PHYSICAL ASSESSMENT/ EXAMINATIONHEAD TO TOE

PHYSICAL ASSESSMENT/ EXAMINATIONHEAD TO TOE

BY : Nelson Muthali Dip/RNDate: 08th March, 2013

OBJECTIVESBy the end of the topic students

should be able to:-1. Define physical assessment2. Describe the four techniques

used in physical assessment3. Know how to do a head to toe

assessment

Physical assessment is a systematic data collection method that uses the senses of sight, hearing, smell and touch to detect health problems.

There are four techniques used in physical assessment and these are:- Inspection, palpation, percussion and auscultation.

Usually history taking is completed before physical examination

InspectionIt’s the use of vision to distinguish

the normal from the abnormal findings.

Body parts are inspected to identify color, shape, symmetry, movement, pulsation and texture.

Principals of inspection• Availability of adequate light• Position and expose body part to view all

surfaces• Inspect each area for size, shape, color,

symmetry, Position and abnormalities.• If possible compare each area inspected

with the same area on the opposite side.• Use additional light to inspect body cavities

PalpationIt involves use of hands to touch body parts for

data collection.The nurse uses fingertips and palms to determine

the size, shape, and configuration of underlying body structure and pulsation of blood vessels.

It help to detect the outline of organs such as thyroid, spleen or liver and mobility of masses.

It detects body temperature, moisture, turgor, texture, tenderness, thickness, and distention.

Principles of palpation• Help client to relax and be comfortable

because muscle tension impairs effective assessment.

• Advise client to take slow deep breaths during palpation

• Palpate tender areas last and note nonverbal signs of discomfort.

• Rub hands to warm them, have short fingernails and use gentle touch

PercussionIt is the technique in which one or both hands

are used to strike the body surface to produce a sound called percussion note that travels through body tissue.

The character of the sound determines the location, size and density of underlying structure to verify abnormalities.

An abnormal sound suggest a mass or substance like air, fluid in an organ or cavity.

AuscultationIt involves listening to sounds and a stethoscope is

mostly used.

Various body systems like cardiovascular, respiratory and gastrointestinal have characterized sounds.

Bowel, breath, heart and blood movement sounds are heard using the stethoscope.

It is important to know the normal sound to distinguish from abnormal.

Preparation for physical exam

Infection preventionFollow IP precaution through out procedureEnvironmentP/A requires privacy and away from other

destructors throughoutEquipmentGet all the necessary equipment, other equipment

needs to be warmed before being placed on the body e.g. rubbing diaphragm of the stethoscope briskly between hands.

Preparation cont…Patient preparationPrepare the patient physically and

make the patient comfortable throughout the physical assessment for successful exam.

Explain to the patient everything to be done.

HEAD TO TOE ASSESSMENT

General surveyThe assessment of the patient/client begins on

the first contact.It includes apparent state of health , level of

consciousness, and signs of distress.The general height, weight, and build can be

noted including skin color, dressing, grooming, personal hygiene, facial expression, gait, odor, posture and motor activity.

NOTE: If there is a sign of acute distress comprehensive health assessment is deferred until when patient is stable.

Vital signsAssessment of vital signs is the first

in physical assessment because positioning and moving the client during examination interferes with obtaining accurate results.

Specific vital signs can be also obtained during assessment of individual body system.

Skin, Hair, scalp and Nails

Inspect all skin surfaces first or gradually while assessing the systems.

Use the skills of inspection, palpation, and olfactory to assess the function.

SkinInspect skin for color, edema, lesions, scars

and vascularity.Palpate to notice moisture, temperature, and

skin turgor,

Hair and scalpAssess and note type of hair i.e. long, coarse,

thick, brittle.Note the color, distribution, quantity, thickness,

texture and lubrication.On inspection separate the hair to determine

the scalp.Wear clean gloves if lesions and lice are

probable.

NailsThe condition of the nails reflects the general

health, state of nutrition, occupation, and level of self care. Nail biting can reveal the person’s psychological state.

Inspect the nail bed for color, cleanliness, length, texture, angle between nail and nail bed and folds around the nail.

Palpate the nail for inflamation

Head and neckThe assessment of the head

includes:- eyes, ears, nose, mouth and pharynx.

