nursing health assessment: Physical examination.ppt

nursing health assessment: Physical examination

1. NURSING HEALTH ASSESSMENT
(PHYSICAL EXAMINATION)
BY C. MWALWENI
1

2. Objectives
To identify purposes of physical
examination.
To explain the frameworks for
physical examination.
To explain the preparation for
physical examination.

3. Objectives Cont..
To describe the techniques
used in physical examination
To discuss physical examination
step by step.

4. Physical Examination
Physical examination is a systematic approach
of collecting objective data about clients’
health status.
It employs through detailed evaluation of
clients’ all body structures, organs, or systems.
It requires the nurse to apply special
techniques, use equipment and knowledge
base, to physically expose each region of
clients’ body and examine it by looking,
listening, touching, or smelling.

5. Purpose
To obtain baseline data about clients
functional abilities.
To supplement, confirm or refute data
obtained in nursing history.
To obtain data that will help establish
nursing diagnosis and plan of care

6. Purpose Cont..
To evaluate the physiological
outcomes of health care.
To identify areas of health
promotion and disease
prevention.

7. Component of Physical Examination:

General survey (the nurses’ initial observation
for the clients’ general appearance and
behavior).
Vital signs measurement
Height and weight measurement
Head-to-toe/Body systems examination

8. Frameworks for Physical
Assessment
There are two major frameworks for
organizing assessment data.
1. Head to toe framework
It is a system for collecting data in an
organized manner starting from the head
and proceeding systematically downward to
the toes.

9. Frameworks for Physical
Assessment Cont..
2. Body systems framework
Mostly used by physicians and
advanced nurse practioners.
It focuses on the pathophysiology
involved within specific system.
This approach can be used in
focused assessment .

10. Preparation
Preparing the client.
Explain the procedure and its significance to
the client.
Explain where and when the procedure is to
take place.
Assure the client of privacy and
confidentiality.

11. Preparing the Client Cont..
Request the client to empty
bladder.
Special consideration on gender,
age and culture
Preparing environment
The environment should be clean,
well lighted and warm.
Ensure audio visual privacy

12. Preparing Instruments and Drapes
All equipment to be used should be cleaned
and in good working condition.
Set equipment on trays for efficiency.
Drapes should be arranged so that only the
area assessed is exposed.

13. Positioning
Several positions are used during physical
assessment.
The nurse considers a clients ability to
assume a position
Examples include supine, sitting, prone,
sims, dorsal recumbent and lithotomy
position.

15. Techniques/Modalities of
Physical Examination
Four primary techniques used
during physical examination
include:
Inspection
Palpation
Percussion
Auscultation.

16. 1.Inspection
means Observing the client in a close, focused manner
using vision, and smell senses.
*It begins during the first contact with client and
continues throughout the assessment
*It provides information about body parts’: color, size,
location, movement, texture, symmetry, odor, and
sound

17. 2.Palpation
Palpation is the use of hands and fingers to
feel different body parts for data collection.
The nurse uses pads of the fingers and palms
to touch and feel the patient’s body parts
with his hands to examine:
Size texture
Location
Tenderness
Body temperature
Lumps or masses

18. Types of palpation

1.1.Light palpationLight palpation
Using the flat part of the right hand or the
pads of the fingers, not the fingertips
The fingers should be together
Depress the skin 1 to 2 cm with your finger
pads, usually the lightest touch possible.

19. Light palpation

20. 2.Deep palpation
Used to determine organ size as well as the presence
of abdominal masses
The flat portion of the right hand is placed on the
abdomen
Depress the skin 4 to 5 cm with firm, deep pressure.
Pressure should be applied to the abdomen gently but
steadily
The patient should be instructed to breathe quietly
through the mouth and to keep arms at the sides

21. 3.Percussion
A methods of “ striking” of body parts
during physical examination with fingers to
evaluate the size, consistency, borders and
presence of fluid in body organs
Percussion of a body part produces a sound
that indicates the type of tissue within the
organ
It is particularly important in examining the
chest and abdomen

22. Methods of Percussion
1.Direct percussion:
Using one or two fingers, tap directly on the
body part. Ask the patient to tell you which
areas are painful and watch his/her face for
signs of discomfort.
Direct percussion is commonly used to assess
an adult patient's sinuses for tenderness.

