Chapter 31
Health Assessment and Physical
Examination
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Purposes of the Physical Examination
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Triage for emergency care
Routine screening to promote health and
wellness
To determine eligibility for:
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Health insurance
Military service
A new job
To admit a patient to a hospital or long-term care
facility
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Purposes of Physical Examination
(Cont.)
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Use physical examination to:
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Gather baseline data about the patient’s health status.
Supplement, confirm, or refute subjective data
obtained in the nursing history.
Identify and confirm nursing diagnoses.
Make clinical decisions about a patient’s changing
health status and management.
Evaluate the outcomes of care.
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Quick Quiz!
1. When meeting a patient for the first time, it is
important to establish a baseline assessment
that will enable a nurse to refer back to:
A. physiological outcomes of care.
B. the normal range of physical findings.
C. a pattern of findings identified when the
patient is first assessed.
D. clinical judgments made about a patient’s
changing health status.
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Cultural Sensitivity
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Culture influences a patient’s behavior
Consider:
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Health beliefs
Use of alternative therapies
Nutritional habits
Relationships with family
Personal comfort zone
Avoid stereotyping
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Preparation for Examination
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Infection control
Environment
Equipment
Physical preparation of patient
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Positioning
Psychological preparation of patient
Assessment of age groups
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Organization of the Examination
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Assessment of each body system
Systematic and organized
Head-to-toe approach
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Compare sides for symmetry
 Assess body systems most at risk for being abnormal
 Offer rest periods as needed
 Perform painful procedures at the end
 Be specific when recording assessments
 Record quick notes during the examination; complete
larger notes at the end of the examination
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Techniques of Physical Assessment
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Inspection
Palpation
Percussion
Auscultation
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Inspection
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Use adequate lighting.
Use direct lighting to inspect body cavities.
Inspect each area for size, shape, color,
symmetry, position, and abnormality.
Position and expose body parts as needed so all
surfaces can be viewed but privacy can be
maintained.
When possible, check for side-to-side symmetry.
Validate findings with the patient.
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Palpation
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Uses touch to gather
information.
Use different parts of
hands to detect
different characteristics.
Hands should be warm,
fingernails short.
Start with light
palpation; end with
deep palpation.
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Percussion
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Tap body with fingertips to produce a
vibration.
Sound determines location, size, and density
of structures.
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Auscultation
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Requires
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Good hearing
A good stethoscope
Knowledge
Concentration and practice
Sound characteristics
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Frequency
Loudness
Quality
Duration
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General Survey
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General appearance and behavior
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Gender and race
Age
Signs of distress
Body type
Posture
Gait
Body movement
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Hygiene and grooming
Dress
Body odor
Affect and mood
Speech
Signs of patient abuse
Substance abuse
Vital signs
Height and weight
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Quick Quiz!
2. A patient complains of thirst and headache.
The patient appears emaciated. Upon initial
examination, you find that the skin does not
return to normal shape. This finding is
consistent with:
A. pallor.
B. edema.
C. erythema.
D. poor skin turgor.
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Head and Neck
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Inspection and palpation
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Inspect the patient’s head, noting the position,
size, shape, and contour.
Examine the size, shape, and contour of the skull.
Palpate the temporomandibular joint (TMJ) space
bilaterally.
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Eyes
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Visual acuity
Extraocular
movements
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Nystagmus
Visual fields
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Eyes (Cont.)
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External eye
structures
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Position and alignment
Eyebrows
Eyelids
Lacrimal apparatus
Conjunctivae and
sclerae
Corneas
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Eyes (Cont.)
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External eye structure
(Cont.)
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Pupils and irises
• PERRLA: pupils equal,
round, reactive to light,
and accommodation
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Eyes (Cont.)
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Internal eye structures
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Retina
Choroid
Optic nerve disc
Macula
Fovea centralis
Retinal vessels
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Ears
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Auricles
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Size
Shape
Symmetry
Landmarks
Position
Color
Discharge
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Ears (Cont.)
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Ear canals and
eardrums
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Color
Discharge
Scaling
Lesions
Foreign bodies
Cerumen
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Ears (Cont.)
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Hearing acuity
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Three types of hearing loss (conduction,
sensorineural, and mixed)
Ototoxicity
If a hearing loss is present, test the hearing using a
tuning fork.
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Tuning Fork Tests
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Weber’s test
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Hold fork at base and tap it
lightly against heel of palm.
Place base of vibrating fork on
midline vertex of patient’s
head or middle of forehead.
Ask patient if he or she hears
the sound equally in both ears
or better in one ear
(lateralization).
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Tuning Fork Tests (Cont.)
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Rinne test
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Place stem of vibrating
tuning fork against
patient’s mastoid
process.
 Begin counting the
interval using watch.
 Ask patient to tell you
when she no longer
hears the sound; note
number of seconds.
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Tuning Fork Tests (Cont.)
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Rinne test
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Quickly place stillvibrating tines 1 to 2
cm (1/2 to 1 inch) from
ear canal, and ask
patients to tell you
when they no longer
hear the sound.
Continue counting
time the sound is
heard by air
conduction.
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Nose and Sinuses
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Nose
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Excoriation
Polyps
Sinuses
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Mouth and Pharynx
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Lips
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Color
Texture
Hydration
Contour
Lesions
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Mouth and Pharynx (Cont.)
