Physical examination

In general, the standard physical exam typically includes: Vital signs: blood pressure, breathing rate, pulse rate, temperature, height, and weight. Vision acuity: testing the sharpness or clarity of vision from a distance. Head, eyes, ears, nose and throat exam: inspection, palpation, and testing, as appropriate.

1. PHYSICAL EXAMINATION FOR ADULT(PERSON) EXAMINATION PRESENTED BY:- MS. SHAFAQ ALAM B.SC(N)4 th YEAR ERA COLLEGE OF NURSING GUIDED BY:- DR.ANJALATCHI MUTHUKUMARAN VICE PRINCIPAL ERA COLLEGE OF NURSING

2. OBJECTIVES Introduction of abdominal examination Definition of abdominal examination Purpose of abdominal examination Principles of abdominal examination Steps of abdominal examination Procedure of abdominal examination After care Summary Conclusion References

3. INTRODUCTION History collection and physical examination typically occurs before the abdominal examination. A fundamental part of physical examination of the abdomen which consists of inspection , palpation , percussion, auscultation. check for possible diseases so they can be treated early identify any issues that may become medical concerns in the future update necessary immunizations ensure that you are maintaining a  healthy diet  and  exercise routine build a relationship with your PCP

4. DEFINITION Abdominal examination is a systemic examination of the abdomen. An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease.

5. NINE QUARANT OF ABDOMEN

6. PURPOSE 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.

7. PRINCIPLES The patient is released and comfortable in the supine position Head supported with a pillow Arms at the side or cross over the chest Ensure that bladder is empty Full exposure of the abdomen Be on the right side of the patient

8. PROCEDURE Introduce yourself and briefly explain examination Confirm the identity of the patient Establish good communication Take consent Wash your hands and position the patient Full exposure of abdomen

9. INSPECTION Contour: Scaphpoid , Flat, Distended The skin over abdomen: Straial , Redness, Scars, Noudule , Tattoing Distended vessels: Normal direction of flow Umbilicus: Position, streated / Everted , Hernia Movement: During respiration, Visible peristalsis, Visible pulsation Cullen‘s sign Grey‘s turner Sign

10. Techniques of Physical Examination The four basic techniques used in physical examination are explained as follows: Inspection 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.

11. 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.

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16. STEP 1:- Ask the patient any pain or tenderness Present in the abdomen. STEP 2:- palate 9 areas lightly, looking at the patient’s face for any sign of discomfort. STEP 3:- palate 9 areas deeply, looking at the patient‘s face for any sign of discomfort. STEP 4:- palpate for liver, start in the RLQ Ask the patient to breathe out and place a hand on the abdomen. As the patient breathes in, feel for a liver edge. Move hand gradually up the abdomen RUQ with every breathe expired . PALPATION

17. PALPATION Superficial application: •Temperature •Tenderness •Soft, guarding and rigidity • Rebound tenderness Deep application: • Palpation of lump: Size, Shape, Location, Movement with respiration, Mobility , Bimanual palpation and Ballotment – if lump is present. • Rest of the abdomen: Liver, kidney, , Spleen, Tenderness over colon, Lower intercostal space, Renal angle, Hernia

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19. 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. 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.

20. PERCUSSION CONTINUED STEP 1 :- Percussion the abdomen , starting at the midline and moving towards you, note any area of dullness . STEP 2 :- Ask the patient to roll onto there side away from you , waiting for 30secs, then re- percuss the same area. STEP 3 :- Note findings

21. Palpation 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.

22. Auscultation 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.

23. Continued 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)

24. AUSCULTATION STEP 1 :- Place the diaphragm of the stethoscope to be right of the umbilicus STEP 2 :- Bowel sounds STEP 3 :- Buits STEP 4 :- Vascular hum STEP 5 :- Friction rub

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26. Manipulation It is the moving of a part of the body to note its flexibility. Limitation of movement is discovered by this method

27. 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.

28. 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:

29. General Appearance Nourishment: well nourished or under nourished Body build: thin or obese Health: healthy or unhealthy Activity: active or dull (tired ) Findings:………………………………….

30. Mental Status Consciousness : conscious, unconscious, delirious, talking, incoherently Look: anxious or worried, depressed etc Findings:…………………

31. Posture Body curves: lordosis , kyphosis , scoliosis Movement: any limp Height : Weight: ABD Girth :

32. 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 Findings:…………………………………..

33. Head and Face Shape of the skull and fontennels (noted in the newborne ) Skull circumference Scalp: cleanliness, condition of the hair, dandruff, pediculi , infections like ringworm Face: pale, flushed, puffiness, fatigue, pain, fear, anxiety, enlargement of parotid glands etc Findings:……………………………………..

34. Eyes examination Eyebrows: normal or absent Eye lashes: infection, sty Eyelids: oedema , lesions, ectropion ( eversion ), entropion (inversion) Eyeballs: sunken or protruded Conjunctiva: pale, red, purulent Sclera: jaundiced 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 ) Findings:……………………………………………….

35. Ear and throat examination Ears External ear: discharges, cerumen obstructing the ear passage Tympanic membrane: perforations, lesions, bulging Hearing: hearing acuity   Nose External nares : crusts or discharges Nostrils: inflammation of the mucus membrane, septal deviations Findings:………………………………………………………

36. 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 Findings:……………………………………………….

37. Neck and chest examination 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, crepitations , pleural rub etc Heart: size and location, cardiac murmurs Breasts: enlarged lymph nodes

38. Abdomen and extremities 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   Extremities Movement of joints, tremors, clubbing of fingers, ankle, oedema , varicose veins, reflexes etc

39. Back and extremities 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) Vaginal discharges Presence of sexually transmitted diseases Haemorrhoids Enlargement of the prostate gland Pelvic masses

40. Neurological Test Coordination tests: reflexes Equilibrium tests: test for sensations Neurological Assessment Neurological assessment includes examination of the reflexes, coordinations , equilibrium, sensations of touch, pain, vibrations, position, temperature discrimination, tonicity and movement of muscles. Coordination Tests 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.

41. P OSITIONS 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.

42. 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. Lighting 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.

43. Continued 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

44. Preparation of the Equipment All the articles needed for the physical examination are kept ready for the examination at hand. Articles Required 1. Sphygmomanometer-Purpose : to measure B.P. 2. Stethoscope-Purpose : to listen to the body sounds 3. Foetoscope -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

45. 6. Pharyngeal retractor-Purpose : to examine the pharynx 7. Laryngoscope-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 11. Ophthalmoscope-To examine the inner part of the eyeball 12. Otoscope -Purpose : To examine the ear

46. 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 17. Proctoscope -Purpose : to examine the rectum 18. Gloves-Purpose : to examine the pelvis internally 19. Sterile specimen bottles, slides, cotton applicators Purpose: to collect the specimens if necessary

47. 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 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. Mental Preparation 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.

48. 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.

49. 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.

50. 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.

51. 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.

52. 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.

53. 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.

54. 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.

55. CONCLUSION Make sure that basic requirements are fulfilled. Use the four physical examination techniques • Inspection •Palpation •Percussion •Auscultation Describe abnormalities properl . Interpretation of physical findings is mandatory.

56. BIBLIOGRAPHY TNAI,” TEXTBOOK OF FUNDAMENTALS OF NURSING” PAGE NO.163-165 SR.NANCY “TEXTBOOK OF PRINCIPLE AND PRACTICE OF NURSING” PG NO.357-361