like tetracycline or doxycycline Artificial tears Keep scalp and eyelids clean Scales must be removed daily with moist applicator or warm,

moist wash cloth

Hordeolum (stye) signs/symptoms

a. Localized pain, swelling to eye lid

b. Often purulent discharge

Treatment - Hot compresses, scrub with neutral soap, topical antibiotic eye drops q3h, and if not resolved in 2-3 days, refer to ophthalmology for I&D

4. Trauma- A. Black eye: Swelling and discoloration around

the eye as a result of injury to the face.

Hyphema : Bleeding into the front of the eye, behind the cornea. a. Cause: 1. is usually caused by trauma. 2. It may be the result of an

athletic injury from a flying object, a stick, a ball, or another player's elbow. 3. Other causes include industrial accidents, falls, and fights.

                      

Blow out fracture When force is applied to the orbit causing contents to spill either

medially or inferiorly. If inferiorly, will end up in maxillary sinus. signs/symptoms

epistaxis enophthalmus entrapment dypesthesia diplopia fracture over infraorbital rim

X-rays needed; CT scan is definitive. If there is entrapment of EOM, need surgery soon otherwise must wait5-

7 days Must R/O ocular injury ; refer to ENT

5. Age-related Vision disorder a. Macular degeneration - is the leading cause

of severe vision loss in people over age 60. It occurs when the small central portion of the retina, known as the macula, deteriorates. The retina is the light-sensing nerve tissue at the back of the eye. Because the disease develops as a person ages, it is often referred to as age-related macular degeneration (AMD).

two main types

Wet form. The "wet" form of macular degeneration is

characterized by the growth of abnormal blood vessels

from the choroid underneath the macula. This is called

choroidal neovascularization. These blood vessels

leak blood and fluid into the retina, causing distortion

of vision that makes straight lines look wavy, as well

as blind spots and loss of central vision. These

abnormal blood vessels eventually scar, leading to

permanent loss of central vision.

Treatments Macular Degeneration There is currently no cure for macular degeneration, but

treatments may prevent severe vision loss or slow the progression of the disease considerably. Several options are available, including: Vitamins. A large study performed by the National

Eye Institute of the National Institutes of Health, called AREDS (Age-Related Eye Disease Study), showed that for certain individuals, vitamins C, E, beta carotene, zinc and copper can decrease the risk of vision loss in patients with intermediate to advanced dry macular degeneration.

Glaucoma is an eye condition that develops when too much

fluid pressure builds up inside of the eye. It tends to be inherited and may not show up until later in life.

The increased pressure, called intraocular pressure, can damage the optic nerve, which transmits images to the brain. If damage to the optic nerve from high eye pressure continues, glaucoma will cause loss of vision. Without treatment, glaucoma can cause total permanent blindness within a few years.

Glaucoma

Symptoms Glaucoma

Cataract-

a clouding of the eye's natural lens, which lies behind the iris and the pupil

Symptoms of Cataract

Ear Anatomy

History

always ask the following hearing loss tinnitus - ringing in the ear vertigo - sense of motion otalgia - ear pain otorrhea - drainage from the ear

ASSESSMENT

SUBJECTIVE DATA Ear aches Infections Discharges Hearing loss Environmental noise Tinnitus Self care behavior

INSPECTION- OTOSCOPE

Cont’d subjective data

Inspect & Palpate the External ear

Size & shape Skin condition Tenderness External auditory

meatus Inspect -otoscope

Inspect otoscope Pull the pinna up &

back(straightens S –shape-canal)

Hold the otoscope & inspect

Note any redness, swelling,lesions, f/b, discharge.

WEBER TEST

RINNE TEST

Hearing loss - 2 types A. Conductive - seen in people with external or middle ear problem.

Occurs when auditory stimuli are not adequately transmitted through the auditory canal, tympanic membrane, middle ear, or ossicles to the inner ear.

History - Have perceived hearing loss & need things repeated Physical exam

Weber - in conductive hearing loss, sound lateralizes to the affected ear.

Rinne - in conductive hearing loss, bone conduction (BC) > air conduction (AC)

Tests audiogram: normal 0-25 db.

Causes Cerumen impaction- usually occurs in persons who naturally

produce large amounts of cerumen. External otitis media- (bacterial and fungal), excessive

moisture in the auditory canal (swimmer’s ear), and trauma Serous otitis media- result from Eustachian-tube obstruction,

sudden changes in atmospheric pressure, allergy and viral disease

Suppurative otitis media- may follow viral disease, tympanic membrane perforation or prolonged forceful nose blowing.

> Common in infants and young children because of their immature and relatively poorly draining Eustachian tubes.

