Physical Assessment or Examination – Purpose, Role of Nurse and Assistance in the Examination
General Examination or Head to Toe Examination
The examination is carried out in an orderly manner focusing upon one area of the body at a time. The observation of the client starts as the client walks into the examination room, e.g., a limp may be noted as the client walks in. the following observations are made:
Nourishment: well nourished or under nourished
Body build: thin or obese
Health: healthy or unhealthy
Activity: active or dull (tired)
Consciousness: conscious, unconscious, delirious, talking, incoherently
Look: anxious or worried, depressed etc
Body curves: lordosis, kyphosis, scoliosis
Movement: any limp
Height and Weight
Color: pallor, jaundice, cyanosis, flushing etc
Texture: dryness, flaking, wrinkling or excessive moisture
Temperature: warm, cold and clammy
Lesions: macules, papules, vesicles, wounds etc
Head and Face
Shape of the skull and fontennels (noted in the newborne)
Scalp: cleanliness, condition of the hair, dandruff, pediculi, infections like ringworm
Face: pale, flushed, puffiness, fatigue, pain, fear, anxiety, enlargement of parotid glands etc
Eyebrows: normal or absent
Eye lashes: infection, sty
Eyelids: oedema, lesions, ectropion (eversion), entropion (inversion)
Eyeballs: sunken or protruded
Conjunctiva: pale, red, purulent
Cornea or iris: irregularities and abrasions
Pupils: dilated, constricted, reaction to light
Lens: opaque or transparent
Fundus: congestion, haemorrhagic spots
Eye muscles: strabismus (squint)
Vision: normal, myopia (short sight), hyperopia (long sight)
External ear: discharges, cerumen obstructing the ear passage
Tympanic membrane: perforations, lesions, bulging
Hearing: hearing acuity
External nares: crusts or discharges
Nostrils: inflammation of the mucus membrane, septal deviations
Mouth and Pharynx
Lips: redness, swelling, crusts, cyanosis, angular stomatitis
Odor of the mouth: foul smelling
Teeth: discoloration and dental caries
Mucus membrane and gums: ulceration and bleeding, swelling, pus formation
Tongue: pale, dry, lesions, sords, furrows, tongue tie etc
Throat and Pharynx: enlarged tonsils, redness and pus
Lymph nodes: enlarged, palpable
Thyroid gland: enlarged
Range of motion: flexion, extension and rotation
Thorax: shape, symmetry of expansion, posture
Breath sounds: sigh, swish, rustle, wheezing, crepitations, pleural rub etc
Heart: size and location, cardiac murmurs
Breasts: enlarged lymph nodes
Observation: skin rashes, scar, hernia, ascites, distension, pregnancy etc
Auscultation: bowel sounds, foetal heart sounds
Palpation: liver margin, palpable spleen, tenderness at the area of appendix, inguinal hernias
Percussion: presence of gas, fluid or masses
Movement of joints, tremors, clubbing of fingers, ankle, oedema, varicose veins, reflexes etc
Spina bifida, curves
Genitals and Rectum
Inguinal lymph glands: enlarged, palpable
Patency of urinary meatus and rectum (in infants)
Descent of the testes (in infants)
Presence of sexually transmitted diseases
Enlargement of the prostate gland
Coordination tests: reflexes
Equilibrium tests: test for sensations
Role of the Nurse in Physical Examination
Preparation of the Environment
Maintenance of Privacy
A separate examination room is needed. Keep the doctors closed. The relatives are not allowed. Drape the client according to the parts that are exposed.
As far as possible, natural light should be available in the examination room because if a client is jaundiced, it may not be detected in the artificial light. There should be adequate lighting.
Comfortable Bed or Examination Table
The client should be placed comfortably throughout the examination. These should be provision for the maintenance of a suitable position e.g., a lithotomy position may be maintained when examining the genitalia. To maintain the position, a special examination table with stirrup rods is needed.
The room should be warm and without draughts
Preparation of the Equipment
All the articles needed for the physical examination are kept ready for the examination at hand.
Purpose: to measure B.P.