23. 2.Indirect Percussion
Press the distal part of the middle finger (pleximeter) of your
nondominant hand firmly on the body part(left hand).
Keep the rest of your hand off the body surface.
 Flex the wrist of your dominant hand.

Using the middle finger (plexor or striking finger) of your
dominant hand, tap quickly and directly over the point where
your other middle finger touches the patient's skin. The
motion of the striking finger should come from the wrist and
not from the elbow
Deliver 2 - 3 quick taps and listen carefully.

24. Types of Sound
Chest:
1.Resonance
This is the most common and normal sound heard during
chest percussion over the lungs.
It has a low-pitched, hollow sound and indicates that the
lungs are filled with air.
2.Dullness
A dull sound can be heard over solid organs like the heart
or liver.
When there's fluid in the lungs (e.g., pleural effusion) or in
cases of consolidation (e.g., pneumonia).
3.Hyper-resonance
A louder, lower-pitched sound; may indicate the presence
of air in the chest in abnormal amounts, such as in
conditions like pneumothorax or emphysema.

25. Types of Sound Cont..
Abdomen:
1.Tympany
The most common sound heard over the abdomen.
It has a drum-like, high-pitched quality and is usually
present over areas with gas in the intestines.
It's normal in most parts of the abdomen.
2.Dullness
Dullness is heard over solid organs (liver, spleen), full
bladder, or areas with fluid (like ascites).
It’s a normal finding over the liver and spleen.
3.Hyper-resonance
In the abdomen, this sound may be heard if there is
excessive gas, such as in cases of bloating or bowel
obstruction.

26. Types of sounds
Sound Quality of
sound
Where it is
heard
Source
Tympany Drumlike soundOver enclosed
air
Air in bowel
Resonance Hollow sound Over areas of
part air and solid
Normal lung
Hyper
resonance
Booming soundOver air Lung with
emphysema
Dullness Thudlike soundOver solid areaLiver, spleen
Flatness Flat sound Over dense
tissue
Thigh Muscle,
bone, over
tumor

27. 4.Auscultation

A method used to “listen” to the body sounds.
 Various body systems like heart, lungs, and
abdominal organs have characterized sounds

Bowel, breath, heart, and blood movement
sound are heard using a stethoscope

It is important to know the normal sound to
distinguish from abnormal sound

28. Types of auscultation
1.Direct auscultation:
* Uses the ear alone to listen, such as when
listening to the grating of a moving joint.
* Sounds are audible without stethoscope

2.Indirect auscultation:
sounds are audible with stethoscope
3.Bell for low pitched sound and diaphragm
for high pitched sound

29. General Survey
General survey is a quick study of the whole
individual and gives an overall impression of
the client
It begins at the first encounter with a
person.
It includes general appearance, level of
comfort , mental status, measurement of
vital signs, height and weight.

30. Performing General Survey
I- Physical Appearance
Normal Range of Findings Abnormal Findings
1- Age – the person appears his or her
stated age.
Appears older, smaller, or younger, as with
chronic disease or retardation.
2- Sex – Sexual development is
appropriate for gender and age
Delayed or early puberty, or inappropriate
to gender.
3- Level of consciousness – the person is
alert and oriented, attends to your
questions and responds appropriately.
Alert.Alert. Follow commands and responds
completely and appropriately to stimuli
LethargicLethargic. . The patient is sleepy or drowsy
and will awaken and respond appropriately
to command.
StuporStupor. . require vigorous stimulation for a
response .
Semi comaSemi coma. . The patient is not awake but
will respond purposefully to deep pain
Coma. Coma. The patient is completely
unresponsive.

