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Physical Assessment
Jennylyn C. Guadalupe, RN
Health History – provides the examiner with complete health profile that guides all aspects of the physical examination. It begins with questions that focus on problems a symptom of concern to the patient.
Chief Complaint - reason for seeking care
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Purposes of Physical Examination
The nurse uses physical assessment for the following reasons:
To gather baseline data about the client’s health To supplement, confirm or refute data obtained in the
nursing history To confirm and identify nursing diagnoses To make clinical judgments about a client’s changing
health status and management Physical examination – usually performed after the
health history is taken.
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Preparation of Examination
Environment
Equipment
Psychological Preparation
Physical Preparation
Positioning
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“ ORGANIZED & SYSTEMATIC EXAMINATION” – key to appropriate Data in a least possible amount
of time
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Order of Examination
General Survey – includes observation of general appearance and behavior, vital signs, height and weight measurement Review of systems Head to toe examination
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INSTRUMENTS
senses of vision, hearing, touch, and smell. Those
human senses may be augmented by special instruments or tools e.g. Stethoscope, OPTHALMOSCOPE)
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EXAMINATION TECHNIQUE
Patient’s Positioning and Prepping SEATED: when seated, the drape should cover the patient’s lap and
legs. It can be moved to uncover parts of the body as they examined.
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Patient’s Positioning and Prepping SUPINE: the patient lies on his or her back, with arms
at the sides and legs extended. The drape should cover the patient from chest and knees or toes. Again, you can move or reposition the drape to give appropriate exposure.
PRONE: the patient lies on his or her stomach. This position may be used for special maneuvers as part of the musculoskeletal examination. Drape the patient to cover the torso.
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Patient’s Positioning and Prepping
DORSAL RECUMBENT: use for genital or rectal areas. The patient lies supine with knees bent and feet on the table. Place the drape in a diamond position from chest to toes. Wrap each leg with the corresponding lateral corner of the ‘diamond”. Turn back the distal corner of the drape to perform the examination.
LATERAL RECUMBENT: This is a side lying position, with legs extended or flexed. The left lateral recumbent position (patient’s left side is down) may be used in listening to heart sounds.
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LITHOTOMY: generally used for pelvic examination.
SIMS: of the rectum or obtaining rectal temperature.
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Assessment techniques
Inspection Palpation Percussion Auscultation
Skills in Physical Examination & The Process of Physical examination
Inspection – to detect normal characteristics or significant physical signs. To inspect body parts accurately the nurse observes the following principles: Make sure good lighting is available Position and expose body parts so that all surface can be viewed Inspect each areas from size, shape, color, symmetry, position and
abnormalities If possible, compare each area inspected with the same area of the
opposite side of the body Use additional light (for example, a penlight) to inspect body cavities
Inspection- the first fundamental process is inspection or observation. General inspection begins at the first moment of contact with the patient.
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Inspection a. Posture and stature Ex. Person who have breathing difficulties ( Dyspnea) secondary to cardiac disease
prefer to sit and may complain of feeling “Smothered”, if forced to lie flat for even brief periods of time.
b. Body Movements Generalized disruption of voluntary or involuntary movement and asymmetry of
movement. Ex. Convulsive movements of epilepsy or tetanus or movements of patients with
rheumatic fever. - Nutrition Ex. Obesity maybe generalized as a function of excessive intake of calories or may
be specifically localized to the trunk in those with endocrine disorders ( Cushing disease).
c. Speech pattern Slurred coz of CNS disease or damage to cranial nerves, laryngeal nerve will produce
hoarseness.
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Skills in Physical Examination & The Process of Physical examination
Palpation Palpation – assessed through touch. Ex. Superficial blood vessels, lympnodes, the thyroid, the
organs of the abdomen and pelvis, and the rectum. It should be noted that when the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds.
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Palpation
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Light palpation
Deep palpation
Skills in Physical Examination & The Process of Physical examination
Percussion – examination by striking the body’s surface with a finger, vibration and sound are produced. This vibration is transmitted through the body tissues and the character of the sound depends on the density of the underlying tissue
Sounds: Tympany – is the drumlike sound produced by percussing the air-filled stomach.
Resonance- is the sound elicited over air-filled lungs. Hyperresonance- is audible when one percusses over
inflated lung tissue in someone with emphysema. Dull sound- percussion of liver. Flatness- percussion of the thigh.
