physical assestment

7/29/2019 Physical Assestment

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PHYSICAL ASSESTMENT

Objectives:

After 4 hours of classroom Discussion and Demonstration the Level II students will be able to:

I. Define the FF. terms:

a. Nursing Assessment

b. Physical Assessment

c. Anthropometric Measurement

d. Health History

e. Health

f. Reflexes

g. Visual Activity

h. Interview

i. Signs

j. Symptoms

II. Know the importance of Physical Assessment

III. Purpose of Physical Assessment

IV. Four basic techniques in Physical Assessment

V. Principles involved in Physical Assessment

VI. Nursing responsibilities before, during and after Physical Assessment

VII. Materials and Equipment used in Physical Assessment and demonstrate Beginning Skills in

Physical Assessment.


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Define the Following terms:

A. Nursing Assessment

-Is a major component of nursing care.

-Is a process which includes both physical and psychological aspect to evaluate clients

condition.

-Enables the nurse to make a judgment about the clients health status, ability to manage

his/her health care and need for nursing.

B. Physical Assessment

-Is a process by which a nurse obtains a data that describes a persons responses to actual or

potential health problems which is analyzed to form pertinent diagnosis.

-Is a head to toe review of each body system that offers objective information about the client

and allows the nurse to make clinical judgment.

C. Anthropometric Measurement

-Comparative measurements of the body. Anthropometric measurements are used in

nutritional assessments. Those that are used to assess growth and development in infants,children, and adolescents include length, height, weight, weight-for-length, and head

circumference (length is used in infants and toddlers, rather than height, because they are

unable to stand). Individual measurements are usually compared to reference standards on a

growth chart. Measurement of size weight and proportion of the body.

-Most commonly used anthropometric measured are height, weight, triceps, skinfold thickness,

elbow breadth and arm and head circumference.

D. Health

-State of being physically fit, mentally stable and socially comfortable.

- It encompasses more than the state of being free of disease.

E. Health History


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-defined as the systematic collection of subjective data (stated by the client) and objective data

(observed by the nurse) used to determine a clients functional health pattern status.

F. Reflexes

-Bent, turned or directed back; or produced by a reflex without intervention of consciousness.

- Is an involuntary and nearly instantaneous movement in response to a stimulus.

G. Visual Acuity

-The degree of detail the eye can discern an image.

-Is a quantitative measure of the ability to identify black symbols on a white background at a

standardized distance as the size of the symbols is varied.

-Is acuteness or clearness of vision, especially form vision, which is dependent on the sharpnessof the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain.

H. Interview

-An interview is a conversation between two or more people (the interviewer and the

interviewee) where questions are asked by the interviewer to obtain information from the

interviewee. "Interview" word is derived from french word "entirevior" it means "glimpse" to

each other.

-Therapeutic interaction that has a purpose.

I. Signs

-A sign is the physical manifestation of an illness, injury or other bodily disorder. A sign is

objective and can be observed.

-Signs can be felt, heard, seen, and measured by the diagnostician or nurse. These include

pulse, respirations, blood pressure, and physical evidence such as bleeding, broken skin,

bruising etc.

J. Symptoms

-Subjective evidence of a disease of physical disturbance observed by the patient.

-Is a departure from normal function or feeling which is noticed by a patient, indicating the

presence of disease or abnormality. A symptom is subjective, observed by the patient, and not

measured.


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Importance of Physical Assessment:

To early detect and treat diseases and disorders.

To identify actual and potential health problems.

To establish a data based from which the subsequent phases of the nursing evolve.

To assess the clients impact of activity and exercise on the clients overall level of health.

To assess the clients routine exercise pattern and observe how the clients body system

response to activity and exercise.

To establish the client-nurse relationship

To obtain information about the clients health including, physiologic, psychologic,

sociocultural, cognitive, developmental and spiritual aspects.

To identify the clients strength and weaknesses.

Purpose of Physical Assessment

To supplement, confirm or refute data obtained in the nursing history.

To confirm and identify nursing diagnosis.

To make clinical judgments about a clients changing health status and management.

To evaluate the physiological outcome of care.

Toobtain and gather data about the clients health basis of data for future assessment.

An excellent way to evaluate an individuals current health status.

