Physical examination


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Physical examination

  1. 1.
  2. 2. Objectives of Health AssessmentDescribe prehospital physicalexamination techniquesDescribe examination equipmentDescribe the general approach to thephysical examinationOutline the steps of the comprehensivephysical
  3. 3. ObjectivesDetail the components of the mentalstatus examinationIdentify abnormal findings in the mentalstatus examinationOutline steps in the general patientsurveyDistinguish between normal andabnormal findings in the general
  4. 4. ObjectivesDescribe examination techniques forspecific body regionsIdentify normal and abnormal findings inthe body region examinationDescribe examination techniques specificto children and older
  5. 5. Health AssessmentComponent of Health assessmentHealth HistoryPhysical
  6. 6. PurposesEstablish a nurse- client relationship.Gather data about the client‟s general healthstatus, integrating physiologic, psychological,cognitive, socio cultural, development andspiritual dimensions.Identify client‟s strengths.Identify actual and potential health problem.Establish a base for the nursing process.To evaluate the physiological outcome of
  7. 7. Techniques of Physical
  8. 8. Health HistoryHealth history is a collection of subjectiveand objective data that provide a detailedprofile of the client‟s health
  9. 9. History TakingIDENTIFICATION DATA OF THE PATIENTPatients name:-Age: - Sex-Hospital Name:-File No./MLC No.:-Source providing history:-Date/ Time of
  10. 10. OPD No.:-IPD No.:-Ward-Bed No.:-Doctor‟s Unit:-Provisional Diagnosis-Surgery done/Date of Surgery:-Name of the Surgery:-Residential
  11. 11. Mother Tongue:-Marital Status-Educational Status: -Occupation-Monthly
  12. 12. DETAILS OF ADMISSION:-Arrived via wheel chair / stretcher /ambulatory: -LOC – Conscious / Semiconscious /UnconsciousFrom admitting room / emergency room.home / any
  13. 13. ORIENTATION TO THE UNIT:-Use of telephone / TV / call lights:-Visiting hours:-No Smoking:-Patient is informed that hospital is notresponsible for the personal belongings: -Yes/NoValuable handed over to (Write relationshipWith patient)Written
  14. 14. BASELINE DATAWeight:- Height:- Abdominal Girth:-Temperature: - Oral: -Axilla: - Rectal:-Respiration:-Pulse: -Blood
  15. 15. REASON FOR ADMISSION(Onset, duration, earlier treatments)ALLERGIES AND MEDICATIONSDrugs / Foods / dyes / Others:-Sign and
  16. 16. VICESAlcohol/ Tobacco/Cigarette/Drug Abuse:-Amount of intake/Day:Duration of intake (Since when) andfrequency of intake (How often in a day?)
  18. 18. FAMILY INFORMATION-Name of Family Members-Relationship with patient-Age-Type of Family-Education-Occupation-Marital Status-Health
  19. 19. Family Income per Year:Family interpersonal relationship / AnyFamily Disharmony:-Family History of illness: (Hypertension,DM, Cancer, Arthritis,
  20. 20. ENVIRONMENTAL BACKGROUND1) HOUSINGType of house:-Lighting :-Ventilation:-Water facilities:-Sanitation:-2) PETS/ANIMALS3) FOOD HYGIENE PRACTICES:4) PERSONAL HYGIENE
  21. 21. 5) COMMUNITY RESOURCESa) Transport: -b) Health facilities:-c) Educational Facilities :-PAST MEDICAL HISTORYHypertension, DM, Cancer, Respiratory,Arthritis, stroke and others:PAST SURGICAL HISTORYPRESENT MEDICAL HISTORY;
  22. 22. CURRENT MEDICATION:-Current MedicationDose/FrequencyRouteLast Dose TakenLABORATORY/OTHER INVESTIGATION:-DateInvestigations NameNormal FindingsPatient’s
  23. 23. SPECIAL ASSISTIVE DEVICESWheel Chair / Braces / Crutches /Walkers / others:-Contact lenses / Hearing aid / Prosthesis /Glasses:-Dentures:- Total /