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Skills in Physical Examination & The Process of Physical examination
Percussion
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Direct percussion
Indirect percussion
Skills in Physical Examination & The Process of Physical examination
Auscultation – is listening to sound created in body organs to detect variations from normal. Some sounds can be heard with the unassisted ear, although most sounds can be heard only through a stethoscope.
Ex. Breath sound- movement of air through the trachea and bronchi, Vesicular, Brochovesicular, Bronchial
Spoken voice- movement of air past functioning vocal cords Bowel sounds- movement of air through the intestine. Murmur- movement of blood through vascular structures that provide critical
resistance to flow Heart sounds Examples of Adventitious Breath Sounds Crackles (previously called rales) Rhonchi Wheeze Friction rub
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Physical assessment
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Assessment Sequencing
Head – to - Toe Assessment
Body Systems Assessment
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EYES - Review of anatomy conjunctiva - mucous membrane of the eye. cornea - protective part of the eye. iris - regulates quantity of light into the eye. lens - expands/contracts in order to focus light. pupil - circular area that allows for the passage of light.
retina - receives images from light and converts them into electrical impulses sent to the brain.
vitreous humor - transparent liquid that gives the eye its shape.
aqueous humor - fluid anterior to the lens that is used in the support of the iris and refraction of the light
EYE ASSESSMENT
SUBJECTIVE DATA Vision difficulty(decrease
acuity, blurring, blind sports.
Pain Strabismus, diplopia Redness, swelling Watering, discharge History of ocular
problems Uses of glasses/contact
lenses Self care behavior.
STRUCTURE - EYE
OBJECTIVE DATA
Preparation
Equipments needed Snellens eye chart Opaque card
/occluder Penlight Applicator stick Ophthalmoscope
E Chart also known Tumbling E Chart
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OPTHALMOSCOPE
OBJECTIVE DATA
Facial and ocular expression
Eye lids & Conjunctiva
Lacrimal system Sclera Cornea
----Prominence of eyes: alert or dull expression.
__Symmetry, presence of edema, ptosis, itching, redness, discharges, blinking, equality, growth.
___Tears, swelling, growth
___Color___Clarity
Cont’d objective data
Anterior chamber
Iris & pupils
Pupillary reflex light
__Depth, presence of blood/pus
__Irregularities in color, shape , size
__Constriction of pupil in response to light in that eye (direct light reaction);equal amount of constriction in the other eye (consensual light reaction)
cont’d objective data
Accommodation
Lens
Peripheral vision
Acuity with or without glasses
Supportive aids
__Convergence of eyes and constriction of pupils as gaze shifts from far to near object
__Transparent or opaque
__Ability to see movements & objects well on both sides of field of vision
Ability to read newsprint, clocks on wall, & recognize faces-b/side/door
Glasses, contact lenses, prosthesis.
Types of refractive errors hyperopia - image is focused behind the retina,
(farsightedness): Inability to see near objects clearly. The eye is “too short” for the lens, or certain eye muscles have weakened with age.
Myopia - image focused anterior to the retina, is also known as short sightedness, near sightedness, and short sight. It is a refractive error and it makes it difficult to see objects from afar.
Presbyopia - accommodation muscles are unable to focus,
People who have this condition will have a hard time focusing, will experience blurry vision, and will have tired eyes more often. People with presbyopia will have trouble reading in poor light conditions, they will have trouble changing their focus from near to far, and they will keep repositioning reading material in order to see things properly.
Astigmatism - uneven focusing / displaced lens,
characterized by abnormalities in the curvature of your eyes. This can cause your vision to blur at any angle.
Inflammation and infection of the eye
Blepharitis - an inflammation of the eyelids.
signs/symptoms Tenderness, reddening, sore sticky exudates Eyelids may become inverted & eyelashes fall out
treatment Antibiotics applied to eyelids oral antibiotics like tetracycline or doxycycline Artificial tears Keep scalp and eyelids clean Scales must be removed daily with moist applicator or warm,
moist wash cloth
Hordeolum (stye) signs/symptoms
a. Localized pain, swelling to eye lid
b. Often purulent discharge
Treatment - Hot compresses, scrub with neutral soap, topical antibiotic eye drops q3h, and if not resolved in 2-3 days, refer to ophthalmology for I&D
4. Trauma- A. Black eye: Swelling and discoloration around
the eye as a result of injury to the face.
Hyphema : Bleeding into the front of the eye, behind the cornea. a. Cause: 1. is usually caused by trauma. 2. It may be the result of an
athletic injury from a flying object, a stick, a ball, or another player's elbow. 3. Other causes include industrial accidents, falls, and fights.