Four Basic Techniques in Physical Assessment

I. Inspection

It is the use of ones senses of vision and smell to consciously observe the patient. It is

also known as concentrated watching. It is a close, careful scrutiny; first of the individual as a

whole and then of each body system. Inspection begins the moment you first meet the

individual and develop a general survey. Then as you proceed through the examination, start

the assessment of each body system with inspection.


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II. Palpation

It is the act of touching a patient in a therapeutic manner to elicit specific information. It

follows and often confirms points you noted during inspection. Palpation applies your sense of

touch to assess these factors: texture, temperature, moisture, organ location and size, as well

as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or

masses and presence of tenderness or pain.

Two distinct types of palpation: Light and deep palpation

Light palpation

It is superficial, delicate and gentle. In light palpation, the finger pads are used to gain

information of the patients skin surface to a depth of approximately -1 inch below the

surface. Light palpation reveals information on skin texture and moisture; overt large or

superficial masses; and fluid, muscle guarding and superficial tenderness.

Deep palpation

It can reveal information about the position of organs and masses, as well as their size,

shape, mobility, consistency, and areas of discomfort. Deep palpation uses the hands to explore

the bodys internal structure to a depth of 1 to 2 inches or more. This technique is most often

used for the abdominal and male and female reproductive assessments. Variations in this

technique are single handed and bimanual palpations.

III. Percussion

It is the technique of striking or tapping the persons skin with short, sharp strokes to

assess underlying structures. The strokes yield a palpable vibration and a characteristic sound

that depicts the location, size and density of the underlying organ. These sounds also are

diagnostic of normal and abnormal findings. Any part of the body can be percussed, but only

limited information can be obtained in specific areas such as heart. The thorax and abdomen

are the most frequently percussed location.

Four types of percussion techniques: Immediate or direct, mediate or indirect, direct fist

and indirect fist percussion:

A. Immediate or Direct Percussion

The striking hand directly contacts the body wall. This produces a sound and is used in

percussing the infants thorax or the adults sinus areas.

B. Mediate or Indirect Percussion


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It is used more often and involves both hands. The striking hand contacts the stationary

hand fixed on the persons skin. This yields a sound and a subtle vibration.

C. Direct Fist Percussion

It is used to assess the presence of tenderness in internal organs, such as the liver or thekidneys. The presence of pain in conjunction with direct fist percussion indicated inflammation

of that organ or a strike of too high in intensity.

D. Indirect Fist Percussion

Its purpose is the same as direct fist percussion. In fact, the indirect method is preferred

over the direct method. It is because in this methods. The non-dominant hand absorbs some of

the force of the striking hand. The resulting intensity should be sufficient force to produce pain

in the patient if organ inflammation is present

Percussion elicits five types of sounds:

1) Flatness (dull) bone and muscle

2) Dullness (thudlike) liver, spleen, heart

3) Resonance (hollow) air-filled lung/ normal lung

4) Hyperresonance emphysematous lung

5) Tympany stomach filled with gas (air)

IV. Auscultation

It is the act of active listening to the body organs to gather information on patients

clinical status. Auscultation includes listening to sounds that are voluntarily and involuntarily

produced by the body such as the heart and blood vessels and the lungs and abdomen.

Auscultated sounds should be analyzed in relation to their relative intensity, pitch, duration,

quality, and location.

Two types of auscultation: Indirect and direct auscultation:

1) Direct of Immediate auscultation

It is the process of listening with the unaided ear. This can include listening to the

patient from some distance away or placing the ear directly on the patients skin surface. An

example is the wheezing that is audible to the unassisted ear in a person having a severe

asthmatic attack.


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2) Indirect or Mediate auscultation

It is the use of stethoscope, which transmits the sounds to the nurses ear.

Principles involved in physical assessment:

Anatomy & Physiology

One has to know the different parts and functions of the body in order to do a thorough

and detailed assessment.

Psychology

Through Psychology, we are able to make good assessments because we can

differentiate a normal mental state and an abnormal one. Privacy must be ensured during the

Physical Assessment to avoid the client from being anxious or uncomfortable.

Microbiology

Do medical handwashing before and after the procedure. Instrument should be sterile.

Time and energy

Starts from lesser to the most sensitive part

Body mechanics

Nurse and patient should maintain proper body mechanics.

Nursing responsibilities before, during and after Physical assessment:

Before

Always dress in clean professional manner, make sure you have your name pin or workplace

identification.