Otosclerosis- a hereditary condition; it affects women twice as often as men and typically develops between ages 15 and 30.

Trauma / tumors

B. Sensorineural - When the eighth cranial nerve or cochlea are damage Involves the inner ear.

Hearing loss resulting from damage to the inner ear or to the neural pathways from the inner ear to the brain

History - similar to conductive hearing loss. PE: Weber - lateralizes to good ear

Rinne - AC>BC Test: Audiogram - both BC and AC below 25db in

affected frequencies

Causes noise induced - most common - occupationally involved trauma - skull fractures (basilar) Tumors

Treatment Hearing conservation; may require baseline adjustment. Hearing aides Other Aids : Alert and signal devices, assisted – listening devices from

telephone companies Surgery : implantable cochlear prosthesis ( direct stimulation of the auditory

nerve)

Otitis Externa Infection of external ear Caused by bacteria, fungi, or may be a

dermatitis

Otitis Media (OM) infection of middle ear caused by a build up of

fluid (mucus) which then becomes infected by bacteria.

OTITIS MEDIA

Contact sports such as boxing can cause ear injuries such as cauliflower ear and bruising and swelling in general. But you can prevent this from happening by wearing a head guard. Motor sports are another potential cause of head and ear injuries although a well fitting helmet can help reduce the risk of that happening.

A pressure sore is the result of trauma to the tissues. They tend to start as a small patch of red skin which has been exposed to constant pressure. This patch gradually worsens until the skin cracks which damages lower layers of tissues.

NOSE

NOSE

SUBJECTIVE DATA Discharge Frequent colds(upper

respiratory infections) Sinus pain Trauma Epistaxis Allergies Altered smell

OBJECTIVE DATA

Equipment NeededOtoscope-short wide tip

nasal attachmentPenlight2 tongue bladesGlovesCotton gauze pad

Inspect and palpate :symmetric ,midline in proportion to other facial features

Inspect for any deformity, asymmetry, inflammation, or skin lesions

Palpate for any pain/break in contour.

Palpate the sinus areas-Tenderness

Figure 14-2. p. 379.

Structures of the Nasal Cavity

Figure 14-8. p. 388.

Inspect Nasal CavityMiddle turbinate

Inferior turbinate

Table 14-1. p. 405.

Abnormalities of Nose

Choanal Atresia

Foreign Body

Perforated SeptumEpistaxis

Epistaxis (nose bleed) Kiesselbach’s plexus - located

anterior septum, supplied by four arteries

Usually bleed from one nostril Most nose bleeds are anterior Causes –

trauma, foreign body, dry air, sinusitis, allergies, colds, foreign objects in the nose, picking the nose, and irritants among others. 

Figure 14-3. p. 379.

Paranasal Sinuses, Adult and Child

Figure 14-11. p. 390.

Palpate Sinuses

Palpate Sinuses

Sinusitis - is an inflammation of the mucous membranes

of one or more paranasal sinuses. a.Acute sinusitis

Inflammation of paranasal sinuses by bacteria, viruses, or fungi

Accompanied by or follows colds signs/symptoms

pain over affected sinus headache purulent rhinorrhea fever and other systemic disease anosmia( Lack of smell)

Physical exam Sinusitis Acute Sinusitis

Mucosa is hyperemic and edematous Turbinates are enlarged and often about the septum Purulent drainage Pain elicited from pressure over involved sinuses Transillumination may reveal air-fluid level. sinus X-rays Four views - Caldwells, Water’s, lateral & base. See air-fluid level in involved sinus or may just be clouded. Not required for diagnosis; more useful in chronic cases.

b.Chronic Sinusitis Irreversible tissue changes have occurred in lining membrane of one or

more of the paranasal sinuses, mucosal thickening becomes apparent. Causes – repeated/persistent bacterial sinusitis signs/symptoms Purulent material in nose. Enlarged turbinates. Similar to acute sinusitis. Persistent nasal obstructions; chronic nasal discharge, clear or

purulent when infected Cough-produced by constant dripping of discharge back into

nasopharynx

Feeling of facial fullness/pressure Headache-may be vague or in same pattern as

acute sinusitis, more noticeable in the morning; fatigue

Physical exam Chronic Sinusitis Purulent material in nose. Enlarged turbinates.

May notice nasal polyps X-rays Sinus series and CT Scan show air-fluid level in acute sinusitis;

thickening of sinus mucous membranes, opacification, and anatomic obstruction patterns in chronic sinusitis

Antral puncture and lavage-provides culture material to identify infectious organism; also a therapeutic modality to clear of bacteria, fluid, and inflammatory cells.

Nasal and sinus endoscopy (the sinuses can be easily accessed after the patient has had an antrostomy).

