General Physical Examination PDF

NS-HAT 201 L 3-Topic General Dr. MasaniPhysical Examination Abdelbagi Ahmed Elmahdy Assistant Professor GMU www.gmu.ac.ae  Objectives: By the end of this session , you will be able to: 1. Follow the principl...

NS-HAT 201 L 3-Topic General Dr. MasaniPhysical Examination Abdelbagi Ahmed Elmahdy Assistant Professor GMU www.gmu.ac.ae  Objectives: By the end of this session , you will be able to: 1. Follow the principles of physical examination 2. Identify and use appropriate equipment for conducting physical examination 3. Demonstrate different techniques of physical examination in routine and emergency situations. 4. Identify legal and ethical aspects of health assessment 5. Document findings in appropriate form Definition of Physical assessment The physical examination or physical assessment is a systematic data collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems. To conduct the examination, the nurse uses techniques of inspection, auscultation, palpation, and percussion. Techniques of Physical Examination Inspection: Visual examination Palpation: Using hands to feel body parts Percussion: Tapping to evaluate underlying structures. Auscultation: Listening to body sounds (e.g., heart, lungs) Olfaction: Noting unusual odors. Physical Examination Techniques Preparing for a Physical Examination 1. Physical examination usually follows the health history assessment. 2. Conduct the exam in a well-lit and warm environment. 3. Ensure the patient undresses and is properly draped, exposing only the area being examined. 4. Prioritize the patient’s physical and psychological comfort throughout the examination. Preparing for a Physical Examination 1. Explain each procedure and expected sensations to the patient beforehand. 2. Wash hands before and after the examination to maintain hygiene. 3. Keep fingernails short to prevent patient injury. 4. Wear gloves when there's a risk of exposure to blood or bodily fluids.  Basic Guidelines for Physical Assessment 1. Obtain a nursing history and survey 2. Maintain privacy 3. Explain the procedure 4. Compare symmetrical sides 5. If abnormality (symptom analysis) 6. Client teaching 7. Allow time for the client’s questions. "Remember: the most important guideline for adequate physical assessment is the conscious, continuous practice of physical assessment skills". 1. Observation Observation is the most important physical assessment technique for practitioners to master.  2. Inspection General Inspection: Observing the overall appearance, behavior, and hygiene of the individual. Specific Inspection: Focusing on specific areas or body parts, such as the skin, head, eyes, ears, nose, throat, chest, abdomen, extremities, etc  Principles of Inspection Provide a room with a comfortable temperature. Use good lighting, preferably sunlight. Look and observe before touching. Completely expose the body part you are inspecting while draping the rest of the client as appropriate. Note the following characteristics while inspecting the client: color, patterns, size, location, consistency, symmetry, movement, behavior, odors, or sounds. Compare the appearance of symmetric body parts (e.g., eyes, ears, arms, hands) or both sides of any individual body part. 3. Palpation Light Palpation: Gently using the fingers to assess surface characteristics, tenderness, or superficial masses. Deep Palpation: Applying more pressure to assess deeper structures, such as organs or deep tissues. Bimanual Palpation: Using both hands to assess organs or structures located between them.  Principles of Palpation Help client relax Rub hands to warm them, have short fingernails and use a gentle touch Advise client to take slow deep breaths during palpation Light (superficial) palpation should always precede deep palpation because heavy pressure on the fingertips can dull the sense of touch. Palpate tender areas last and note nonverbal signs of discomfort. Three different parts of the hand—the finger pads, ulnar/ palmar surface, and dorsal surface—are used during palpation. Each part of the hand is particularly sensitive to certain characteristics.  Light palpation: To perform light palpation place your dominant hand lightly on the 4 Types of Palpation surface of the structure. There should be very little or no depression (less than 1 cm). Feel the surface structure using a circular motion. Use this technique to feel for pulses, tenderness, surface skin texture, temperature, and moisture.  