Remove all bracelets, necklaces, or earrings that can interfere during the physical assessment.

Be sure your hair will not fall forward and obstruct your vision or touch to the patient.

Ensure that all necessary equipment is ready for use and within reach.

Introduce yourself to the patient. Enlist the patients cooperation by explaining what you are

about to do, where it will be done, and how it may feel.

Explain to the patient why you may be spending a long time performing one particular skill.


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Do medical hand washing

Position the patient as dictated by the body system being assessed.

Warm all instruments prior to their use

During

Conduct the assessment in a systematic fashion every time.

While performing each step in the physical assessment process you may need to inform the

patient of what to expect, where to expect it, and how it should feel.

Avoid making crude or negative remarks, be cognizant of your facial expression when dealing

with malodorous and dirty patients or with disturbing findings.

Proceed from the least invasive to the most invasive procedure for each body system.

If the patient complains of fatigue, continue the assessment later.

After

Provide recognition to the patient when the physical assessment concluded; inform the

patient what will happen next.

Place patient in a comfortable position.

Do after care.

Do medical hand washing.

Document assessment findings in the appropriate section of the patient record.

Materials and Instruments of Physical Treatment

Instrument/Material Purpose

Flashlight or penlight To assist in viewing of the pharynx and cervix

or to determine the reaction of the pupils of

the eye.

Laryngeal or dental mirror To observe the pharynx and oral cavity.

Nasal septum To permit visualization of the lover and middle

turbinates; usually a penlight is used for

illumination.

Ophthalmoscope A lighted instrument to visualize the interior of

the eye.

Otoscope A lighted instrument to visualize the eardrum


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and external auditory canal (a nasal speculum

may be attached to the Otoscope to inspect

nasal cavities).

Percussion (reflex) hammer An instrument with a rubber head to test

reflexes.

Tuning Fork A two-prolonged metal instrument used totest hearing acuity and vibratory sense.

Cotton applicators To obtain specimens.

Gloves To protect the nurse

Lubricant To ease the insertion of instruments

(ex.Vaginal Speculum)

Tongue blades

(depressors)

To depress the tongue during assessment of

the mouth and pharynx.

Various positioning of the patient

Dorsal recumbent

Back-lying position with knees flexed and hips externally rotated; small pillow under the

head; soles of feet on the surface.

Supine (horizontal recumbent)

Back-lying position with legs extended; with or without pillow under the head

Sitting

A seated position. The back is unsupported and legs hanging freely.

Lithotomy

Back-lying position with feet supported in stirrups; the hips should be in line with the

edge of the table.

Sims

Side-lying position with the lowermost leg flexed at the hip and knee, upper arm flexed

at the shoulder and elbow.

Prone

Lies on the abdomen with head turned to the side, with or without a small pillow.


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BODY PARTS

Assessment of Body Parts

Head & NeckHead

Inspection:

For size, shape & symmetry

Palpation:

For contour, masses, depressions.

Hair

Inspection:

For color, evenness of growth over the scalp,

presence of parasites, amount of body hair.

Palpation:

Thickness or thinness texture and oiliness.

Scalp

Inspection:

For Color, oiliness, presence of scars, lice and

dandruff.

Palpation:

For lesions or masses tenderness.

Forehead

Inspection:

For symmetry, skin appearance, presence of

rushes, scars or pimples.

Palpation:

For masses, lumps and tenderness

Face

Inspection:

For shape and symmetry, presence of scars,

pimples or acne

Normal Findings

The head should be round

(normocephalic) and symmetrical.

The normal skull is smooth, and without

masses or depressions, non-tender.

Can be black, brown or burgundy

depending on the race, evenly

distributed covers the whole scalp

(no evidences of Alopecia), no parasites, and

the amount is variable.

Maybe thick or thin, coarse smooth neither

brittle nor dry.

Lighter in color than the complexion, can be

moist or oily, no scars noted, free from lice,nits and dandruff.

NO lesions should be noted, neither

tenderness nor masses.

Symmetrical, light to dark brown, no rushes,

scars and pimples.

Non-tender, no lumps and absence of masses.

The shape of the face can be oval, round, or

slightly square, the face is symmetrical,


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Palpation:

For any swelling, masses, lumps, and the four

sinuses (sphenoidal sinuses, frontal sinuses,ethmoid sinuses and maxillary sinuses).

Eyes

Inspection:

For symmetry.

