physical assessment

• Physical Assessment


  Identifies actual or potential health problems but also to discover your patient's strengths
• Physical Assessment


  Can be used to validate the health history
• Physical Assessment


  Essential in formulating nursing diagnosis and developing a plan of care for your patient
• Physical Examination


  A process which the senses are used to collect objective data
• Skills needed for Physical Examination

  • Cognitive
  • Psychomotor
  • Interpersonal
  • Affective
  • Ethical/legal
• Need to know normal findings to distinguish abnormal ones
• Complete Physical Assessment


  Includes general survey, vital sign measurements, assessment of height and weight, physical examination of all structures, organs, and body systems
• Focused Physical Assessment


  Includes general survey, vital sign measurements, assessment of height and weight, assessment of the specific area of concern
• Physical Examination Equipment


  • Gloves (bloody body fluids)
  • Sphygmomanometer (bp apparatus)
  • Stethoscopes
  • Thermometers
  • Watch with second hand
  • Wong baker faces
  • Caliper
  • Tape measure ( for HT,HC,AC,CC Length of arms)
  • Weighing scale
  • Ruler(size diameter)
  • Magnifying glass (infectious organisms glowing under wood's lamp illumination)
  • Penlight
  • Snellen's chart
  • Ophthalmoscope
  • Over card
  • News paper( basahonon sa pt)
  • Otoscope
  • Tuning fork
  • Tongue depressor/blade
  • Gauze
  • Marker
  • Lubricating jelly(suppository)
  • Specimen cap/bottle
  • Paper clip
  • Cotton ball
  • Doppler
  • Goniometer angle( 180* 45* 15*)
  • Soap or coffee( for smell)
  • Last,sugar,coffee(for taste)
  • Reflex hammer/percussion hammer
  • Key(stereognosis)
  • Coin( graphesthesia)
  • Vaginal speculum
• Inspection


  The most frequently used assessment technique
• Inspection


  • There should be adequate lighting
  • Sufficient expose the area being assessed
  • Working from head to toes and noting key landmarks and normal findings
  • View findings in light of the patient's growth and developmental stage and cultural background
  • Maybe direct inspection or indirect inspection
• Palpation


  Using the sense of touch to assess surface characteristics such as texture, consistency, and temperature, and allows you to assess for masses, organs, pulsations, muscle rigidity
• Percussion


  Used to assess density of underlying structures, areas of tenderness and deep tendon reflexes
• Percussion


  • Entails striking a body surface and quick, light blows and eliciting vibrations and sounds
  • The sound determines the density of the underlying tissue and whether it is solid tissue or filled with air or fluid
  • Two factors influence the sound produced during percussion - thickness of the surface being percussed and technique
  • Types of percussion - direct or immediate and indirect or mediate
• Auscultation


  Involves using sense of hearing to collect data
• Auscultation


  • Listen to sounds produced by the body such as heart sounds, lung sounds, bowel sounds and vascular sounds can be both direct and indirect auscultation
  • Listen for characteristics of sound-pitch, intensity, duration, quality
• Auscultation Tips


  • Always have earpieces pointing forward to seal to ear canal
  • Warm stethoscope
  • Work on the patient's right side- this stretched your stethoscope across the patient's chest and minimizes interference
  • Never listen through clothes
  • Make sure the environment is quiet
  • If hair is a problem- wet to minimize artifact
  • Use light pressure to detect low-pitched sounds
  • Use firm pressure to detect high-pitched sounds
  • Close your eyes to help you focus
  • Learn to become a selective listener
  • Most of all-practice
• Approach to the Physical Assessment

  • Be systematic - either by systems or by region
  • Begin by introducing yourself and telling the patient what is to be done
  • Examination takes time
  • Be conscious of non-verbal behaviour
  • Maintain professional demeanor and caring attitude and be sensitive to patient's needs
  • Examination room is quiet and private, no interruptions
  • Room should be warm and well lit
  • Ask patient to void before the examination
  • Assemble all equipment and make sure that everything is in working order
  • Wash hands, wear gloves if there is a possibility to bloods or body fluid exists
  • Drape patient, expose only areas being assessed
  • Use all four techniques of physical examination
  • More private areas are performed last
• Positions for physical assessment

  • Supine
  • Prone
  • Lithotomy
  • Sim's (left lateral) position –for suppository
  • Right lateral recumbent
  • Left lateral recumbent
  • Knee-chest position
  • Good posture
• Components of the physical assessment

  • General survey
  • Signs of distress
  • Facial characteristics
  • Body type, posture and gait
  • Speech(flat affect-no emotion in delivering a speech)
  • Dress,grooming,hygiene
  • Mental state
  • Cultural consideration
  • Developmental consideration
• Documenting the general survey

  • Records the first overall impression of the patient
  • Includes age, gender, race, LOC, dress, posture, speech affect and any obvious abnormalities and signs of distress
• Vital signs and measurements

  • Height
  • Weight