Types of Palpation Moderate palpation: Deep palpation: Place your dominant hand on the skin surface and your non-dominant Depress the skin surface 1 hand on top of your dominant hand to apply to 2 cm (0.5 to 0.75 inch) pressure. This should result in a with your dominant hand, surface depression between 2.5 and 5 cm (1 and 2 inches). and use a circular motion to This allows you to feel very deep organs or feel for easily palpable body structures that are covered by thick muscle organs and masses. Note the size, consistency, and mobility of structures you palpate.  Types of Palpation Bimanual palpation: Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated. Use one hand to apply pressure and the other hand to feel the structure. Note the size, shape, consistency, and mobility of the structures you palpate. 4. Percussion Direct Percussion: Striking the body surface directly with the fingertips. Indirect Percussion: Striking an object (such as a reflex hammer) placed on the body surface. Tympanic Percussion: Tapping to assess the resonance of hollow organs (e.g., lungs, stomach). Dullness Percussion: Tapping to assess the density of solid organs (e.g., liver). 91 9/ Direct percussion 1 8 Types of Percussion / 2 0 2 4 Indirect Percussion  Types of Percussion Indirect Percussion is the striking of an object Direct percussion is the direct tapping of a (e.g., a finger) held against the body area to be body part with one or two fingertips to examined. elicit possible tenderness (e.g., tenderness over the sinuses). The nurse strikes the area middle finger of the nondominant hand, to be percussed directly with the pads of referred to as the pleximeter, is placed firmly two, three, or four fingers or with the pad of on the client’s skin. the middle finger. The strikes are rapid, and the movement is from the wrist. Only the distal phalanx and joint of this finger should be in contact with the skin. Using the tip of the flexed middle finger of the other hand, called the plexor, the nurse strikes the pleximeter, usually at the distal interphalangeal joint or a point between the distal and proximal joints.  *Sounds (Tones) Elicited by Percussion Sound Intensity Pitch Length Quality Example of Origin Resonance (part air and part Loud Low Long Hollow Normal lung solid) Hyper-resonance Very loud Low Long Booming Lung with emphysema (hyperinflated,mostly air) Tympany (heard over air) Loud Hihg Moderate Drum-like Puffed out cheek, air-filled stomach Dullness (heard over more Medium Medium Moderate Thud-like Diaphragm, pleural effusion, solid tissue) liver, heart, spleen Flatness (heard over very dense Soft High Short Flat Muscle, bone, sternum, thigh tissue) 5. Auscultation Listening with a Stethoscope: Using a stethoscope to hear sounds produced by the body, such as heart sounds, lung sounds, and bowel sounds. Auscultatory Areas: Specific locations on the body where certain sounds are best heard Auscultation Stethoscope Part Purpose Technique DIAPHRAGM To detect high-pitched Press firmly on sounds. body part Ex: breath sounds Normal heart sounds Bowel sounds BELL To detect low-pitched Press lightly sounds. over body part Ex: Abnormal heart sounds (murmur) 6. Olfaction: Assessing Odors: Smelling for abnormal or characteristic odors that may indicate certain conditions (e.g., infections). 7. Measurement: Height: Measuring the individual's standing height. Weight: Measuring body weight. Body Mass Index (BMI): Calculating BMI using height and weight measurements. Vital Signs: Measuring key indicators such as heart rate, blood pressure, respiratory rate, and body temperature Adult Physical Assessment Equipment Basic Tools: Stethoscope Blood pressure cuff Thermometer Penlight Reflex hammer Tongue depressor Measuring tape Specialized Equipment: Ophthalmoscope Otoscope Tuning fork  Instruments/ Equipment 1. Tuning Fork 14. Lubricant 25. Otoscope 2. Visual Occluder 15. Goniometer 26. Key & cotton ball (for 3. Ruler 16. Clean gloves neurologic assessment) 17. Cervical Spatula 4. Visual Acuity Chart 27. Sterile needle 18. Cervical Brush 5. Buck Hammer 28. Slide & Fixative 19. Cotton tip 6. Reflex Hammer 29. Specimen cup applicator 7. Pen & Marking Pen 30. Vaginal Speculum 20. Tongue Depressor 8. Penlight 21. Guaiac Material 9. Thermometer 22. Tape Measure 23. Stethoscope 10. Sphygmomanometer 24. Ophthalmoscope  Assessment Sequencing Head-to-Toe Examination: Systematic approach from head down to toes System Wise Examination: Assessing one system at a time (e.g., cardiovascular, respiratory) Emergency Assessment: Rapid assessment focusing on life-threatening conditions (e.g., ABCs: Airway, Breathing, Circulation)  Legal and Ethical Aspects of Health Assessment Confidentiality and Patient Privacy: HIPAA regulations, maintaining patient dignity. Informed Consent: Explanation of procedures and obtaining consent. Professional Boundaries and Ethical Conduct: Respecting patient rights and cultural differences.  