Eyebrows

Inspection:

For hair distribution and alignment and skinquality and movement, presence of pimples,

dandruff and color of the hair.

Palpation:

For the presence of lumps, pain and nodules.

Eyelashes

Inspection:

For evenness of distribution and direction of

curl and color

Sclera

Inspection:

For color, moisture, texture and the presence

of lesions.

Conjunctivae

Inspection:

For lesions, swelling, color and moisture.

Palpation:

Presence of pain

Cornea

Inspection:

absence of scars, pimples or acne. There

should be no edema, disproportionate

structures, or involuntary movements.

No lumps and swelling of the face, absence of

masses and there is no pain felt duringpalpation of face

Symmetrical or evenly placed and in line with

each other. Non-protruding and equal

palpebral fissure.

Hair evenly distributed; skin intact. Eyebrowssymmetrically aligned; equal movement,

absence of pimples and dandruff, maybe black

brown or blond depending on race.

No lumps, no nodules and no pain felt during

palpation.

Equally distributed; curled slightly outward

and black in color.

The sclera appears white, although blacks

occasionally have a grayblue or muddy color

to sclera. It should be moist and without

lesions.

Both conjunctivae are shiny, smooth, and pinkor red, absence of swelling, no lesions and it

should be moist.

There should be no pain felt during palpation.


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For clarity, texture and moisture

Iris

Inspection:

For appearance, coloration and shape.

Pupil

Inspection:

For color size, shape and equality of the pupils

Muscle function

Corneal Light Reflex or the Hirschberg Test

(Observe the location of reflectedlight on the cornea)

Cover Test

This test detects small degrees of deviated

alignment by interrupting the fusion reflex

that normally keeps two eyes parallel.

(Observe the cover eye for movement)

Diagnostic Position test

Leading the eye through the six cardinal

positions of gaze will elicit any muscleweakness during movement. (Observe for

convergence of gaze).

Muscle balance

Test for pupilary light reflex(Cardinal Fields of

Gaze)

Test for Accommodation

The corneal surface should be moist, shiny and

transparent, with no discharges and

cloudiness.

The iris is normally appears flat, with a regularshape and even coloration.

Black in color; appears round, regular, smooth

border and of equal size in both eyes,

normally 3-7 mm in diameter.

The reflected light (light reflexes) should be

seen symmetrically in the centers of thecornea.

If the eyes are in alignment, there will be no

movement of the either eye.

A normal response is parallel tracking of the

object with both eyes. Both eyes should movesmoothly and symmetrically in each of the six

fields gaze and convergence on the held

object as it moves toward the nose.

Normally you will see:

-Constriction of the same-sided pupil (a direct

light reflex).

-Simultaneously (a consensual light reflex).

A normal response includes:

-Papillary constriction.

-Convergence of the axes of the eye.

Record the normal response to all

these maneuver as:


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Visual Acuity

Snellen eye Chart

The Snellen eye chart is the most commonly

used and accurate measure of visual acuity.

Peripheral Vision

Test Visual Fields

Confrontation Test

Nose

External Inspection:

Inspect the nose nothing any bleeding,

inflammation, or lesions, masses, swelling, andsymmetry, discharges and color, sense of

smell.

External Palpation:

For tenderness and presence of pain.

Internal Inspection:

Inspect for nasal septum for deviation,

perforation, lesions and bleeding.

Frontal Sinuses

Inspection:

For any swelling around the eyes

P - Pupils

E - Equal

R - Round

R - React to

L - Light and

A - Accommodation

Normal Visual is 20/20 The Top number

(numerator) indicates the distance the person

is standing from the chart, while the

denominator gives the distance at which a

normal eye could have read that particular

line. Thus 20/20 means you can read that 20

ft. with the normal eye could have read at 20ft.

The patient is able to see the stimulus at

about 90 degrees temporally, 60 degrees

nasally, 50 degrees superiorly, and 70 degrees

inferiorly.

The shape of the external nose can vary

greatly among individual. Normally, it islocated symmetrically on the midline of the

face that is without swelling, bleeding, lesions,

or masses. No discharge or flaring and uniform

color, there is a sense of smell.

Non-tender; absence of pain

The nasal mucosa should be pink or dull red

without swelling. The septum is at the midlineand without perforation, lesions or bleeding,

the small amount of watery discharge is

normal.

