Physical assessment

SHOULD BE USEFUL FOR MEDICAL AND PARAMEDICAL STUDENTS

1. Physical assessment -BY KHYATI CHAUDHARI NURSING TUTOR

2. INTRODUCTION 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 . It is 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.

3. PURPOSES To understand the physical and mental well being of the clients. To detect diseases in its early stage. To determine the cause and the extent of disease. To understand any changes in the condition of diseases, any improvement or regression. To determine the nature of treatment nursing care needed for the client.

4. Continue.. To safeguard the client and his family by noting the early signs especially in case of a communicable diseases. To contribute to the medical research. To find out whether the person is medically fit or not for a particular task.

5. TECHNIQUES OF PHYSICAL EXAMINATION The basic techniques used in physical examination are explained as follows: Inspection Palpation Percussion Auscultation Manipulation Testing of the reflexes

6. 1. Inspection It is the systematic visual examination of the client, or it is the process of performing deliberating purposeful observations in a systematic manner. It involves observation of the color, shape, 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 lightning.

7. 1. INSPECTION General inspection of a client focuses on the following areas: O verall appearance of health or illness Signs of distress Facial expression and mood Body size 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.

8. 2. PALPATION It is use of hands and fingers to gather information through touch. It is the assessment technique which uses senses of touch. It is feeling of body parts with hands to note the size and position of organs. The hands and fingers are sensitive tools and can assess temperature, turgor, texture, moisture, vibrations, size, positions, 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.

9. CONTINUE… Vibration is palpated best with the palm of the hand. The nurse’s hands should be warm and fingernails short and the touch should be gentle and respectful. Areas of tenderness are palpated last . Light, moderate, or deep palpation may be used. The purpose of deep palpation is to locate organs, determine their size and to detect abnormal masses.

10. 3. PERCUSSION 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.

11. CONTINUE… 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 Flat

12. CONTINUE… Percussion of the abdomen is tympanic, inflated lung tissue is hyper resonant, normal tissue is resonant the liver is dull and the bone flat. There are two type of percussion. Direct and Indirect. Direct Percussion : It is accomplished by tapping an area directly with the finger tip of the middle finger or thumb. Indirect Percussion : It involves two hands. The hand is placed on the area to be percussed and the finger creating vibrations that allows discrimination among five different tones.

13. CONTINUE… DIRECT 2. INDIRECT

14. 4. AUSCULTATION It is the purpose of listening to sounds that are generated within the body. Auscultation is usually done with the help of 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 quite.

15. CONTINUE… Four characteristics of sound are assessed by auscultation: Pitch- ranging from high to low Loudness- ranging from soft to loud Quality- gurgling or swishing Duration- short, medium or long

16. 5. MANIPULATION It is moving a part of the body to note its flexibility. Limitation of movement is discovered by this method.

17. 6. 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.

18. CONTONUE…

19. GENERAL EXAMINATION OR HEAD TO TOE EXAMINATION The examination is carried out is an orderly manner focusing upon one area of the body at a time. The observation of the client s tarts 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:

20. General Examination GENERAL APPEARANCE Nourishment- well nourished or under nourished Body Built- thin or obese Health- healthy or unhealthy Activity- active or dull (tired) MENTAL STATUS Consciousness- conscious, unconscious, delirious, talking incoherently Look- anxious or worried, depressed etc…

21. General Examination HEIGHT WEIGHT POSTURE Body curves- Lordosis, kyphosis, scoliosis Movement- any limp.

22. POSTURE

23. General Examination SKIN CONDITIONS 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 & FACE Shape of the skull and fontanels(noted in the newborns) Skull circumference: Scalp- cleanliness, condition of the hair, dandruff, pediculi, infectious like ringworm. Face- pale, flushed, puffiness, enlargement of parotid glands, fear, fatigue, pain, anxiety, etc.

24. Skin Lesions Macules Papules

25. Skin Lesions Vesicles Wounds

26. Face Expressions Pale Flushed

27. Face Expressions Puffiness Fatigue

28. Face Expressions Pain Fear

29. Face Expressions Anxiety Enlargement of parotid glands

30. Anatomy of An Eye -JUST FOR REVISION

31. General Examination EYES Eyebrows- normal or absent Eye lashes- infection, sty. Eyelids- edema, lesions, ectropion ( eversion ), entropion ( inversion). Eyeballs- sunken or protruded Conjunctiva- pale, red, purulent Sclera- jaundiced C ornea and Iris- irregularities and abrasions. Pupils- dilated constricted, reaction to light

32. General Examination Lens- opaque and transparent Fundus- congestion, hemorrhagic spots Eye muscles- strabismus (squint Vision- normal, myopia (short sight), hyperopia (long sight)