31. I- Physical Appearance
Normal Range of Findings Abnormal Findings
4- Skin color – color tone is
even, skin is intact with
no obvious lesions
•Pallor, (loss of color)
•cyanosis, (bluish
discoloration)
• jaundice
•lesions.
5- Facial features –
symmetric with movement.
6- No signs of acute distress
are present
•Immobile, masklike,
asymmetric, drooping.
•shortness of breath,
wheezing.
•facial grimace, holding body
part. (Pain)

32. II- Body Structure
1- Stature – the height
appears within normal
range for age.

•Excessively short or tall
2- Nutritional status – the
weight appears within
normal range for height
and body build.
•Underweight
•Obese

33. II- Body Structure
3- Symmetry – body parts
look equal bilaterally
•Unilateral atrophy
•hypertrophy
(enlargement of musc
le)
4- Posture – the person
stands comfortably erect
as appropriate for age.
• Rigid spine and neck
(moves as one unit)
e.g., arthritis. Stiff
and tense.

34. 5- Position – the person sits
comfortably in a chair or on the
bed or examination table, arms
relaxed at sides, head turned
to examiner.
•Leaning forward with arms
braced on chair arms (chronic
pulmonary disease).
•Sitting straight up and resists
lying down, (left-sided congestive
heart failure).
7- Physical deformities–
Absence of any congenital or
acquired defects.
Presence of deformities or
congenital defect

35. III- Mobility
1-Gait: the walk is smooth,
even, and well-balanced;
and associated movements,
(symmetric arm swing), are
present.
Limping with injury.
Difficulty stopping
2-Range of motion – the person
has full mobility for each joint.
3- Involuntary movement:
absent
Limited joint range of motion.
Paralysis – absent movement.
Movement jerky,
uncoordinated
Tics, tremors, seizers

36. IV- Behavior
1- Facial expression – the
person maintains eye contact
expressions are appropriate
to the situation.
Flat, depressed, angry, sad
anxious. However, note that
anxiety is common in ill
people.
2- Mood and affect – the
person is comfortable and
cooperative with the
examiner and interacts
pleasantly.
Hostile, distrustful, suspicious,
crying

37. Vital signs are the key physiologic measures of the
person’s general health state. The nurse obtains vital
signs to:
a.Establish baseline measurement.
b.Identify physiologic problems.
c.Monitor clients’ response to therapy.
Pulse rate
Respiratory rate
Blood pressure
Temperature
Oxygen saturation
Presentation on Vital signs

38. 3 Measuring Height and weight
Body mass index _Weight_(kg)____
(Height) 2
Where
 Weight is measured in kilograms.
 Height is measured in meters
Body Mass Index Finding
 <18.5 Under Weight
 18.5-<25 Healthy weight
 25-<30 Overweight
 >30 Obese

39. Example
Calculate body mass index of person, his
weight is 98kg, his height is172 cm .
Answer steps:
Transfer height from cm to meter
=172/100=1.72m
Body mass index (BMI) = 98/(1.72)2 =33
BMI = 33, so the person is obese.

40. References
Bickley, L.S (2016). Bates’ guide to physical examination and
history taking. (12
th
Ed.) Philadelphia: Lippincott
Williams & Wilkins.
Jarvis, Carolyn (2012) Physical Examination and Health
Assessment, 6th Edition, Philadelphia, PA. W.B.
Saunders Co
Jensen, S. (2014). Pocket Guide for Nursing Health Assessment:
A best practice approach (2
nd
Ed). Philadelphia William
and Wilkins.
Kozier, B. (2016). KOZIER & ERB`S Fundamentals of nursing:
concepts, process, and practice (10
th
Ed.). New
Jersey: Prentice Hall.
Lewis, S.L., et al., (2016). Medical Surgical Nursing-Assessment
and Management of Clinical Problems (10
th
Ed.).
Mosby. Inc., St. Louis.

41. Thank You
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