There is no evidence of swelling around the


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Palpation:

Presence of pain and tenderness

Percussion:

Note any sound

Maxillary Sinuses

Inspection:

For any swelling around the eyes

Palpation:

Presence of pain and tenderness

Percussion:

Note any sound

Transillumination of the sinuses

You may use this technique in the frontal and

maxillary sinuses when you suspect sinus

inflammation, although it is of limited

usefulness.

Mouth

Lips

Inspection:For color, texture, cracking, symmetry, lesions

and hydration

Palpation:

For any presence of pain, lumps and

tenderness.

Gums

Inspection:

For color, texture, swelling, bleeding,retraction form the teeth

Palpation:

For the presence of pain, tenderness and

lumps.

Teeth

eyes.

The patient should not feel pain during

palpation and no tenderness felt.

The sound should be flat or dull.

There is no evidence of swelling around the

nose and eyes.

The patient should not feel any pain and

tenderness during palpation.

The sound should be flat or dull.

The glow on each side is equal, indication air-

filled frontal and maxillary sinuses.

The lips should be pink, soft moist, smooth

texture with no evidence of lesions or

inflammation. Not crack and symmetrical.

There is no presence of lumps and pain. It is

tender.

The gums should be pink, moist, firm texture,

no retraction, no swelling or bleeding. Thegum margins at the teeth are tight and well-

defined.

There should be no pain felt during palpation,

no lumps and non-tender.


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Inspection:

For discoloration, numbers of tooth and

texture.

TongueInspection:

For color, texture, surface characteristics,

symmetry, presence of lesions, and sense of

taste.

Palpation:

For any nodules, lumps and presence of pain

Frenulum

Inspection:

For the color, texture.

Sublingual Area

Inspection:

For color, moisture and presence of lesion.

Hard palate

Inspection:

For color, shape, texture, presence of lesions

and malformation.

Soft Palate

Inspection:

For color, shape, texture, presence of lesions,

malformation

Uvula

Inspection:

For position, mobility and color.

Tonsils

Inspection:

The adult normally has 32 teeth, which should

be white, straight and smooth edges in proper

alignment or evenly placed, clean and free of

debris or decay.

The tongue is in the midline of the mouth, the

dorsal surface should be pink, moist, rough

and without lesions. The tongue is

symmetrical and moves freely. The strength of

the tongue is symmetrical and strong. The

ventral surface of the tongue has prominent

blood vessels and should be moist without

lesions, looks smooth and glistening. There is a

sense of taste.

There should be no presence of nodules,

lumps and pain.

It should be attached to the tongue, pinkish in

color and moist.

It should be pink in color, moist and no

presence of lesions.

The hard palate is concave and lighter in pink

in color, it has many ridges and it is moist,

without any lesion or malformation.

The soft palate is also concave and light pink in

color, it is smooth and no lesions or

malformations noted.

It normally looks like a flesh pendant hanging

in the midline of soft palate.


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For color, shape, size and discharge.

Palpation:

Presence of pain

Ears

External ear

Inspection:

For position, color, size, shape, any

deformities, inflammation, or lesions

Palpation:

Presence of pain, tenderness, and lumps.

Auditory Acuity

Voice-Whisper test

Tuning fork test

Webers Test

Rinnes Test

Tonsils are present and pink in color.

It is pink in color and smooth. Oval in shape.

No discharge. Of normal size or not visible, no

inflammation, and not swollen.

There should be no pain felt during palpation.

The ear matches the flesh color of the rest of

the patients skin and should be positioned

centrally and in proportion to the head. The

top of the ear should cross an imaginary line

drawn from the outer canthus of the eye tothe occiput with no swelling or thickening.

Cerumen should be moist and not obscure the

lympanic membrane. There should be no

foreign bodies, redness, drainage, deformities,

nodules or lesions.

They should feel firm (not tender) and

movement produce pain.

The patient should be able to repeat words

whispered from a distance of 2 feet.

Measures hearing by air conduction (AC) or by

bone conduction (BC), in which the sound

vibrates through the cranial bones to the inner

ear.

The patient should perceive the sound equally

in both ears or in the middle. Nolateralization of sound is known as negative

Webster test.

Air conduction is heard twice as long a bone

conduction when the patient hears the sound

through the external auditory canal (air) after

it is no longer heard at the mastoid process


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Neck

Inspection:

For symmetry of the sternocleidomastoid

muscles anteriorly, and the trapeziusposteriorly.