33. E yeball Sunken eyeball Protruded eyeball

34. General Examination EARS External ear- discharges, cerumen obstructing the ear passage Tympanic membrane- perforations, lesions, budging Hearing acuity tests Weber’s test Rinne’s test Whisper’s test

35. Weber’s test W rap the tuning fork strongly on your palm and then press the butt of the instrument on the top of the patient's head in the midline and ask the patient where they hear the sound. WHERE CAN YOU HEAR BUZZY NOISE ? The patient is asked to report in which ear the sound is heard louder. In a normal patient, the sound is heard equally loud in both ears (no lateralization). However a patient with symmetrical hearing loss will have the same findings. Thus, there is diagnostic utility only in asymmetric hearing losses.

36. Rinne’s test In the Rinne’s test, a comparison is made between hearing elicited by placing the base of a tuning fork applied to the mastoid process (bone) and then after the sound is no longer appreciated, the vibrating top is placed one inch from the external ear canal (air). RESULTS NORMAL - Air conduction > B one conduction ABNORMAL – Air Conduction < Bone Conduction Air Conduction = Bone Conduction ---------which suggest that patient may have conductive hearing loss.

37. Whisper’s test Confirm if patient understands instructions. E xhale. Whisper a combination of 3 random numbers and letters from 2 feet behind patient (e.g. 6, K, 0). Ask them to repeat. Perform a second time (using a different combination) if there are any incorrect responses. >3/6 incorrect: fail.

38. General Examination NOSE 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 & dental caries Mucus membrane & gums- ulceration and bleeding, swelling, pus formation Tongue- pale, dry, lesions, sords, furrows, tongue tie etc. Throat & pharynx- enlarged tonsils, redness and pus.

39. General Examination NECK Lymph nodes- enlarged, palpable Thyroid gland- enlarged Range of motion- flexion, extension and rotation Chest Thorax- shape, symmetry of expansion, posture Breath sounds- sigh, swish, rustle, wheezing, crepitation, pleural rub etc. Heart- location, cardiac murmurs Breasts- enlarged lymph nodes ABDOMEN Observation- skin rashes, scar, hernia, ascites, distension, pregnancy etc. Auscultation- bowel sounds, fetal heart sounds Palpation- liver margin, palpable spleen, tenderness at the area of appendix, inguinal hernias Percussion- presence of gas, fluid or mass

40. General Examination Symmetry of Thorax Neck Lump

41. General Examination EXTREMITIES Movement of joints, tremors, clubbing of fingers, ankle edema, varicose veins, reflexes

42. General Examination BACK Spina bifida, curves. 17. GENITALS & RECTUM Inguinal lymph glands- enlarged, palpable Patency of urinary meatus and rectum Descent of the testes(infants) Vaginal discharges Presence of STDs. Hemorrhoids Enlargement of the prostate gland Pelvic masses

43. General Examination

44. General Examination NEUROLOGICAL TEST Coordination tests- reflexes Biceps Reflex Triceps R eflex Knee jerk(Patellar tendon) Reflex Ankle jerk(Achilles tendon) Reflex Babinski’s Reflex Equilibrium tests- test for sensations

45. Anatomical terms of Motion

46. Anatomy Of The Elbow

47. Biceps Reflex Have the patient’s elbow at about a 90 ° angle of flexion with the arm slightly bent down as shown in figure. Grasp the elbow with your left hand so the fingers are behind the elbow and your abductee thumb presses the biceps brachial tendon. Strike your thumb a series of blows with the rubber hammer, varying your thumb pressure with each blow until the most satisfactory response is obtained. Normal reflex is elbow flexion.

48. Triceps Reflex Grasp the patient’s wrist with your left hand and pull his arm across his chest so the elbow is flexed about 90 ° and the forearm is partially bent down. Tap the triceps brachial tendon directly above the olecranon process. The normal response is elbow extension.

49. Anatomy Of The Knee

50. Patellar Tendon Reflex or Knee Jerk Reflex The patellar reflex is elicited by striking the patellar tendon just below the patella. The patient may be in a sitting or a lying position. If the patient is supine, the examiner supports the legs to facilitate relaxation of the muscles. Contraction of quadriceps and knee extension are normal responses.

51. Achilles Tendon

52. Achilles Tendon Reflex or Ankle Jerk Reflex To elicit an Achilles reflex, the foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon. This reflex normally produces flexion.

53. Babinski’s Reflex To elicit Babinski’s reflex, stroke the lateral aspect of the sole of the patient’s foot with you thumbnail or another moderately sharp object. Normally, this elicits flexion of all toes, as shown in the right (1 st ) illustration. With a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out, as shown in the right (2 nd ) illustration.