The assessment of the neck includes:- lymph nodes, carotid artery, thyroid gland and trachea.

EyesAssess visual acuity, position and alignment of

the eyes, eyebrows and eyelids.Note any abnormal discharges and color of

conjunctiva and sclera.EarsIt determines the intergrity of the ear

structures and hearing acuity. Inspect for sore and discharges

Nose and sinusesAssess the integrity of the nose and sinuses by

using inspection and palpation.NoseObserve for shape, size, skin color, and presence of

deformity or inflammation.SinusesThe exam involves palpation. Incase of allergy or

infection the inside is inflamed and swollen so palpate for tenderness

Mouth and pharynxAssess mouth and pharynx to

determine overall health and hygiene.

Use pen light and tongue depressor to assess oral cavity.

LipsInspect lips for color, texture,

hydration, contour, sores and lesions.

Buccal mucosa, gums, and teethAsk client to clench teeth and smile to observe to

observe teeth occlusion, symmetry. A symmetrical smile shows normal nerve function.

Inspect teeth for hygiene, position, and alignment.Let client open with lips relaxed, use tongue

depressor to inspect the mucosa for color, moisture and sores.

Inspect gums for color, edema, retraction, bleeding and lesions.

Tongue and floor of mouthCarefully inspect tongue on all sides as well as

floor of mouth for color, size, position, texture, moisture sores and lesions.

PalateHave client extend the head backwards,

holding the mouth open, inspect the hard and soft palate for color, shape, texture and extra bonny prominences or defects.

PharynxLet the client tip the head back slightly,

open mouth wide and say “Ah”, with penlight inspect the uvula and soft palate, they should rise centrally as the client say “Ah” to determine the function of cranial( vagus ) nerve function.

Check the uvula and tonsils for redness and inflammation.

NeckPalpate the muscles, lymph nodes,

carotid artery jugular veins for tenderness and distention.

Thyroid glandAsk client to hyperextend the neck

and view the thyroid and palpate for masses.

Normally thyroid gland is not visible.

ChestInspect the skin for scars, sores, color, lesions,

chest, movement and respiratory rate.Palpate to notice any masses, and tenderness

in axillae and breast.LungsAuscultate to assess respiratory and sounds

from the lungs and chest cavity.Percussion is done to detect accumulation of

fluid or air in the chest cavity.

HeartAuscultate to hear the heart sound.Learn to know the normal heart

sound to be able to detect the abnormal

BreastInspect the breast for skin color,

scars and lesions.Palpate to notice any presence of

masses.

ExtremitiesUpper and lower extremitiesInspect hand and legs for symmetry, alignment,

skin color, temperature, sores, scars, lesions inflammation and varicosity.

Palpate for tenderness, edema and pulsation of arteries. Use the brachial, radial, ulna, femoral, popliteal, posterior tibia and dorsalis pedis pulses.

Check capillary refill on nails, clubbed toes /fingers and joint mobility.

Deep tendon reflexesNormally done on high risk patients

and needs specialized practice and special hammer to assess the reflexes.

Areas that are assessed are on biceps, triceps, patella, and Achilles.

AbdomenInspect the skin for color, sores, lesions, scars, position

of umbilicus, distention and contours.Palpate for tenderness, masses and enlargement of

other organs like liver, spleen and kidney.Ask for bowel and bladder elimination.Percussion is used to detect the location of organs that

are normally palpable e.g. liver, spleen and intestines.Always auscultate before palpation or percussion

because touching can alter mobility of bowel and increase sound.

GenitaliaStart assessment of genitalia with asking

questions and do inspection to confirm a positive answer.

FemaleAsk about presence of abnormal discharge,

sores, warts and itchingMaleAsk any presence of sores, itching, warts and

abnormal discharge.

Rectum and anusInspect for the skin color, sores,

hemorrhoids and lesions.Do digital palpation to examine the

anal canal for masses and sphincters function only when important.

Reference1. Ruth F. Craven Constance J. Hirnle,

Fundamentals of Nursing, Human Health and Function, sixth edition(2009), Lippincott Williams & Wilkins.

2. Potter. Perry, Fundamentals of Nursing, 7th edition(2009) Mosby Elsevier.

3. Barbara F. Weller, Nurses Dictionary for nurses and health care workers, 24th edition,Elsevier.