Palpation:

For the presence of masses and tenderness.

Lymph Nodes

Inspection:For any enlargement or inflammation.

Palpation:

For size, shape, dellimination, mobility,

consistency, and tenderness

Trachea

Palpation:

Thyroid Gland

Inspection:

For symmetry and visible masses.

Palpation:

For nodules or enlargement and tenderness.

Thorax

Chest Anterior

Inspection: For the breathing patterns, rate,

depth, the coastal angle, shape of patients

chest, and color.

(bone). This is denoted as AC>BC.

The muscles of the neck are symmetrical with

the head at a central position. The patient isable to move head through a full range of

motion without complaint of discomfort or

noticeable limitation. The patient may be

breathing through a stoma or tracheostomy.

The muscles are symmetrical without palpable

masses or spasm.

Lymph nodes should not be visible or

inflamed.

Normally, lymph nodes should not be palpable

in the healthy adult patient; however, small,

discrete, movable nodes are sometimes

present but are of no significance.

Space should be systemic on both sides or on

central placement in midline of neck; spacesare equal on both sides.

Thyroid tissue moves up with swallowing but

often the movement is so small it is not visible

on inspection. In males, the thyroid cartilage,

or Adams apple, is more prominent than in

females.

No enlargement, masses, or tendernessshould be noted on palpation.

Quiet, rhythmic, and effortless respirations.

Breathing pattern should be smooth. Costal

angle is less than 90, and the ribs insert into

the spine at approximately a


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Palpation:

For respiratory excursion. Tenderness, masses

and temperature.

Percussion:

For its different sound

Auscultation:

For full two breaths and sounds

Lungs

Inspection:For breath sounds over the following:

Trachea

Alveolar Tube (-large-stem bronchi)

Lung Field (lung periphery)

Heart

Palpation:

45 angle. Normal rate of breathing in adult is

46/16 per min. red patches present, ribs

sloping downward with symmetric

interspaces. Colors should be even and

consistent with the color of the patients face.

Shoulder should be at the same height. shapeof thorax

elliptical shape

It should be full symmetric excursion; thumbs

normally separate to 3-5 cm (1 to 2 in).

Equal expansion, no tenderness, no masses,

skin should be warm and dry, no pulsation

should be present. Fremitus is normally

decreased over heart and breast tissue.

Normal lung tissue-resonant sound, rib flat

sound.

Air brushing through the respiratory tract

during inspiration expiration generates

different breath sounds.

Bronchial (loud, tubular) breath sounds heard

over trachea; expiration longer than

inspiration; short silence between inspiration

and expiration.

Bronchovesicular breath sound heard over

main stem bronchi: below clavicles and

between scapulae (inspiratory phase equal toexpiatory phase).

Vesicular (low, soft, breezy) breath sounds

heard over lung periphery (inspiration longer

than expiration).

No pulsation palpable over aortic and


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Auscultation:

For murmurs and sound

Chest Posterior

Inspection:

For shape and symmetry, spinal alignment for

deformities, color, abnormal inspiratory.

Palpation:

For clients who have no respiratory

complaints, temperature.For clients who have respiratory complaints.

For respiratory excursion

For vocal and tactile fremitus

Percussion:

For sounds

For diaphragm excursion

Auscultation:

For sounds

pulmonic areas.

Apical has the loudest sound; it should be 60-

80 beats/min. No murmurs should be heard.

Anteroposterior to transverse diameter in

ratio of 1.2; chest symmetric; spine column

vertically aligned. No patches, no abnormal

inspiratory retraction of interspaces.

The skin should be intact; uniform

temperature.

The chest wall intact; uniform temperature.

Full and symmetric chest expansion. [Ex.

When the client takes a deep breath, your

thumbs should be move apart an equal

distance and at the same time; normally the

thumbs separate 3 to 5 cm (1 to 2 in.) during

deep palpation].

Bilateral symmetry of vocal fremitus. Fremitus

is heard most clearly at the apex of the lungs.Low-pitched voices of males are more readily

palpated than higher pitched voices of

females.

Percussion notes resonate except over

scapula.

Lowest point of resonance is at the

diaphragm. (Note: percussion on a rib

normally elicits dullness)

Excursion is 3-5 cm (1 to 2 in.) bilaterally in

women and 5-6 (2 to 3 in.) in men. Diaphragm

is usually slightly higher on the right side.

