Physical Assessment�

Presented by Mr. Prince Attah Obeng

 � �Guidelines for conducting Physical Examination�

To conduct effective physical exam, the following guidelines must be adhered to:

1. Explain to the client that you want to conduct physical examination on him to ascertain how the various systems of the body are functioning.

2. The nurse must also explain to the client where the examination will take place and what will happen during the procedure

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The Guidelines cont’d

3. Reassure the client that all information gathered and documented during the examination will be kept confidential

4. Ensure that the client’s urinary bladder is emptied before the exam to make him feel relaxed, and also, to avoid interference during palpation of the abdomen.

5. Determine which positions are conducive to be assumed by the client

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The guidelines cont’d

6. Ensure that the room is well illuminated to enhance inspection

7. Avoid unnecessary noise in the environment, which could hinder hearing

8. Make sure all instruments that may be needed for the examination are assembled on a tray or trolley to guarantee smooth examination

9. Ensure privacy to boost the client’s confidence of confidentiality

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The guidelines cont’d

10. Avoid unnecessary exposure of the client; only examining part should be exposed at a time

11. Avoid unnecessary touching during the exam

12. Be a good listener to avoid unnecessary delays in listening to sounds

13. Avoid unprofessional facial expressions during the procedure

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The guidelines cont’d

14. The nurse must wash and dry hands before and after conducting physical examination

15. Communicate findings to the client if possible

16. Make patient comfortable and thank him for his co-operation after the procedure

17. Document findings

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Techniques or methods of Physical Examination �

• There are four main techniques used in performing the physical examination
• These are:

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

Inspection�

• It is the visual examination of a part or region of the body to assess normal conditions or deviations from normal.
• It is deliberate, systematic and focused
• The eye is the main sense organ used in inspection.
• However, senses of smell (olfactory) and hearing (auditory) can be used

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Inspection cont’d

• Visual examination is applicable in assessing: colour, shape and size, symmetry of the body, position, facial expression, moisture and personal hygiene.
• It requires well illumination of the environment.
• In case of using the sense of hearing, the environment must be quiet enough for accurate hearing.

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Inspection cont’d

• The nurse needs to compare what is seen with what is known. For instance, it is known that every lady must have well developed breast. The absence of well developed breast may indicate hormonal insufficiency

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Palpation�

• It is the examination of the body through the use of the sense of touch.
• The hands are used in palpation.
• Different parts of the hand are more sensitive for specific assessment.
• For example:

1. The tips of the fingers are used to palpate lymph nodes and arteries for heart beat

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Palpation cont’d

2. The dorsa of hands and fingers are used to assess temperature

3. The palmer surface is best suited for feeling of vibrations

• Palpation is made up of two types

1. light palpation

2. deep palpation

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Light palpation�

• It is used in assessing tenderness, temperature, vibrations, texture of the hair and consistency of masses.
• The nurse extends the fingers parallel to the skin surface and presses gently, while moving the hand in a circle.
• It should be done before deep palpation to avoid dulling the sense of touch of the fingers

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Deep palpation�

• In deep palpation, one or two hands are used in assessing position and size of organs and tenderness (especially in rebound tenderness)
• One hand is placed on top of the other to exert deep pressure on the skin to assess the organ
• Sometimes too, whiles one hand is used in palpation, the other is used to support or stabilize the organ or mass.

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Guidelines for Palpation�

• The nurse’s hands should be cleaned and warm
• The fingernails should be short
• Areas of tenderness should be palpated last
• Deep palpation is done after light palpation
• During palpation, the nurse must pay attention to the client’s facial and verbal responses

Percussion

• It is an assessment technique involving the production of sound to obtain information about the underlying area
• There are two types of percussion:

1.Direct percussion

2.Indirect percussion

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Direct percussion�

• It is performed by directly tapping the body with one or two fingers to elicit sound

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Indirect percussion�

• This technique is achieved by placing the middle finger (pleximeter) of the non-dominant hand firmly on the area of the body to be examined.
• The tip of the middle finger of the dominant hand (plexor) strikes the distal phalanx of the pleximeter.
• A relaxed wrist and a rapid strike produces the best sound.

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Percussion cont’d

• Percussion produces five types of sound. These are:

1. Flatness: extremely dull sound produced by very dense tissue e.g. muscle and bone

2. Dullness: dull sound produced by dense organs such the heart, liver or the spleen.

3. Resonance: hollow sound such as that produced by lung filled with air

Percussion cont’d

• Hyperresonance: booming sound produced in only emphysematous lung
• Tympany: musical or drum- like sound produced from an air filled stomach or intestine.
• Percussion is therefore used to determine the shape and size of internal organs by identifying their borders.