  24. 24. PSYCHOSOCIAL HISTORYAny recent stress?Who is with the patient in the hospital?Does the patient have anybody who willgive financial support if needed?Who will care for the patient at home?Calm: Yes / NoAnxious: Yes /
  25. 25. Skills of Physical
  26. 26. InspectionVisual assessment of the patient andsurroundingsFindings that may be significant:– Patient hygiene– Clothing– Eye gaze– Body language– Body position– Skin color– Odor
  27. 27. Nurse observe body partPay attention to client, watching allmovement & looking carefully at any bodypart.It help to know physical characteristics.Quality of inspection depend on thenurse‟s willingness to spend time during
  28. 28. If the emergency response was to thepatients home, make a visual inspectionfor– Cleanliness– Prescription medicines– Illegal drug– Weapons– Signs of alcohol
  29. 29. PrinciplesMake sure good lighting is available.Position and expose body parts so that allsurface can be viewed.Inspect each area of size, shape,colour,symmetry, position and abnormalities.If possible, compare each area inspected withthe same area on the opposite side of the body.Use additional light to inspect body cavities.Do not hurry inspection. Pay attention to
  30. 30. PalpationA technique in which the hands and fingers areused to gather information by touch.Palmar surface of fingers and finger pads areused to palpate for– Texture– Masses– Fluid--And assess skin temperatureClient should be relax and positionedcomfortably because muscle tension duringpalpation impair its effectiveness.Asking the patient to take deep & slow
  31. 31. Types of PalpationLight palpationDeep palpationBimanual
  32. 32. Light PalpationThe nurse apply tactile pressure slowly,gentely and deliberately.The nurse‟s hand is placed on the part tobe examined and depressed about
  33. 33. Deep PalpationIt is done after light palpation.It is used to detect abdominal masses.Technique is similar to light palpationexcept that the finger are held at a greaterangle to the body surface and the skin isdepressed about 4-5
  34. 34. Bimanual PalpationIt involve using both hand to trap astructure between them. This techniquecan be used to evaluate spleen, kidney,breast, uterus and ovary.Sensing hand – Relax & place lightly overthe skin.Active hand – Apply pressure to thesensing
  35. 35. Deep Bimanual
  36. 36. PercussionPercussion involve tapping the body with thefingertips to evaluate the size, border andconsistency of body organs and todiscover fluid in body
  37. 37. PercussionUsed to evaluatefor presence of airor fluid in bodytissues– Sound wavesheard aspercussion tones(resonance)
  38. 38. Methods of PercussionMediate or Indirect PercussionImmediate PercussionFist
  39. 39. Mediate or Indirect Percussion It can be performed by using the fingeron one hand as a plexor (Striking finger)and the middle finger of the other hand asa pleximeter (the finger being struck). Used mainly to evaluate the abdomen
  40. 40. Immediate PercussionUsed mainly to evaluate the sinus or aninfant thorax.It can be performed by striking the surfacedirectly with the fingers of the
  41. 41. Fist PercussionUsed to evaluate the back and kidney fortenderness.It involves placing one hand flat againstthe body surface and striking the back ofthe hand with a clenched fist of the
  42. 42. Sounds Produced by PercussionSound : TympanyIntensity : LoudPitch : HighDuration : ModerateQuality : DrumlikeCommon location : Air containing space,enclosed area, gastric air bubble, Puffed out
  43. 43. Sounds Produced by PercussionSound : ResonanceIntensity : Moderate to LoudPitch : LowDuration : LongQuality : HollowCommon location : Normal