Purpose: to listen to the body sounds
Purpose: to listen the F.H.S
4. T.P.R Tray
Purpose: to assess the vital signs
5. Tongue depressor
Purpose: to examine the mouth and throat
6. Pharyngeal retractor
Purpose: to examine the pharynx
Purpose: to examine the larynx
8. Tape measure
Purpose: to measure height, circumference of the head and abdomen
9. Flash light
Purpose: to visualize any part
10. Weighing machine
Purpose: to check the weight
To examine the inner part of the eyeball
Purpose: To examine the ear
13. Tuning fork
Purpose: to test the hearing
14. Nasal speculum
Purpose: to examine the nostrils
15. Percussion hammer, safety pins, cotton wool, cold and hot water in test tubes
Purpose: to test reflexes
16. Vaginal speculum
Purpose: to examine the genitals in women
Purpose: to examine the rectum
Purpose: to examine the pelvis internally
19. Sterile specimen bottles, slides, cotton applicators
Purpose: to collect the specimens if necessary
Preparation of the Client
Keep the client clean. Shave the part if necessary. Keep the client in a comfortable position which is convenient for the doctor to examine the client. Empty the bladder prior to the examination. Empty the bowels by an enema, if required. Loosen the garments and change into the hospital dress, if it is the custom. Drape the client with extra sheets and expose only the needed areas. Avoid unnecessary exposure.
The client may be quite new to the hospital situation and the may be anxious about his illness. He may have false ideas about the medical examination. It is the duty of the nurse to allay his anxieties and fears by proper explanation. Explain the sequence of the procedure to gain his confidence and cooperation. As far as possible a nurse should remain with a female client during the physical examination.
Assistance in the Examination
To take Height and Weight
To measure the length of the baby who cannot stand, place the baby on a hard surface, with the soles of the feet supported in an upright position. The knees are extended and the measurement is taken from the sole of the feet to the vertex of the head. The head should be in such a position that the eyes are facing the ceiling.
After a child can stand, the height can be measured, if the child stands with the heels, back and head against the wall. A small flat board held from the top of the head to the wall will give accurate measures of the height that is the distance from the floor to the board.
The weight of a person who can stand is generally measured by a standing scale. The client stands on the platform and the weight is noted on the dial. Usually the weight is taken without shoes. To take the weight of a baby, a baby weighing scale is used, in which there is a container, where the baby can be laid. It is important to weigh a baby unclothed or to weigh the clothes separately and subtract this weight.
To Measure the Skull Circumference
The skull is measured at its greatest diameter from above the eyes to the occipital protuberance.
Examination of the Eyes
The examination is done in a lying or sitting position. The examiner frequently uses a head mirror that reflects light to the client’s face. The first examination is one of inspection to determine the movements of the eyes, reaction to light, accommodation to near and far objects. For detailed examination of the internal parts of the eye an ophthalmoscope is used.
Examination of the Ears
The client may be placed either in a lying or sitting position with the ear to be examined turned towards the examiner. Articles used for the examination are a head mirror, ear speculum of various sizes, cotton tipped applicators and autoscope. Tuning fork is used to test the hearing.
A child needs to be carefully restrained. Young children sit on their mother’s lap with their legs restrained between the mother’s knees and their arms held against their back. The mother then holds the child’s head against her chest. Very small infants can be laid on the examination table.
Examination of the Nose, Throat and Mouth
The client is usually seated with the head resting against the back of the chair. For the examination of the throat, a tongue depressor and a good light are needed. For examination of the nose, a nasal speculum and a head mirror are used. Sometimes the autoscope is also used.
Examination of the Neck
The neck needs to be palpated for lymph nodes. In order to assess the thyroid glands, the client is asked to swallow saliva.
Examination of the Chest
While examining the anterior chest, the client is placed in a horizontal recumbent position. The chest is examined in several ways. It is percussed to determine the presence of fluid or congested areas. The physician listens to the sounds within the chest by means of a stethoscope.
To examine the posterior chest, the client is placed in a sitting position. The heart and lungs are examined by percussion and auscultation.
The breasts are examined by palpation for the presence of lumps or growths. The axillae are palpated for enlarged lymph nodes.
During the examination, the client’s face is turned away from the doctor.