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Buccal mucosa
Gums
Teeth
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Mouth and Pharynx (Cont.)
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Tongue
Floor of mouth
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Mouth and Pharynx (Cont.)
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Palate
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Hard
Soft
Pharynx
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Neck
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Neck muscles
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Anterior triangle
Posterior triangle
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Neck (Cont.)
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Lymph nodes
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Inspection
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Neck
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Lymph nodes (Cont.)
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Palpation
• Face the patient
• Use a methodical
approach
• Inspect and palpate
both sides of neck for
comparison
• Tenderness almost
always indicates
inflammation.
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Neck (Cont.)
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Thyroid gland
Carotid artery and
jugular vein
Trachea
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Neurological System
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Responsible for many functions
Full assessment requires time and attention to
detail.
Many variables must be considered during
evaluation: level of consciousness (LOC),
physical status, chief complaint.
Collect all equipment before beginning.
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Neurological System (Cont.)
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Mental and emotional status
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Mini-Mental State Examination (MMSE)
Cultural considerations
Delirium
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Neurological System (Cont.)
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Level of consciousness
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Behavior and appearance
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Glasgow Coma Scale
Nonverbal and verbal
Language
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Aphasia
• Sensory (receptive)
• Motor (expressive)
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Neurological System (Cont.)
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Intellectual function
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Memory
Knowledge
Abstract thinking
Association
Judgment
Cranial nerve function
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Neurological System (Cont.)
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Motor function
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Coordination
Balance
• Have the patient perform a Romberg’s test by standing with
feet together, arms at the sides, both with eyes open and
eyes closed.
• Have the patient close the eyes, with arms held straight at
the sides, and stand on one foot and then the other.
• Another test involves asking the patient to walk a straight line
by placing the heel of one foot directly in front of the toes of
the other foot.
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Neurological System (Cont.)
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Sensory function
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Neurological System (Cont.)
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Reflexes:
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0: no response
 1+: sluggish/diminished
 2+: active/expected
response
 3+: more brisk than
expected, slightly
hyperactive
 4+: brisk and hyperactive
with intermittent or transient
clonus
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Neurological System (Cont.)
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Reflexes
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Position.
Tap tendon briskly.
Compare
corresponding sides.
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Thorax and Lungs
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Examination
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Thorax and Lungs (Cont.)
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Identify anatomical landmarks.
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Thorax and Lungs (Cont.)
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Posterior thorax
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Thorax and Lungs (Cont.)
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Tactile fremitus
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Created by vocal cords
Transmitted through lungs to chest wall
Palpation
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Thorax and Lungs (Cont.)
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Auscultation
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Normal breath sounds
Abnormal or
adventitious sounds
•
•
•
•
Crackles
Rhonchi
Wheezes
Pleural friction rub
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Quick Quiz!
3. A patient is admitted with pneumonia. When
auscultating the patient’s chest, you hear lowpitched, continuous sounds over the bronchi.
These sounds are labeled as:
A. crackles.
B. rhonchi.
C. wheezes.
D. pleural rub.
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Thorax and Lungs (Cont.)
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Lateral thorax
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Vesicular sounds
Anterior thorax
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Observe accessory muscles.
Palpate muscles and skeleton.
Assess tactile fremitus.
Compare right and left sides.
Auscultate for bronchial sounds.
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Heart (Cont.)
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Compare assessment
of heart functions with
vascular findings.
Assess point of
maximal impulse
(PMI).
Locate anatomical
landmarks.
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Heart (Cont.)
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Heart sounds
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S1
S2
S3
S4
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Heart (Cont.)
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Inspection and
palpation
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Patient must be
relaxed and
comfortable
 Inspect and palpate
simultaneously
 PMI
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Heart (Cont.)
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Auscultation
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Normal heart sounds
• Dysrhythmia
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Extra heart sounds
Murmurs
• Grade
• Pitch
• Quality
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Vascular System
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Blood pressure
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Always record the highest
reading.
Carotid arteries
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Reflect heart function better
than peripheral arteries
Commonly auscultated
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Vascular System (cont’d)
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Carotid bruit
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Narrowed blood vessel
creates turbulence,
causes
blowing/swishing
sound
Pronounced “brew-ee”
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Vascular System (cont’d)
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Jugular veins
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Most accessible
Right internal jugular
vein follows more
direct path to right
atrium.
Note distention.
Assess pressure.
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Vascular System (Cont.)
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Peripheral arteries and veins
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Assess the adequacy of blood flow to the extremities
by measuring arterial pulses and inspecting the
condition of the skin and nails.
 Assess the integrity of the venous system.
 Assess the arterial pulses in the extremities to
determine sufficiency of the entire arterial circulation.
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Vascular System (Cont.)
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Peripheral arteries
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Assess each peripheral artery for elasticity of the
vessel wall, strength, and equality.
Pulses
•
•
•
•
•
0: absent, not palpable
1: pulse diminished, barely palpable
2: expected/normal
3: full pulse, increased
4: bounding pulse
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Vascular System (Cont.)
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Peripheral arteries
(Cont.)