Blow out fracture When force is applied to the orbit causing contents to spill either
medially or inferiorly. If inferiorly, will end up in maxillary sinus. signs/symptoms
epistaxis enophthalmus entrapment dypesthesia diplopia fracture over infraorbital rim
X-rays needed; CT scan is definitive. If there is entrapment of EOM, need surgery soon otherwise must wait5-
7 days Must R/O ocular injury ; refer to ENT
5. Age-related Vision disorder a. Macular degeneration - is the leading cause
of severe vision loss in people over age 60. It occurs when the small central portion of the retina, known as the macula, deteriorates. The retina is the light-sensing nerve tissue at the back of the eye. Because the disease develops as a person ages, it is often referred to as age-related macular degeneration (AMD).
two main types
Wet form. The "wet" form of macular degeneration is
characterized by the growth of abnormal blood vessels
from the choroid underneath the macula. This is called
choroidal neovascularization. These blood vessels
leak blood and fluid into the retina, causing distortion
of vision that makes straight lines look wavy, as well
as blind spots and loss of central vision. These
abnormal blood vessels eventually scar, leading to
permanent loss of central vision.
Treatments Macular Degeneration There is currently no cure for macular degeneration, but
treatments may prevent severe vision loss or slow the progression of the disease considerably. Several options are available, including: Vitamins. A large study performed by the National
Eye Institute of the National Institutes of Health, called AREDS (Age-Related Eye Disease Study), showed that for certain individuals, vitamins C, E, beta carotene, zinc and copper can decrease the risk of vision loss in patients with intermediate to advanced dry macular degeneration.
Glaucoma is an eye condition that develops when too much
fluid pressure builds up inside of the eye. It tends to be inherited and may not show up until later in life.
The increased pressure, called intraocular pressure, can damage the optic nerve, which transmits images to the brain. If damage to the optic nerve from high eye pressure continues, glaucoma will cause loss of vision. Without treatment, glaucoma can cause total permanent blindness within a few years.
Glaucoma
Symptoms Glaucoma
Cataract-
a clouding of the eye's natural lens, which lies behind the iris and the pupil
Symptoms of Cataract
Ear Anatomy
History
always ask the following hearing loss tinnitus - ringing in the ear vertigo - sense of motion otalgia - ear pain otorrhea - drainage from the ear
ASSESSMENT
SUBJECTIVE DATA Ear aches Infections Discharges Hearing loss Environmental noise Tinnitus Self care behavior
INSPECTION- OTOSCOPE
Cont’d subjective data
Inspect & Palpate the External ear
Size & shape Skin condition Tenderness External auditory
meatus Inspect -otoscope
Inspect otoscope Pull the pinna up &
back(straightens S –shape-canal)
Hold the otoscope & inspect
Note any redness, swelling,lesions, f/b, discharge.
WEBER TEST
RINNE TEST
Hearing loss - 2 types A. Conductive - seen in people with external or middle ear problem.
Occurs when auditory stimuli are not adequately transmitted through the auditory canal, tympanic membrane, middle ear, or ossicles to the inner ear.
History - Have perceived hearing loss & need things repeated Physical exam
Weber - in conductive hearing loss, sound lateralizes to the affected ear.
Rinne - in conductive hearing loss, bone conduction (BC) > air conduction (AC)
Tests audiogram: normal 0-25 db.
Causes Cerumen impaction- usually occurs in persons who naturally
produce large amounts of cerumen. External otitis media- (bacterial and fungal), excessive
moisture in the auditory canal (swimmer’s ear), and trauma Serous otitis media- result from Eustachian-tube obstruction,
sudden changes in atmospheric pressure, allergy and viral disease
Suppurative otitis media- may follow viral disease, tympanic membrane perforation or prolonged forceful nose blowing.
> Common in infants and young children because of their immature and relatively poorly draining Eustachian tubes.
Otosclerosis- a hereditary condition; it affects women twice as often as men and typically develops between ages 15 and 30.