Examination of the Abdomen
The abdomen is examined while the client is in a dorsal recumbent position and the knees are slightly flexed to promote relaxation of the abdominal muscles. The abdomen is inspected palpated, auscultated and percussed to detect any abnormalities.
Examination of the Extremities (arms and legs)
Extremities are inspected, palpated and moved. A fine tremor suggestive of hyperthyroidism can be observed, if the client is asked to hold the arms out in front of him for a few minutes. A pitting oedema may be observed at the ankle joint by pressing the skin against the bone. Varicose veins may be observed on the posterior part of the leg over the calf muscles. The joints are moved in all directions to assess the movements of joints.
Examination of the Spine
In a standing position the spine is examined for abnormal curvature. The fingers are moved over the spine to detect the spina bifida in a newborn infant.
Examination of the Genitalia
The client is placed in a dorsal recumbent or lithotomy position. For the examination of the female genitalia, clean rubber gloves, vaginal speculum, a good source of light and a lubricant are necessary. The abnormalities of the vulva, vagina, cervix, uterus and the ovaries are detected. The inguinal region is palpated for the enlarged lymph nodes.
Examination of the Rectum
To examine the rectum and anus, the client is placed in a dorsal recumbent or left lateral position. Initially the anus is observed for the haemorrhoids, fissures or cracks. If the client is asked to bear down, as if to defecate, the internal haemorrhoids may become visible.
To examine the rectum, a clean glove (a finger cot may be sufficient), proctoscope, Vaseline as lubricant and a good source of light are necessary. The rectum is palpated for the presence of masses on the anterior or posterior wall. In females, on anterior wall of the rectum, the cervix will be palpated. In the males, the prostate gland can be palpated.
Neurological assessment includes examination of the reflexes, coordinations, equilibrium, sensations of touch, pain, vibrations, position, temperature discrimination, tonicity and movement of muscles.
This includes finger to nose test, heel to shin test. In finger to nose test, the client is asked to abduct and extend the arms at shoulder height and rapidly touch the nose alternately with one index finger, then with the other. In abnormal response, the client will miss the nose.
Abnormalities of gait or posture can be detected by this test. The client is asked to stand with the eyes open and the feet together. If he does not loose balance or does not fall (with the eyes open), the test is repeated with the eyes closed. It is important to be prepared to help the client, should he begin to fall.
Tests for Sensations
Sensation of touch is tested with the wisp of cotton. The client is asked to close the eyes and to respond whenever the cotton touches the skin. The vibratory sense is tested by a tuning fork which is held firmly against a bone. Sensation of temperature difference is tested by touching the skin with test tubes filled with hot and cold water. The client identifies the test tube that feels hot or cold.
Muscle strength is tested by asking the client to move a particular joint and the examiner opposes the motions.
It is the systematic collection of objective information that is directly observed or is elicited through examination techniques. Physical examination involves the use of one’s senses to obtain information about the structure and function of an area being observed or manipulated. It is the thorough inspection or a detailed study of the entire body or some parts of the body to determine the general physical or mental conditions of the body.
1. To understand the physical and mental well-being of the clients.
2. To detect diseases in its early stage.
3. To determine the cause and the extent of disease.
4. To understand any changes in the condition of diseases, any improvement or regression.
5. To determine the nature of the treatment or nursing care needed for the client.
6. To safeguard the client and his family by noting the early signs especially in case of a communicable disease.
7. To contribute to the medical research.
8. To find out whether the person is medically fit or not for a particular task.
Techniques of Physical Examination
The four basic techniques used in physical examination are explained as follows:
It is the systematic visual examination of the client, or it is the process of performing deliberate purposeful observation in a systematic manner. It involves observation of the color, shape, size, symmetry, position and movements. It also use the sense of smell to detect odor, and sense of hearing to detect sounds.
Inspection begins with the initial contact with the client and continues through the entire assessment. The optimal conditions for effective inspection are full exposure of the area and adequate lighting.
AUTHOR: S J SALMA
POSITIONS AND DRAPINGS USED FOR PHYSICAL EXAMINATION
It is the responsibility of the nurse to place the client in a position that is suitable for the examination of the body or part of the body.