  44. 44. Sounds Produced by PercussionSound : Hyper ResonanceIntensity : Very LoudPitch : Very LowDuration : Longer than resonanceQuality : BoomingCommon location : Emphysematous
  45. 45. Sounds Produced by PercussionSound : DullnessIntensity : Soft to moderatePitch : HighDuration : ModerateQuality : ThudlikeCommon location :
  46. 46. Sounds Produced by PercussionSound : FlatnessIntensity : SoftPitch : HighDuration : ShortQuality : FlatCommon location :
  47. 47. AuscultationAuscultation is listening to sound produce by thebody.Through auscultation the nurse note thefollowing characteristics of sound. Frequency or the number of oscillationgenerated per second by a vibrating object. Loudness – Loud or soft Quality – Blowing or Gurgling Duration – Length of time that sound vibrationlast. Short / medium /
  48. 48. AuscultationBest performed in a quiet environmentRequires a stethoscope– Body sounds produced by movement of fluids orgases in patients organs or tissuesNote:– Intensity– Pitch– Duration–
  49. 49. StethoscopeUsed to evaluate sounds created bycardiovascular, respiratory,and gastrointestinal systemsPosition stethoscope betweenindex and middle
  50. 50. OlfactionWhile assessing a client, the nurseshould be familiar with the nature andsource of body
  51. 51. Preparation for ExaminationInfection control : If patient have anyopen skin lesions and any drainage. Nursehas to maintained infection control andavoid infection.- use gloves- use apron- use mask- use
  52. 52. EnvironmentPrivacyWell equipped examination roomAdequate lightingSound proofed roomComfort environmentExamination
  53. 53. EquipmentAll necessary equipments for
  54. 54. Physical preparationBladder and Bowel eliminationDraped properlyDressed
  55. 55. Psychological preparationExplain procedureIf both are opposite sex then third personis necessary.Observe facial expressionClient should free from anxious feeling.Clarify client
  56. 56. General examination1.Gender and race :Example – Skin cancer is 20% higher inwhite than black people. Prostate canceris higher in African American than whiteAmerican.2. Age : old age people and childrens aremore prone to get
  57. 57. 3. Signs of distress :Pain, Difficulty in breathing4. Body type : Thin, Fat5. Posture : Standing. Upright position,Knee flexed6. Gait : Co-ordination proper or not, personnormally walk with the arms swingingfreely at the sides, with the head and faceleading the
  58. 58. 7. Body movement :- Movement are purposefully.- If any part is immobile.8. Hygiene and grooming :- Personal hygiene maintain or not.- Cosmetic used or
  59. 59. 9. Dress : culture, life style, socio economicstatus. It should be appropriate accordingto weather condition.10. Body odor :- Unpleasant odor- Poor hygiene- Bad breath- Poor oral
  60. 60. 11. Affect and mood :- Feeling‟s to other- Emotionally expression- Mood appropriate as per situation12. Speech :Pressure, tone,
  61. 61. 13. Client abuse : any problem duringgrowing and serious health problem duringchildhood.14. Substance abuse :- Drugs- Alcohol- Smoking-
  62. 62. Vital signsTemperaturePulse rateRespiratory rateBlood
  63. 63. Temperature MeasurementOral temperatureHold thermometerfirmly under tongueTell child to “kiss”Caution to avoidbiting
  64. 64. Axillary TemperatureHold arm downfirmlyShould beapproximately 1 Fless than
  65. 65. Rectal TemperatureRisk of perforationAvoid inuncooperative,
  66. 66. PulseRateRhythmQualityConsider ECG
  67. 67. RespirationsAdult rate– 16-24 breaths per minuteObserveFeel for chest
  68. 68. Blood
  69. 69. Blood Pressure CuffSphygmomanometerMeasures systolicand diastolic bloodpressureManual or
  70. 70. AnthropometryHeightWeightAbdominal girthMid arm