Documentation of Findings Importance of Accurate Documentation: Legal record, communication tool, continuity of care Formats: SOAP (Subjective, Objective, Assessment, Plan). Narrative notes. Electronic health records (EHR). Skin Inspect all skin surfaces first or gradually while assessing the systems. Use the skills of inspection, palpation, and olfactory to assess the function. Inspect the skin for color, edema, lesions, scars, and vascularity. Palpate to notice moisture, temperature, and skin turgor 22  SKIN ASSESSMENT Check skin turgor Check for lesions, abrasions, rashes Check for tenderness, lumps, lesions Check if patient is pale, clammy, dry, cold, hot, flushed  Nails The condition of the nails - general health, state of nutrition, occupation, and level of self-care. Nail biting - psychological state. Inspect the nail bed- color, cleanliness, length, texture, angle between nail and nail bed, and folds around the nail. Palpate the nail for inflammation 24  Hair and Scalp Assess and note type of hair - long, coarse, thick, brittle Note the color, distribution, quantity, thickness, texture and lubrication. On inspection separate the hair to determine the scalp condition 23  Ears, Eyes, Nose, Throat Assess patient hearing with whisper test Palpate nose and assess Tuning Fork test (Weber’s test, Rinne test) symmetry Look inside ear Check septum and inside EAR - discharge and tympanic membrane nostrils Verify patency of nares Check conjunctiva and sclera Check patient’s sense of Assess eye symmetry smell Check vision with Snellen Chart Palpate sinuses o LIPS - color and moistness o Teeth and gums o Examine Tongue o Examine tonsils  NECK Palpate lymph nodes Observe and palpate the trachea and neck Check for Jugular Venous Distention Check neck range of motion Check shoulder shrug with resistance NECK  Thorax and Lungs Listen to lung sounds front and back Assess respiratory expansion level Ask about coughing Palpate thorax  CARDIAC ASSESSMENT Palpate the carotid and Pulses temporal pulses bilaterally Check pulses in arms/legs/feet including: Radial Listen to the heartbeat Femoral Posterior tibial Dorsalis pedis CARDIAC ASSESSMENT  ABDOMEN Inspect abdomen Listen to 4 quadrants of abdomen for bowel sounds Palpate 4 quadrants of abdomen for pain/tenderness Ask about problems with bowel or bladder EXTREMITIES Assess range of motion and strength in arms/legs/ankles Assess sharp and dull sensations on arms/legs Check capillary refill on fingernails/toenails  NEUROLOGICAL ASSESSMENT Orientation to time, place, person Assess gait Check coordination Assess reflexes Check the Glasgow Coma Scale score  Deep Tendon Reflexes Normally done on high-risk patients and needs specialized practice and a special hammer to assess the reflexes. Areas that are assessed are on biceps, triceps, patella, and Achilles. 34  Genitalia Rectum and Anus Start assessment of genitalia by Inspect for skin color, sores, asking questions and doing an hemorrhoids, and lesions. inspection to confirm a positive Do digital palpation only when answer. important. Female Ask about the presence of abnormal discharge, sores, warts, and itching Male Ask for any presence of sores, itching, warts, and abnormal 35 discharge GENERAL SURVEY a. Physical Appearance Skin color Facial features Body shape and build Body symmetry Height and weight Nutrition Signs of distress GENERAL SURVEY b. Mental Status d. Patient Behavior Affect and mood Dress and grooming Level of anxiety Body odor Orientation and speech Facial expression c. Mobility Ability to make eye contact Gait Posture Range of motion  References 1. Brunner LS. Brunner & Suddarth's textbook of medical-surgical nursing. Lippincott Williams & Wilkins; 2021. 2. Berman AT, Snyder S, Frandsen G. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice. Global Edition. 11th ed. London, England: Pearson Education; 2021. ISBN-13: 978-1-292-35979-3. 3. Nettina, S. M. (2018). Lippincott manual of nursing practice (11th ed.). Lippincott Williams and Wilkins. Thank you