Methods of draping vary with the position. Draping should be such that it avoids all unnecessary exposure but allows exposure of the part that is to be examined. It should not interfere with the examination of the body. Loose draping is preferable as it allows a quick change of position.
Before the examination starts, a screen is placed to provide privacy. Remove all personal clothing of the client and put on the hospital gown. Place a sheet or cotton blanket over the client and expose the parts as necessary.
During the chest examination, fold the bed clothes to the waist line, remove the gown and place a towel across the chest. Prevent draughts and exposure.
For the examination of the vulva, vagina, rectum and pelvis, leggings are used as drapes. The perineum is covered with a towel that can be removed just before the examination. When the leggings are not available a sheet is used. One corner of the sheet is tucked on one foot and the opposite corner is tucked on the other foot. Both legs are covered with the sheet and only the vulva is exposed. For the examination of the rectum, if the client is in a side-lying position, cover the client with a sheet and fold back a small portion of the sheet to expose only the rectum.
For the examination of the lower extremities, cover the genitalia with a towel extending from the lower abdomen to the buttocks and cover him with a sheet. Expose only one or both leg as desired.
When the client is in a knee chest position, use two sheets, one for the upper part of the body and the other for the lower part of the body. The buttocks are covered with a slit (a towel having an opening in the centre) to expose only the anus.
General inspection of a client focuses on the following areas:
1. Overall appearance of health or illness
2. Signs of distress
3. Facial expression and mood
4. Body size
5. Grooming and personal hygiene
Besides being used in general survey, inspection is the first method used in examination of a specific area. The chest and abdomen are inspected before palpation and auscultation.
It is use of the hands and fingers to gather information through touch. It is the assessment technique which uses sense of touch. It is feeling the body or part with hands to note the size and position of the organs.
The hands and fingers are sensitive tools and can assess temperature, turgor, texture, moisture, vibrations, size, position, consistency, masses and fluid. The dorsum (back) surfaces of the hand and fingers are used to measure temperature. The palmar (front) surfaces of the fingers and finger pads are used to assess texture, shape, fluid, size, consistency and pulsation. Vibration is palpated best with the palm of the hand.
The nurse’s hand should be warm and fingernails short and the touch should be gentle and respectful. Areas of tenderness are palpated last. The purpose of deep palpation is to locate organs, determine their size and to detect abnormal masses.
It is the examination by tapping the fingers on the body to determine the condition of the internal organs by the sounds that are produced. Percussion is the act of striking one object against another to produce sound. The sound waves produced by the striking action over body tissues are known as percussion tones or percussion notes. Percussion provides information about the nature of an underlying structure. It is used to outline the size of an organ such as bladder or liver. Percussion is also used to determine if a structure is air filled, fluid filled or solid.
The degree to which sound propagates is called resonance. Percussion produces five characteristic tones: tympanic, hyper-resonant, resonant, dull and flat. Percussion of the abdomen is tympanic, hyper-inflated lung tissue is hyper-resonant, normal lung tissue is resonant, the liver is dull and the bone flat. There are two types of percussion, direct and indirect. Direct percussion is accomplished by tapping an area directly with the finger tip of the middle finger or thumb. Indirect percussion involves two hands. The hands are placed on the area to be per cussed and the finger creating vibrations that allows discrimination among five different tones.
It is the process of listening to sounds that are generated within the body. Auscultation is usually done with the help of a stethoscope. The heart and blood vessels are auscultated for circulation of blood; the lungs are auscultated for moving air (breath sounds); the abdomen is auscultated for movement of gastrointestinal contents (bowel sounds). When auscultating a part, that area should be exposed, and should be quiet.
Four characteristics of sound are assessed by auscultation:
1. Pinch (ranging from high to low)
2. Loudness (ranging from soft to loud)
3. Quality (gurgling or swishing)
4. Duration (short, medium or long)
It is the moving of a part of the body to note its flexibility. Limitation of movement is discovered by this method.
Testing of the reflexes
The response of the tissues to external stimuli is tested by means of a percussion hammer, safety pin, wisp of cotton, or hot and cold water.