  71. 71. Height and BuildDescriptions include:– Average, tall, short, lanky ( long & thin ),muscularMay also be affected by age and
  72. 72. WeightObserve general appearance– Obese to emaciatedRecent changes may be key finding– Recent weight loss or
  73. 73. Head to toe ExaminationHair: Hair type :Terminal Hair : long, thick, found on axillaand pubic area.Vellus Hair : small, soft, found all overbody except palm or
  74. 74. Colour:Distribution:Quantity:Shiny:Dry:Curly:Using
  75. 75. Bittle hairWith puberty hair colour, distribution andamount change.HirsutismLubrication of
  76. 76. ScalpUnusual
  77. 77. DandruffReaction with shampooWigUsing chemical for pediculosis treatmentUsing chemical to
  78. 78. Fore HeadLesionsMarkHead
  79. 79. EyesVisual activity:Visual field:Eye movement:Eye structure:Shape:Symmetry:Reactive to lightRedness and swellingEye chart reading ( snellen‟s chart )
  80. 80. Discharges:Eye alignment:Eye brows:Eye lids:Use of glasses or contact lenses:Corneal reflexLacrimal functionOphthalmoscope used to see anyabnormalities in
  81. 81. EarsStructure:Symmetry:Obstruction:Position and
  82. 82. Shape:Discharge:Inflammation:Hearing AID:Otoscope is used to see internal earstructureHearing activity:Weber‟s test:Rinne
  83. 83.
  84. 84. Mucus colour:Patency of Nair:Epistaxis:Discharge:Polyp‟s:DNS:Pen light and nasal speculum is used tosee
  85. 85. SinusFrontal sinusMaxillary
  86. 86. LipsColour:-Cherry :carbon-monoxide poisoning-Pallor: Anemia-Cyanosed: Respiratory or cardiac
  87. 87. DrynessSmoothnessCrack lips With mouth closed the nurseview the lips from end to end.Remove lipstick before examination of
  88. 88. TeethArrangement:Dental hygiene:Loose teeth:Colour of
  89. 89. Upper molar should rest directly on thelower molar with upper incisors slightlyoverriding the lower incisors.Dental caries – discoloration of the
  90. 90. GumsColour:Edema:Gingivitis:Ulcer:Healthy gums are pink, smooth and moist.Spongy gums bleed easily ( vit-cdeficiency )
  91. 91. Oral mucosaColor: Pinkish redmoist/dry:Ulcer:Lesion:Leuckoplakia: thick white patches becauseof smoking and
  92. 92. TongueThe client first relax the mouth and sticks thetongue out halfway.Slightly rough on the top surface and smoothalong the lateral margin.Under surface of the tongue and floor of themouth are highly vascular.Observe for cyst, lesions, swelling and noduleon the back side of tongue.Examination of tongue : Protrude the tongue,grasp the tip and gently pulls it to one
  93. 93. Movement:Shape:Ulcer:Lesions:Protrude of tongue:Taste of
  94. 94. PalateExtend the Head backward and open the mouthand inspect hard palate & soft palateHard palate: Anterior part of palateShape: Dome shapeColour: WhitishSoft palate: Posterior part of palateShape: „C” shapeColour: Light
  95. 95. PharynxProcedure : Extend his neck slightly, openthe mouth widely and say „ah‟. Placetongue depressor on the middle third oftongue. Use penlight for inspection.Inspect for edema, ulcer, inflammation,lesions.Gag
  96. 96. NeckExamine the anatomical position of neck.Function of sternocleidomastoid muscle :the nurse ask the client to flex the neckwith the chin to the chest.Function of the trapezius muscles :movement of the head sideway so that theear moves toward the shoulder.Neck should move freely without any
  97. 97. Movement of neck :Stiff ness:Swelling:Neck muscle:ROM:Lymph nodes : With the client‟s chin raisedand head tilted slightly, the nurse firstinspect the area where lymph nodes aredistributed.Inspect for size, shape, inflammation