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Percussion cont’d

• NOTE: Sounds and vibrations produced are relative to the underlying structures. Deviations from an expected sound could indicate a problem.

E.g. if flatness sound is heard in the right upper quadrant, it indicates cancer/ cirrhosis of the liver.

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Auscultation�

• It is listening to sounds produced by the body to assess normal conditions and deviations from normal.
• It is usually indirect, using stethoscope to amplify the sound.
• The bell(placed lightly on the skin to avoid flattening the skin and reducing audible vibrations) of the stethoscope is more sensitive to low-pitched, very-low frequency (i.e. high intensity) sounds e.g. diastolic heart murmurs.

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Auscultation cont’d

• The diaphragm of the stethoscope is more sensitive to high-pitched (i.e. low intensity) sounds. E.g. heart sounds.
• Note: high intensity sound has low pitch, and vice versa.
• Normal stethoscope tube should be 30-35cm long and a diameter of 0.3cm.
• Auscultation is particularly useful in evaluating sounds from the heart, lungs, abdomen and vascular system

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NOTE: �

1. Not all techniques are applicable to all body parts

2. Physical examination is performed in the sequence of: inspection →palpation →percussion→ auscultation

3. The only exception to this sequence is for the abdominal examination, which is inspection→ auscultation→ percussion →palpation.

This is because, palpation and percussion before auscultation can alter bowel sounds.

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NOTE: �

Bowel sounds

Normal – sounds heard about 5 to 20 seconds

Hypoactive – 1 or 2 sounds in 2 minutes

Hyperactive – 5 to 6 sounds heard in less than 30 seconds

Absent – no sounds in 3 to 5 minutes

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Preamble

• Akua Sekyewaa, an 18-year old girl comes to the Emergency ward with a history of productive cough for 3 days and a recent onset of dyspnoea.
• What is her chief complaints?
• What histories would you take from the patient and why?
• What physical examination would you conduct?

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Land marks of the chest�

• These are imaginary lines on the chest that help nurses to identify the position of underlying organs, and help document abnormal assessment findings.

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Land marks of the chest cont’d�

•  These include:

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• Anteriorly
• Midsternal line- vertical line running through the centre of the sternum.
• Midclavicular lines (right and left)- vertical line from the midpoints of the clavicles

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Land marks of the chest cont’d

• Posteriorly
• Vertebral line- vertical line along the spinous process
• The scapular lines (right and left)- vertical lines from the inferior angles of the scapulae.

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Land marks of the chest cont’d�

• Laterally
• Anterior axillary lines (Rt. & Lt.)- vertical lines from the anterior axillary folds
• Midaxillary lines (Rt. & Lt.)- vertical lines from the apex of the axilla
• Posterior axillary lines(Rt. & Lt.)- vertical line from posterior axillary folds

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Heart Sounds�

• When the precordium is auscultated, two distinct sounds called heart sounds are heard
• The two heart sounds are often described by two syllables “lub” and “dup”
• The sequence is lub-dup’ pause, and so on
• The first heart sound –S₁ (lub) is caused by the closing of atrioventricular valves

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Heart Sounds cont’d

• The second heart sounds- S₂ (dup) is caused by the closing of the semilunar valves
• The S₁ is longer and louder than the S₂which tends to be short and sharp
• The sounds are best heard with the diaphragm of the stethoscope because they are high-pitched

Location of Heart Valves/ Sounds �

• Aortic valve [S₂]- 2^nd Rt intercostal space (ICS) at sternal border
• Pulmonic valve [S₂]- 2nd Lt intercostal space (ICS) at sternal border
• Tricuspid valve [S₁]- 5^th Lt ICS at sternal border
• Bicuspid or Mitral valve [S₁]- 5^th Lt ICS at midclavicular border

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●

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Erb’s point

S₁

S₁

S₂ -Aortic

Angle of Louis

S₂ (pulmonic)

Heart Sounds cont’d

• NOTE
• Erb’s point [ 3^rd Lt ICS at sternal boarder] is where S₂ is best heard
• The ICS is named according to the rib above it.
• Angle of Louis- it’s the junction of manubrium and body of sternum

Heart Sounds

Murmurs

• These are abnormal or unusual heart sounds produced when blood flows through partially opened valves as a result of the blood striking against the obstruction
• In normal situation, the flow is supposed to be silent as long as the flow is smooth and uninterrupted.