Upper extremities
• Brachial artery
channels blood to radial
and ulnar arteries of
forearm and hand
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Vascular System (Cont.)

Peripheral arteries (Cont.)
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Radial pulse: thumb side of wrist
Ulnar pulse: little finger side of wrist
Brachial pulse: inside of elbow
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Vascular System (Cont.)

Peripheral arteries
(Cont.)
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Lower extremities
• Femoral artery
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Vascular System (Cont.)
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Peripheral arteries (Cont.)
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Femoral pulse
Popliteal pulse
Dorsalis pedis pulse
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Vascular System (Cont.)

Peripheral Arteries
(Cont.)
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
Ultrasound
stethoscopes
Tissue perfusion
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Vascular System (Cont.)
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Peripheral Veins
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Varicosities
Peripheral edema
• Pitting edema

Phlebitis
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Lymphatic System

Lymphatic system

Lower extremities
• Assess during examination of
vascular system or genital
examination

Upper extremities
• Palpate the epitrochlear
nodes, located on the medial
aspect of the arms
• Assess proximal portion
during breast examination
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Abdomen


Complex assessment because of organs located
in abdominal cavity
Begin with inspection and follow with
auscultation
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Abdomen (Cont.)
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Inspection

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Skin
Umbilicus
Contour and symmetry
Enlarged organs or masses
Movements or pulsations
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Abdomen (Cont.)

Auscultation

Bowel motility
• Peristalsis
• Borborygmi

Vascular sounds
• Bruits

Kidney tenderness
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Abdomen (Cont.)
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Palpation
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Performed last
Detects tenderness,
distention, or masses
May be light or deep,
as appropriate
Aortic pulsation
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Quick Quiz!
4. When conducting an abdominal assessment,
the first skill a nurse puts to use is:
A. auscultation.
B. inspection.
C. palpation.
D. percussion.
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Female Genitalia
and Reproductive Tract
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Assessment includes both internal and external
organs.
Understand cultural sensitivity.
Identify changes across the life span.
Use inspection and palpation.
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Male Genitalia
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
Assesses the integrity
of the external
genitalia, inguinal
ring, and canal.
Use a calm, gentle
approach to lessen
the patient’s anxiety.
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Rectum and Anus
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Perform after genital examination.
Explain all steps to the patient.
Provide privacy.
Use inspection and digital palpation.
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After the Examination
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Record findings.
Give the patient time to dress; assist if needed.
If findings are serious, consult health care
provider before informing the patient.
Delegate cleaning of examination area.
Record complete assessment; review for
accuracy and thoroughness.
Communicate significant findings.
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