  98. 98. Thyroid glandIt lies anterior lower neck, in front of neck andboth side of trachea.Inspect for visible mass of thyroid gland,symmetry and fullness at the base of neck.Give water then see for bulging of the gland.Palpation : Client flex the neck forward andlaterally toward the side being examined. Theclient hold a cup of water and take a sip
  99. 99. Anterior Part : using the pads of the indexand middle finger, the nurse palpate theleft lobe with the right hand and right lobewith left hand.Posterior Part : Both hand of the nurse arekeep around the neck with two finger ofeach hand on the side of
  100. 100. BreastFemale:– Symmetry– Pain:– Lump:– Discharge:– Swelling:– Trauma:– History of breast disease:–
  101. 101. Male:-Lump:-Swelling:-
  102. 102. Thorax & LungThorax size:Thorax shape:Chest movement:Respiratory rate:Rhythm:Breathing
  103. 103. Breathing sound:Chest pain with breathing:Cough:Productive &
  104. 104. Cardio vascular systemApical pulse: To find the apical pulse the nurselocate the 5th ICS just to the left to the sternumand move the fingers laterally, just medial to theleft mid- clavicular line.Redial: Rt…………….. Lt…………….Heart
  105. 105. Perfusion:Edema: because of heart failureSite of edema:Cyanosis or Pallor: Because of MIFatigue: Because of decrease
  106. 106. Gastro- intestinal systemAbdomenSize:Shape:Abdomen distention:Surgical
  107. 107. Stool frequency / Character:Last movement :Ostomy present:Bowel
  108. 108. Reproductive systemUrinary complain:Discharge:Anuria:Haematuria:Dysuria:Urinary Incontinence:Urinary
  109. 109. Urine last voided:Catheter present:Any other:Male– Opening of penis:– Penile Discharge:If „Yes‟
  110. 110. Female-LMP:-Vaginal discharge:-If „Yes‟
  111. 111. SkinColour:Rashes:Lesion:Surgical scar:Abnormal growth:Secretion:If „Yes‟ then
  112. 112. MusculoskeletalROM:Weakness / paralysis / contracture / jointswelling / pain /other:Extremity
  113. 113. Wrist
  114. 114. Elbow
  115. 115. Shoulder
  116. 116.
  117. 117.
  118. 118. SpineCurvature of spine observe for:Lordosis: Increase lumber curvatureScoliosis: Lateral spinal curvatureKyphosis: Exaggeration of posteriorcurvature of thoracic
  119. 119.
  120. 120. Mental
  121. 121. Neurological ExaminationOrientation – To place / person / timeLevel of conscious - confused / alert /restless / lethargic / comatoseCo-ordination to walk:Equilibrium test:Sensation test:
  122. 122. Romberg
  123. 123. Pronator Drift
  124. 124.
  125. 125. BicepsIdentify biceps tendon have patient flexelbow against resistance while you palpateantecubital fossaPlace arm so it‟s bent ~ 90 degreesPlace one of your fingers on tendon andstrike it.Reflex : Flexion of arm at
  126. 126.
  127. 127. TricepsFlex client‟s arm at elbow, holding armacross chest or hold upper armhorizontally. Strike triceps tendon justabove elbow.Reflex : Extension at
  128. 128.
  129. 129. PatellarHave client sit with leg hanging freely overside of table. Tap patellar tendon justbelow patella.Reflex : Extension of lower
  130. 130.
  131. 131. AchillesHave client assume same position as forpatellar reflex. Slightly dorsiflex client‟sankle by grasping toes in palm of yourhand. Strike Achilles tendon just aboveheel at ankle malleolus.Reflex : Planter flexion of
  132. 132.
  133. 133. Planter:Have client lie supine with legs straightand feet relaxed. Take handle end ofreflex hammer and stroke lateral aspect ofsole from heel to ball of foot, curvingacross ball of foot toward big toe.Reflex : Planter flexion of all
  134. 134.
  135. 135. Gluteal:Have client assume side lying position.Spread buttocks apart and lightly stimulateperineal area with cotton applicator.Reflex : Contraction of anal
  136. 136. Thank