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NORMAL BREATH SOUNDS�

• There are three normal breath sounds:

1. Vesicular

2. Bronchovesicular

3. Bronchial  

Vesicular

• Sounds are relatively soft, low-pitch, gentle and rustling sounds created by air moving through the alveoli and bronchioles.
• They are heard over lung areas but best heard at the base of lungs.

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Bronchovesicular�

• Moderate intensity and moderate pitch sound created by air moving through the bronchi.
• Heard between the scapulae and also at 1^st and 2^nd intercostals spaces.

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Bronchial

• High pitched, loud sound resembling air blowing through a hollow pipe.
• It is created by air moving through the trachea.
• They are heard over the manubrium.

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ABNORMAL BREATH SOUNDS�

1. Crackles or Crepitations:

• Fine short interrupted crackling sound due to air passing through fluid or mucus.

2. Rhonchi

• Snoring or rattling sound due to obstruction of airway with secretions.

3. Wheezing

• Continuous high-pitched musical whistling sound due to air rushing through narrowed airway (Heard best on expiration)

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Abnormal Breath Sounds

4. Friction Rub

• Crackling or grating sound due to rubbing together of inflamed pleural surfaces.

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AN OUTLINE FOR THE SCREENING PHYSICAL EXAMINATION�

A. General Survey:

• Observe the client’s general state of health including body features, state of consciousness, speech, body movements, physical signs, nutritional status, stature and personal hygiene.

B. Vital Signs:

• Temperature, pulse, respiration, Blood Pressure, weight, height and BMI. MUAC for SAM and MAM

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C. Integumentary System:�

• Inspect and palpate for lesions, colour, bruises, oedema, moisture, texture, temperature, turgor, vascularity, nails for colour, flexibility, capillary refill (within 3 seconds).

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D. Head�

• Inspect and palpate for shape and symmetry of skull, masses, tenderness, hair for alopecia, scalp.
• Eye
• Inspect and palpate for visual acuity, eyebrows, position and movement of eyelids, visual fields, colour, discharges, stye, cataract, squint.
• Ears
• Inspect and palpate for auditory acuity (weber or rinne, whispered voice or ticking watch) mastoid process, pinna, auditory canal, tympanic membrane, pain and discharge

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Nose and sinuses�

• Inspect and palpate external nose (shape, blockage, discharge) and internal (patency of nasal cavity) polyps, discharge, frontal and maxillary sinuses for tenderness.
• Mouth
• Inspect for (and occasionally palpate lips), buccal mucosa, teeth, gums, tongue, tonsils, uvula and offensive mouth (Halitosis).

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Neck

• Inspect and palpate (occasionally auscultate) thyroid gland, lymph nodes, symmetry, skin (vascularity and visible pulsations)

Neurologic examination

• Motor status, walk, observe gait, coordination, finger to nose. Inspect and palpate spine for scoliosis (lateral curvature of spine).

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Extremities�

• Inspect and palpate arms, fingers, wrist and shoulder for strength, range of motion, joint pains, swelling, reflex, oedema, extra digits, club fingers, dorsalis tabes, talipes.

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F. Thorax�

• Inspect, palpate, percuss and auscultate for breath sounds, respiratory rate, anterio-posterior diameter, symmetry and curvature of the ribcage, tactile fremitus, breast for lumps, nature of nipple (retracted, flat) discharge, tenderness, heart sounds (S1 and S2) Erb’s point.

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H. Abdomen�

• Inspect, auscultate, percuss, palpate for scars, shape, symmetry, umbilical cord (herniation and discharge), borders of liver, bowel sounds, size for distention, urinary bladder for distention, visible vessles, rashes, linea nigra, tenderness, inguinofemoral pulses, ascites.

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Genitalia�

• Male:
• Inspect hair distribution, prepuce, glans, urethral meatus, scars, ulcers, penile discharge.
• Palpate scrotum for both testes, masses, pain, hydrocele or scrotal hernia, prostate enlargement.

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Female:�

• Inspect hair distribution, mons pubis, vulva, clitoris, urethral meatus, vaginal orifice, discharge, ulcer, oedema of labia majora and perineum for rashes, vaginal speculum examination to assess walls of vagina and cervix.

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THANK YOU!