Vesicular and bronchovesicular breathe

sounds.


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Abdomen

Inspection:

-Color

-Scars

-Striae

-Dilated Veins

-Rashes and lesions

-Umbilicus

-The contour of the abdomen

-Hair distribution

-Symmetry

-Respiratory movement

Auscultation:

Auscultate the four quadrants for basic

sounds. Auscultate over the aorta, renal, iliac

and femoral arteries. (Vascular sounds)

Percussion:

Percuss the four quadrants to as tympany and

dullness.

Right Upper Quadrant:

- liver

- gallbladder

- duodenum

- head of pancreas

- right kidney and adrenal

- hepatic flexure of colon- Part of ascending and transverse

colon

Right Lower Quadrant:

-Cecum

-Appendix

-Right ovary and tube

-Surface is uniform in color and in

pigmentation.

-Flawless no scars is present. If scars are

present draw its location in the personsrecord indicating the length in cm.

-No striae / stretch marks are present.

-A few small veins may be visible normally.

-No rashes or lesions are present.

-Is normally in the midline and inverted with

no sign of inflammation, discoloration or

hernia.

-Normally range from flat to rounded.

-Diamond shape in adult males, inverted

triangular shape in adult female.-Symmetric bilaterally and smooth.

-The abdomen rises with inspiration and falls

with expiration.

High pitched, irregular gurgles (5-35 times/

min) present equally in all four quadrants. No

bruits, no venous hums, no friction.

Tympany is usually predominating because of

air in the stomach and intestines. Dull soundsare heard over solid masses such as liver,

spleen, and kidneys.

Left Upper Quadrant:

- stomach

- spleen

- left lobe of liver

- body of pancreas

- left kidney and adrenal

- spleen flexure of colon- part of transverse & descending

colon

Left Lower Quadrant:

-Part of descending colon

-Sigmoid colon

-Left ovary and tube


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-Right ureter

-Right spermatic cord

Midline:

-Aorta

-Uterus(if enlarged)-bladder(if enlarged)

Palpation:

Perform palpation to judge the size, location

and consistency of certain organs and to

screen for an abnormal mass or tenderness.

Light Palpation (1/2 - 1 inch) on all areas of

abdomen moving clockwise and in rotary

motion.

Deep Palpation (2-3 inches) on all areas on the

abdomen moving clockwise and in rotary

motion.

Liver Palpation:

Located in the RUQ (Right Upper

Quadrant).Place your left hand under the

persons back parallel to the 11th and 12th

ribs and lift up to support the abdominal

contents. Place your right hand on the RUQwith fingers parallel to the midline. Push

deeply down and under the right costal

margin then ask the person to take a deep

breath.

Hooking Technique

An alternative method of palpating the liver.

Stand up at the persons shoulder and swivel

your body to the right so that you face the

persons feet. Hook your fingers over thecostal margin from above.

Ask the person to take a deep breath then try

to feel the liver edge bump from your

fingertips.

Spleen Palpation:

Search spleen by reaching your left hand over

-Left ureter

-Left spermatic cord

Normally there is no pain, tenderness, rigidity

and muscle guarding

Normally there is no pain, tenderness, rigidity

and muscle guarding

It feels like a firm rectangular ridge. Often the

liver is not palpable and you feel nothing firm.

Normally you should feel nothing firm. When

enlarged the spleen extends into the lower

quadrants.

A person normally feels a thud but no pain.


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the abdomen and behind the left side at the

11th and 12th

ribs. Lift for support. Place your

hand obliquely on the LUQ with the fingers

pointing toward the left axilla and just inferior

to the rib margin. Push your hand deeply

down and under the left costal margin and askthe person to take a deep breath.

Kidney

Percussion:

Indirect fist percussion causes the

tissues to vibrate instead of producing a

sound. Locate kidney by placing hand over the

12th rib at the costoverbral angle on the back.

Thump that hand with the ulnar edge of your

other fist.

Palpation:

locate kidney by placing your hand together in

a duck-bill position at the persons right flank.

Press your two hands together firmly (you

need deeper palpation than that used to liver

and spleen) then ask the person to take a

deep breath.