Table 14-1. p. 406.

Abnormalities of Nose

Acute RhinitisAllergic Rhinitis

Sinusitis Rhinitis Polyps

Rhinitis - is a disorder of the nose that interrupts its

normal functions of olfaction, and warming, filtering, and humidifying inspired air.

Allergic (hay fever) Rhinitis seasonal or perennial

Sneezing, lacrimation, itching, nasal discharge etc.

Must obtain good history; key to diagnosis. Caused by pollen, grasses, dust/house

mites etc. frontal headache trouble breathing through nose

Allergic rhinitis-IgE-mediated response causing release of vasoactive substances from mast cells

Physical exam Hay fever pale mucosa

turbinates (inferior) enlarged clear/thin secretions possible deviated septum nasal polyps Hypersecretion-wet, running/dripping nose or post-nasal drip Nasal obstruction symptoms-nasal congestion, pressure, or stuffiness Headache labs/allergy testing (in severe cases) intradermal allergy testing rast test (blood test)

b. Acute Rhinitis

common cold cause - rhinovirus signs/symptoms - fatigue, sore

throat, nasal discharge, headache, fever, nasal obstruction, sneezing

physical exam nasal mucosa red inferior turbinates enlarged and

erythematous clear watery discharge

Foreign body (Nose) is the blockage of the nasal passages due to foreign

objects common in younger children difficulty in breathing foul smelling, bloody, unilateral discharge consult ENT for removal

4. Trauma Nasal fracture result of blunt trauma

signs/symptoms epistaxis nasal dyspnea edema pain ecchymosis

Physical exam - crepitus, mobile nose, deviation, edema, ecchymosis. Must look into nose to R/O septal hematoma. If found, refer to ENT.

Look for and rule out other facial fractures. X-rays of little valve

Table 14-1. p. 407.

Abnormalities of Nose

Furuncle Carcinoma

Throat

Anatomy The throat (pharynx) is located behind the mouth,

below the nasal cavity, and above the esophagus and windpipe (trachea). It consists of an upper part (nasopharynx), a middle part (oropharynx), and a lower part (hypopharynx).

The throat is a muscular passageway through which food is carried to the esophagus and air is carried to the lungs.

The tonsils are located on both sides of the back of the mouth, and the adenoids are located at the back of the nasal cavity.

Figure 14-4. p. 380.

Oral Cavity Structures

Figure 14-5. p. 381.

Salivary Glands

Figure 14-14. p. 391.

Inspect Mouth

Figure 14-20. p. 396.

Inspect Throat

TONSILITIS

Pharyngitis - inflammation of pharynx causes -viral - Epstein-Barr virus (mono),

adenovirus, etc. bacterial - group A & B strep

signs/symptoms odynophagia sore throat dysphagia fever, fatigue, otalgia

Physical exam (Pharyngitis) tender anterior cervical adenopathy

erythmatous posterior pharynx exudates palatal petechiae differentiation throat C&S severe symptoms suggest bacterial etiology Often have concurrent tonsillitis

Treatment ( Pharyngitis)

throat C&S Pen V-K 500 mg QID x 10 days increase/force fluids, analgesics

Tonsillitis - inflammation of tonsils. causes - similar to pharyngitis - viral - Epstein-Barr virus (mono), adenovirus, etc. bacterial - group A & B strep Signs/symptoms - more odynophagia and dysphagia due to increase of

tonsil size. Physical exam - similar to pharyngitis. tonsils enlarged, red, and exudate (white patchy) palatal erythema and edema cervical nodes may be tender, usually palpable treatment - similar to pharyngitis if severe and persistent surgery is

recommended tonsillectomy- removal of the tonsils tonsillitis rare without pharyngitis but can have vice-versa

Peritonsillar abcess abcess of peritonsillar region, pus within surrounding tissues signs/symptoms

hot potato voice trismus - inability to open mouth fully increased odynophagia foul odor from mouth unilateral pain

physical exam uvular deviation tender over anterior fauces arch tonsils red, swollen protuding and flunctuant on one side

Epiglottis - inflammation of epiglottis. causes - Haemophilus influenzae type B Signs/symptoms –

severe throat pain difficulty swallowing fever drooling muffled voice. Because the infection is in the epiglottis, the back of

the throat often does not appear infected. As swelling of the epiglottis starts to narrow the airway, the person first begins to make a squeaking noise when breathing in (stridor) and then has

progressively worse trouble breathing.

References: Brunner & Suddarth’s, Medical-Surgical

Nursing, 8th edition Henry M. Seidel, Mosby’s Guide to

Physical Examination, 7th edition Barbara Kozier, Fundamental of Nursing,

4th edition

103