Trauma / tumors
B. Sensorineural - When the eighth cranial nerve or cochlea are damage Involves the inner ear.
Hearing loss resulting from damage to the inner ear or to the neural pathways from the inner ear to the brain
History - similar to conductive hearing loss. PE: Weber - lateralizes to good ear
Rinne - AC>BC Test: Audiogram - both BC and AC below 25db in
affected frequencies
Causes noise induced - most common - occupationally involved trauma - skull fractures (basilar) Tumors
Treatment Hearing conservation; may require baseline adjustment. Hearing aides Other Aids : Alert and signal devices, assisted – listening devices from
telephone companies Surgery : implantable cochlear prosthesis ( direct stimulation of the auditory
nerve)
Otitis Externa Infection of external ear Caused by bacteria, fungi, or may be a
dermatitis
Otitis Media (OM) infection of middle ear caused by a build up of
fluid (mucus) which then becomes infected by bacteria.
OTITIS MEDIA
Contact sports such as boxing can cause ear injuries such as cauliflower ear and bruising and swelling in general. But you can prevent this from happening by wearing a head guard. Motor sports are another potential cause of head and ear injuries although a well fitting helmet can help reduce the risk of that happening.
A pressure sore is the result of trauma to the tissues. They tend to start as a small patch of red skin which has been exposed to constant pressure. This patch gradually worsens until the skin cracks which damages lower layers of tissues.
NOSE
NOSE
SUBJECTIVE DATA Discharge Frequent colds(upper
respiratory infections) Sinus pain Trauma Epistaxis Allergies Altered smell
OBJECTIVE DATA
Equipment NeededOtoscope-short wide tip
nasal attachmentPenlight2 tongue bladesGlovesCotton gauze pad
Inspect and palpate :symmetric ,midline in proportion to other facial features
Inspect for any deformity, asymmetry, inflammation, or skin lesions
Palpate for any pain/break in contour.
Palpate the sinus areas-Tenderness
Figure 14-2. p. 379.
Structures of the Nasal Cavity
Figure 14-8. p. 388.
Inspect Nasal CavityMiddle turbinate
Inferior turbinate
Table 14-1. p. 405.
Abnormalities of Nose
Choanal Atresia
Foreign Body
Perforated SeptumEpistaxis
Epistaxis (nose bleed) Kiesselbach’s plexus - located
anterior septum, supplied by four arteries
Usually bleed from one nostril Most nose bleeds are anterior Causes –
trauma, foreign body, dry air, sinusitis, allergies, colds, foreign objects in the nose, picking the nose, and irritants among others.
Figure 14-3. p. 379.
Paranasal Sinuses, Adult and Child
Figure 14-11. p. 390.
Palpate Sinuses
Palpate Sinuses
Sinusitis - is an inflammation of the mucous membranes
of one or more paranasal sinuses. a.Acute sinusitis
Inflammation of paranasal sinuses by bacteria, viruses, or fungi
Accompanied by or follows colds signs/symptoms
pain over affected sinus headache purulent rhinorrhea fever and other systemic disease anosmia( Lack of smell)
Physical exam Sinusitis Acute Sinusitis
Mucosa is hyperemic and edematous Turbinates are enlarged and often about the septum Purulent drainage Pain elicited from pressure over involved sinuses Transillumination may reveal air-fluid level. sinus X-rays Four views - Caldwells, Water’s, lateral & base. See air-fluid level in involved sinus or may just be clouded. Not required for diagnosis; more useful in chronic cases.
b.Chronic Sinusitis Irreversible tissue changes have occurred in lining membrane of one or
more of the paranasal sinuses, mucosal thickening becomes apparent. Causes – repeated/persistent bacterial sinusitis signs/symptoms Purulent material in nose. Enlarged turbinates. Similar to acute sinusitis. Persistent nasal obstructions; chronic nasal discharge, clear or
purulent when infected Cough-produced by constant dripping of discharge back into
nasopharynx
Feeling of facial fullness/pressure Headache-may be vague or in same pattern as
acute sinusitis, more noticeable in the morning; fatigue
Physical exam Chronic Sinusitis Purulent material in nose. Enlarged turbinates.
May notice nasal polyps X-rays Sinus series and CT Scan show air-fluid level in acute sinusitis;
thickening of sinus mucous membranes, opacification, and anatomic obstruction patterns in chronic sinusitis
Antral puncture and lavage-provides culture material to identify infectious organism; also a therapeutic modality to clear of bacteria, fluid, and inflammatory cells.
Nasal and sinus endoscopy (the sinuses can be easily accessed after the patient has had an antrostomy).
Table 14-1. p. 406.
Abnormalities of Nose
Acute RhinitisAllergic Rhinitis
Sinusitis Rhinitis Polyps
Rhinitis - is a disorder of the nose that interrupts its
normal functions of olfaction, and warming, filtering, and humidifying inspired air.
