General Physical Assessment Techniques

General Physical Assessment Overview

• Physical assessment is a systematic method of data collection using senses like vision, hearing, smell, and touch.
• The purpose of physical assessment is to detect health problems.
• The four main techniques in physical assessment are inspection, palpation, percussion, and auscultation.
• History taking is typically completed before the physical examination.

Preparation for Examination

• Infection control is crucial, especially with patients who have open skin lesions or drainage.
• Nurses must maintain strict infection control measures to avoid infection.
• Use of personal protective equipment is mandatory: apron (outer protective garment), gloves, mask, and gown.

Equipment Required

• Essential equipment includes: stethoscope, sphygmomanometer, thermometer, torch, measuring tape, weighing scales, height measuring device, and wooden spatula.
• Additional equipment: magnifying glass, ophthalmoscope, otoscope, tuning fork, tendon hammer, cotton wool, and disposable neurotips (pins).

Patient Preparation

• Physically prepare the patient while ensuring comfort throughout the examination; explain the steps and address concerns.
• Physical preparation includes bladder and bowel elimination, proper draping and dressing, and correct positioning.
• Psychological preparation involves ensuring the patient is free from anxiety; a third person is required if both patient and examiner are of opposite sex, and the patient's facial expressions are observed.

Patient Setting

• Privacy is critical during the examination.
• Using curtains obscures vision but not sound.
• Communication should be quiet, but comprehensive.
• The room should be warm and well-lit, even for detecting mild jaundice.
• The examination couch or bed should be adjustable.
• Practitioners need to seek permission to expose areas for examination, covering the rest.
• Avoid unnecessary exposure and embarrassment.

Communication with Patient and Others

• Relatives should be asked to leave room tactfully, except for scenarios involving a child patient, opposite-sex examiner, apprehensive patient, need for a translator, a patient's request or an intimate examination..

Principles of Inspection

• Inspection uses vision to distinguish normal from abnormal findings.
• Expose the body part for viewing all surfaces, and inspect for size, shape, color, symmetry, position, and abnormalities.
• Comparing each area with the same area on the opposite side is preferable.

Visual Inspection During Emergency Response

• During an emergency response at a patient's home, perform a visual inspection for cleanliness, prescription medicines, illegal drugs, weapons, and signs of alcohol use.
• Comprehensive health assessment is deferred if there are signs of acute distress until the patient is stable.

First Impressions

• Initial assessment involves observing the patients' general behavior and external appearance.
• Note how patients rise from their chair and walk into the room.

Head-to-Toe Assessment - General Examination (GAD-5B-2P-GASA)

• Consider gender and race; for example, skin cancer is 20% higher in white individuals than black individuals, and prostate cancer is more prevalent in African American men compared to white American men.
• Age: children and the older adults are more prone to infection.
• Note any distress signs, like pain or difficulty in breathing.
• Assess the body type as thin or fat.
• Evaluate body movement - are they purposeful, or is any part immobile?
• Assess personal hygiene: note the use of cosmetics.
• Evaluate the dress: is it appropriate to culture, lifestyle, socio-economic status and weather?
• Assess body odor: unpleasant odors indicates poor hygiene or poor oral hygiene.
• Position and Posture: Evaluate if standing, upright position or knee flexed static and dynemic

Gait

• Assess coordination: a person should walk with arms swinging freely, head and face forward.
• Affect and mood: feelings to others and emotionally expression.
• Appropriateness of mood per situation.
• Speech: asses pressure, tone, and speed of speech.
• Client abuse: Note any problems during growing and serious health problem during childhood.
• Note any Substance abuse issues; drugs, alcohol, or smoking.

Patient Positions

• Standing
• Supine and prone,
• Sitting/Fowler's: Semi-upright position (45-60 degrees) facilitates relaxing of tension in abdominal muscles, improving breathing which is ideal for oral and gastric feeding.
• Lateral decubitus position: It indentifies free intraperitoneal gas/pneumoperitoneum).
• Dorsal and Supine Positions
• Tripod position
• Curled up position
• Mohammedian Prayer position,
• Sitting and leaning forward Position
• Dorsal recumbent position; patient lies on their back with lower extremities moderately flexed is in pelvic and abdominal examinations.
• Lithotomy Position: Patient lies on the back with lower extremities moderately flexed and rotated outward during vaginal exams and application of obstetrical tools.
• Knee-chest position
• Sim’s; treatments and enemas and rectal examination.

Gait and Posture Observations

• Gait and posture indicate neurological or musculoskeletal disorders and overall patient function.
• Gait disorders occur because of pain, immobile joints, muscle weakness, or limb control issues.
• If the patient is in bed, assess their posture.

Specific Gait Abnormalities

• Spastic hemiparesis: one arm held immobile, wrist and fingers flexed, leg extended, dragging toe in a circle. Caused by upper motor neuron lesions, stroke.
• Steppage gait: Foot dragged or lifted high and slapped onto the floor due to loss of dorsiflexion. Caused by foot drop by a lower motor neuron lesion.
• Sensory or cerebellar ataxia: unsteady, wide-based gait, throwing feet forward. With eyes closed, he cannot stand steadily. In cerebellar ataxia, turns are difficult and caused by polyneuropathy or posterior column damage (e.g. syphilis).
• Parkinsonian gait: curved posture, flexed arms, shuffling steps caused by a lesion in the basal ganglia.
• Gait abnormalities: Spastic gait and scissoring gait caused by upper motor neurone lesion, stroke or spastic cerebral palsy &UMNL, propulsive gait caused by lesion in the basal ganglia and waddling gait is caused by weakness of the proximal muscles of the pelvic girdle as in pregnancy or muscle atrophy.

Clothing Clues

• Clothing reflect personality, state of mind, and social circumstances.
• Young individual wearing dirty clothes due to alcohol/drug addiction and elderly with faecal or urinary soiling.
• Anorectic patients wear baggy clothing to cover weight loss.

Odors

• Normal odor can be altered by deodorants and perfume.
• Excessive sweating and poor hygiene increase body odor.

Body Odor Indicators

• Excessive body odor occurs in extreme old age/weakness, major mental illness, alcohol/drug misuse, physical disability preventing normal hygiene and severe learning difficulties.
• Tobacco scent saturates hair and clothing.
• Marijuana can be identified by smell.
• Alcohol smell suggests an alcohol problem.

Halitosis (Bad Breath)

• Causes: decomposing food, gingivitis, stomatitis, atrophic rhinitis, tumors.
• Halitosis: Decomposing food wedged between the teeth, Gingivitis, Stomatitis, Atrophic rhinitis and Tumors of the nasal passages.

Other Characteristic Odors

• Fetor hepaticus: breath of the dead in patients with liver failure.
• Ketones: Sweet smell due to acetone in diabetic ketoacidosis or starvation.
• Uraemic fetor: fishy smell on the breath in uraemia.
• Putrid or fetid smell: Chronic anaerobic suppuration due to bronchiectasis or lung abscess.
• Foul-smelling belching: Gastric outlet obstruction.
• Strong faecal smell: Gastrocolic fistula.