54. GCS SCALE

55. Role of the Nurse in Physical Examination PREPARATION OF THE ENVIRONMENT Maintenance of Privacy – A separate examination room is needed. Keep the doors closed. The relatives are not allowed. Drape the client according to the parts that are exposed. Lighting A s far as possible, natural light should be available in the examination room because if a c lient is jaundiced, it may not be detected in the artificial light. There should be adequate lighting.

56. Role of the Nurse in Physical Examination Comfortable bed or Examination table T he client should be placed comfortably throughout the examination. There should be provision for the maintenance of a suitable position. e.g., a lithotomy position may be maintained when examining the genitelia. To maintain the position, a special examination table with stirrup rods is needed. The room should be warm and without draughts.

57. Role of the Nurse in Physical Examination PREPARATION OF THE EQUIPMENT All the a rticles needed for the physical examination are kept ready for the examination at hand.

58. Role of the Nurse in Physical Examination ARTICLES REQUIRED PURPOSE Sphygmomanometer To measure B.P. Stethoscope To listen to the body sounds. Foetoscope To listen the F.H.S. T.P.R. Tray To assess the vital signs. Tongue Depressor To examine the mouth and throat. Pharyngeal Retractor To examine the pharynx.

59. Role of the Nurse in Physical Examination ARTICLES REQUIRED PURPOSE Laryngoscope To examine the larynx. Tape measure To measure height, circumference of the head and abdomen. Flash light To visualize any part. Weighting machine To check the weight. Ophthalmoscope To examine the inner part of the eyeball. Otoscope To examine the ear. Tuning fork To test the hearing.

60. Role of the Nurse in Physical Examination ARTICLES REQUIRED PURPOSE Nasal speculum To examine the nostrils. Percussion hammer, safety pins, cotton wool, cold & hot water in test tubes To test reflexes. Vaginal speculum To examine the genitals in women. Proctoscope To examine the rectum. Gloves To examine the pelvis internally. Sterile specimen bottles, slides, cotton applicators To collect the specimens if necessary.

61. Sphygmomanometer

62. Laryngoscope

63. Foetoscope

64. Tongue Depressor

65. Ophthalmoscope

66. Otoscope

67. Tuning fork

68. Nasal Speculum

69. Percussion hammer

70. Vaginal speculum

71. Proctoscope

72. Role of the Nurse in Physical Examination PREPARATION OF THE CLIENT Physical Preparation 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 bowels by an enema, if required. Loosen the garments and change into the hospital dress, if it is the custom.

73. Role of the Nurse in Physical Examination Drape the client with extra sheets and expose only the needed area. Avoid necessary exposure. Mental preparation The client may be quite new to the hospital situation and he 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 & fears by proper explanation. Explain the sequence of procedure to gain his confidence & cooperation.

74. Role of the Nurse in Physical Examination 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 soles of the feet to the vertex of the head. The head should be in such a position that the eyes are facing the ceiling.

75. Role of the Nurse in Physical Examination After a child can stand, the height can be measured, if the child stands with the heels, back & head against a wall. A small flat board held from the top of the head to the wall will give an 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 & 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.

76. Role of the Nurse in Physical Examination It’s important to weigh a baby unclothed or to weigh the clothes separately & subtract this weight.

77. Role of the Nurse in Physical Examination To measure the skull circumference The skull is measured at its greatest diameter from above the eyes to the Occipital protuberance.

78. Role of the Nurse in Physical Examination 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 clients face. The first examination is one of inspection to determine the movements of the eyes, reactions to light, accommodation to near and far objects. For detailed examination of the internal parts of the eye an ophthalmoscope is used.

79. Role of the Nurse in Physical Examination 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 & otoscope. 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 mother’s knees & their arms her chest. Very small infants can be laid on the examination table.

80. Role of the Nurse in Physical Examination Examination of the nose, throat & 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 & a good light are needed. For e xamination of the nose, a nasal speculum & a head mirror are used.

81. Role of the Nurse in Physical Examination 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.

82. Role of the Nurse in Physical Examination 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.

83. Role of the Nurse in Physical Examination The heart & lungs are examined by percussion & 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.

84. Role of the Nurse in Physical Examination Examination of the abdomen The abdomen is examined while the client is in a dorsal recumbent position & the knees are slightly flexed to promote relaxation of the abdominal muscles. The abdomen is inspected, palpated, auscultated and percussed to detect any abnormalities.

85. Role of the Nurse in Physical Examination Examination of the extremities Extremities are inspected, palpated & 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 edema 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 the joints.

86. Role of the Nurse in Physical Examination 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.

87. Role of the Nurse in Physical Examination