Palpation:

Light palpation in all 4 quadrantsDeep palpation in all 4 quadrants

Extremities

Upper and Lower

Inspection:

-Observe for size, color, contour, symmetry

and involuntary movement

-Look for deformities, edema, and presence of

lesions.

- Always compare both extremities

Palpation:

-Feel evenness of temperature. Normally it

should be even for all the extremities.

Sharp pain occurs with inflammation of

kidneys or paranephric area.

Lower pole of the kidney is round, smooth

mass slide in between your fingers.

Both extremities are equal in size

Have the same contour with prominences of

joints.

No involuntary movements. No edema. Color

is even.

Temperature is warm and even. Has equal

contraction.


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- Perform range of motion

-Test for muscle strength

Can perform complete range of motion

Can counter act gravity and resistance in ROM

Balance Test

Gait

Observe as the person walk 10-20 feet, turns and returns to the starting point. Normally,

the person moves with a sense of freedom. The gait is smooth, rhythmic, and effortless, the

opposing arm swing is coordinated, and the turns are smooth.

Rombergs Test

Ask the person to stand up with feet together and arms at the side. Once in a stable

position, ask the person to close the eyes and to hold the position. Wait about 20 seconds.

Normally, a person can maintain posture and balance even with the visual orienting

information blocked, although slight swaying may occur. (Stand close to catch the person in

case he or she falls)

Tandem Walking

Ask the person to walk straight line in a heel-to-toe fashion. This decreases the base ofsupport and will accentuate any problem with coordination. Normally, the person can walk

straight and stay balance.

Coordination and Skilled Movements

Rapid Altering Movements (RAM)

Ask the person to pat the knees with both hands, lift up, turn hands over, and pat the

knees with the backs of the hands. Then ask the person to do this faster. Normally, this is done

with equal turning and a quick rhythmic pace.

Finger-to-nose Test

Ask the person to close the eyes and to stretch out the arms. Ask the person to touch

the tip of his nose or her nose with each index finger, alternating hands and increasing speed.

Normally, this is done with equal turning & a quick rhythmic pace.


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Heel-to-shin Test

Test lower extremity coordination by asking the person who is in a supine position, to

place the heel on the opposite knee, and run it down the shin from to the ankle. Normally, the

person moves the heel in a straight line down the skin.

Reflex

It is an automatic response of the body to a stimulus. It is not voluntarily learned or

conscious. Reflexes are tested using a percussion hammer. The response is described from 0 to

4. Experience is necessary to determine appropriate scoring of an individual. Several reflexes

are normally tested during the physical examination: a) the biceps reflex, b) the triceps reflex, c)

the brachioradialis reflex, d) the patellar reflex, e) Achilles reflex, f) the plantar reflex.

Test the Reflex

The reflex response is guided on a 4 point scale:

4+ very brisk, hyperactive

3+ brisker than average, may indicate disease

2+ average, normal

1+ diminished, low normal

0 no response

Upper Extremity

Biceps Reflex (Flexion)

Support the persons forearm on yours; this position relaxes, as well as partially flexes,

the persons arm. Place your thumb on the biceps tendon and strike a blow on your thumb. You

can feel as well as see the normal response, which are contraction of the biceps muscle and the

flexion of the forearm.

Triceps Reflex (Extension)

Tell the person to let the arm just go dead as you suspend it by holding the upper arm.

Strike the triceps tendon directly just above the elbow. The normal response is extension of the

forearm.

Brachioradialis Reflex (Flexion and Supination of the arm)


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Hold the persons thumbs to suspend the forearm in relaxation. Strike the forearm

directly, about 2 to 3 cm above the radial styloid process. The normal response is flexion and

supination of the arm.

Lower Extremity

Quadriceps Reflex (patellar or knee jerk reflex)

Let the lower legs dangle freely to flex the knee and stretch the tendons. Strike the

tendon directly just below the patella. Extension of the lower legs is the expected response.

Achilles Reflex

Position the person with the knee flexed and the hip externally rotated. Hold the foot in

dorsiflexion, and strike the Achilles tendon directly. Feel the normal response as the foot

plantar flexes against your hand.

Plantar Reflex

Position the thigh in slight external rotation. With the reflex hammer, draw a light stroke

up the lateral side of the sole of the foot and inward across the ball of the foot, like an upside-

down J. The normal response is plantar flexion if all the toes and inversion and flexion of the

forefoot.

physical assestment

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