Allergic (hay fever) Rhinitis seasonal or perennial
Sneezing, lacrimation, itching, nasal discharge etc.
Must obtain good history; key to diagnosis. Caused by pollen, grasses, dust/house
mites etc. frontal headache trouble breathing through nose
Allergic rhinitis-IgE-mediated response causing release of vasoactive substances from mast cells
Physical exam Hay fever pale mucosa
turbinates (inferior) enlarged clear/thin secretions possible deviated septum nasal polyps Hypersecretion-wet, running/dripping nose or post-nasal drip Nasal obstruction symptoms-nasal congestion, pressure, or stuffiness Headache labs/allergy testing (in severe cases) intradermal allergy testing rast test (blood test)
b. Acute Rhinitis
common cold cause - rhinovirus signs/symptoms - fatigue, sore
throat, nasal discharge, headache, fever, nasal obstruction, sneezing
physical exam nasal mucosa red inferior turbinates enlarged and
erythematous clear watery discharge
Foreign body (Nose) is the blockage of the nasal passages due to foreign
objects common in younger children difficulty in breathing foul smelling, bloody, unilateral discharge consult ENT for removal
4. Trauma Nasal fracture result of blunt trauma
signs/symptoms epistaxis nasal dyspnea edema pain ecchymosis
Physical exam - crepitus, mobile nose, deviation, edema, ecchymosis. Must look into nose to R/O septal hematoma. If found, refer to ENT.
Look for and rule out other facial fractures. X-rays of little valve
Table 14-1. p. 407.
Abnormalities of Nose
Furuncle Carcinoma
Throat
Anatomy The throat (pharynx) is located behind the mouth,
below the nasal cavity, and above the esophagus and windpipe (trachea). It consists of an upper part (nasopharynx), a middle part (oropharynx), and a lower part (hypopharynx).
The throat is a muscular passageway through which food is carried to the esophagus and air is carried to the lungs.
The tonsils are located on both sides of the back of the mouth, and the adenoids are located at the back of the nasal cavity.
Figure 14-4. p. 380.
Oral Cavity Structures
Figure 14-5. p. 381.
Salivary Glands
Figure 14-14. p. 391.
Inspect Mouth
Figure 14-20. p. 396.
Inspect Throat
TONSILITIS
Pharyngitis - inflammation of pharynx causes -viral - Epstein-Barr virus (mono),
adenovirus, etc. bacterial - group A & B strep
signs/symptoms odynophagia sore throat dysphagia fever, fatigue, otalgia
Physical exam (Pharyngitis) tender anterior cervical adenopathy
erythmatous posterior pharynx exudates palatal petechiae differentiation throat C&S severe symptoms suggest bacterial etiology Often have concurrent tonsillitis
Treatment ( Pharyngitis)
throat C&S Pen V-K 500 mg QID x 10 days increase/force fluids, analgesics
Tonsillitis - inflammation of tonsils. causes - similar to pharyngitis - viral - Epstein-Barr virus (mono), adenovirus, etc. bacterial - group A & B strep Signs/symptoms - more odynophagia and dysphagia due to increase of
tonsil size. Physical exam - similar to pharyngitis. tonsils enlarged, red, and exudate (white patchy) palatal erythema and edema cervical nodes may be tender, usually palpable treatment - similar to pharyngitis if severe and persistent surgery is
recommended tonsillectomy- removal of the tonsils tonsillitis rare without pharyngitis but can have vice-versa
Peritonsillar abcess abcess of peritonsillar region, pus within surrounding tissues signs/symptoms
hot potato voice trismus - inability to open mouth fully increased odynophagia foul odor from mouth unilateral pain
physical exam uvular deviation tender over anterior fauces arch tonsils red, swollen protuding and flunctuant on one side
Epiglottis - inflammation of epiglottis. causes - Haemophilus influenzae type B Signs/symptoms –
severe throat pain difficulty swallowing fever drooling muffled voice. Because the infection is in the epiglottis, the back of
the throat often does not appear infected. As swelling of the epiglottis starts to narrow the airway, the person first begins to make a squeaking noise when breathing in (stridor) and then has
progressively worse trouble breathing.
References: Brunner & Suddarth’s, Medical-Surgical
Nursing, 8th edition Henry M. Seidel, Mosby’s Guide to
Physical Examination, 7th edition Barbara Kozier, Fundamental of Nursing,
4th edition
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