Nur 102 Spring 2015
Belinda Lowry, MSN, RN, CCRN
QUIZ
QUIZ
 a. examination using fingers
 1. _____ inspection
 2. _____ auscultation
 3. _____ palpation
 4. _____ distention
 5. _____ percussion
and hands to feel underlying
body parts
 b. state of being enlarged or
swollen from internal
pressure
 c. examination by listening
 d. examination by using
short, sharp taps of the
fingers
 e. visual examination
Good Morning!
Rationale for Physical Exam
 Triage, routine, health promotion & wellness, eligibility,
military service, new job, admission to hospital
 Gather baseline data about the patient's health status.
 Support 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.
 Sometimes focused assessment is performed first, with
comprehensive assessment completed later
Environmental Preparation
 Respectful & private
 Patient room
 Pull curtains when able
 Private room if home health
setting
 Well-equipped
 Adequate lighting
 Proper patient positioning
Equipment
 Gloves
 Vitals machine or
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
sphygmomanometer
with appropriate size
cuff
Pulse-ox
Pen light
Stethoscope
Drapes/sheet
Patient gown
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Thermometer
Scale
Tongue depressors
Watch with second hand
Advanced Exam:
 Ophthalmoscope
 Otoscope
 Snellen Chart
 Tuning fork
Patient Positioning
Patient Preparation
 Explain procedure thoroughly prior to starting
 Use terms patient can understand
 Encourage patient to ask questions
 Consider cultural and social norms
 Modesty, family presence, another health team member
for escort when necessary
 Encourage patient to verbalize discomfort and adjust as
needed
 Continually reassess patient’s comfort & anxiety
Techniques
 Inspection
 Palpation
 Percussion
 Auscultation
Inspection
 Look, listen openly, and smell
 Guidelines:
 Adequate lighting, preferable direct light source
 Inspect size, shape, color, symmetry, position,
abnormality
 Compare bilaterally
 Validate findings with patient
Palpation
 Using sense of touch to gather information
 Skin: temp, moister, texture, turgor, thickness
 Abdomen: tenderness, distention, masses
 Etc.
 Different parts of your hand can detect different
characteristics
 Maintain dignity of patient
 Always explain before performing
 Palpate tender areas last
Palpation
Palpation
Percussion
 Tapping the skin with the fingertips to vibrate
underlying tissues and organs
 Useful for detecting organ borders, masses, and
determining size
 Mostly used by physicians and advanced practice
nurses
Auscultation
 Listening to body sounds
 Blood, air, gastric, organ motion
Auscultation
 Sound characteristics
 Frequency: sound wave cycles

Higher frequency = higher pitch
 Loudness: amplitude

Range soft to loud
 Quality: sounds of similar frequency

Blowing, gurgling
 Duration: length of time vibrations last

Short, medium, long
General Survey
 General appearance & behavior
 Signs of distress
 Gender & race, age, body type, posture
 Gait, body movement, hygiene/grooming/dress
 Affect & mood, speech
 Signs of abuse (physical, substance)
 Vital signs
 Height & weight
Skin, Hair, Nails
 Skin
 Color
 Moisture
 Temperature
 Texture
 Turgor
 Edema
 Lesions
Skin, Hair, Nails
 Head & Scalp
 Be aware of normal hair distribution
 Assess for hair brittleness, moisture, texture, & alopecia
 Nails
 Can generally reflect general health and self-care
Nail Abnormalities
 Normal
 Clubbing
 Causes: Chronic lack of oxygen:
heart or pulmonary disease
Nail Abnormalities
 Beau’s lines
 Causes: Systemic illness such as severe
infection; nail injury
 Koilonychia (spoon nail)
 Causes: Iron deficiency, syphilis
 Splinter hemorrhages
 Causes: minor trauma, bacteria
Head & Neck
 Head
 Eyes
 Ears
Head & Neck
 Nose & Sinuses
 Mouth & Pharynx
 Neck
Thorax & Lungs
 Symmetry
 Overall shape,
deformities, bony
structures
 Rate & rhythm of
breathing
 Breath sounds
Breath Sounds
Sound
Site
Auscultated
Cause
Character
Are most
common in
dependent
lobes: right and
left lung bases
Random, sudden
reinflation of
groups of alveoli;
disruptive passage
of air through small
airways
Fine crackles are highpitched fine, short;
interrupted crackling
sounds heard during end of
inspiration; usually not
cleared with coughing.
Medium crackles are lower;
moister sounds heard
during middle of
inspiration; not cleared with
coughing.
Coarse crackles are loud,
bubbly sounds heard during
inspiration; not cleared with
coughing.
Breath Sounds
Sound
Site Auscultated
Cause
Character
Are primarily heard
over trachea and
bronchi; if loud
enough, able to be
heard over most lung
fields
Muscular spasm,
fluid, or mucus in
larger airways; new
growth or external
pressure causing
turbulence
Loud, low-pitched,
rumbling coarse
sounds are heard
either during
inspiration or
expiration; sometimes
cleared by coughing.
Heard over all lung
fields
High-velocity airflow
through severely
narrowed or
obstructed airway
High-pitched,
continuous musical
sounds are like a
squeak heard
continuously during
inspiration or
expiration; usually
louder on expiration.
Breath Sounds Audio
 http://www.meddean.luc.edu/lumen/meded/medicin
e/pulmonar/IMAGES/CD-LungSounds/mac/cugell07july11.swf
 http://www.practicalclinicalskills.com/breath-sounds-
reference-guide.aspx
Heart
 Inspection & Palpation
 Auscultation
Heart
Vascular System
 Blood pressure
 Carotid arteries
 Jugular veins
 Peripheral arteries &
veins
 Lymphatic system
Abdomen
 Inspection
 Skin, umbilicus,
contour,
symmetry,
pulsations
 Auscultation
 Bowel motility
 Palpation
Musculoskeletal System
 General Inspection
 Palpation
 ROM
 Muscle tone & strength
Neurological System
 Level of consciousness (LOC)
 Motor function
 Intellectual function
 Mental & emotional status
Completion of Assessment
 Document!
 Return patient to comfortable position
 Bed low, side rails up as necessary
 Call light in reach
 Education
 Hourly rounds
 When you will return
 Does patient have any questions/concerns
NCLEX Review
 The nurse prepares to conduct a general survey on an
adult patient. Which assessment is performed first
while the nurse initiates the nurse-patient
relationship?
 A. Appearance and behavior
 B. Measurement of vital signs
 C. Observing specific body systems
 D. Conducting a detailed health history
NCLEX Review
 On admission, a patient weighs 250 pounds. The
weight is recorded as 256 pounds on the second
inpatient day. The nurse should evaluate the patient
for
 A. Fluid retention.
 B. Fluid loss.
 C. Decreased nutritional reserves.
 D. Anorexia.
NCLEX Review
 The nurse is assessing a patient who returned 3 hours
ago from a cardiac catheterization, during which the
large catheter was inserted into the patient’s femoral
artery in the right groin. Which assessment finding
would require immediate follow-up?
 A. Palpation of a femoral pulse with a heart rate of 76
 B. Auscultation of a heart murmur over the left thorax
 C. Identification of mild bruising at the catheter
insertion site
 D. Palpation of a right dorsalis pedis pulse with strength
of +1
NCLEX Review
 A client who is alert and responsive was admitted
directly from the provider’s office with a diagnosis of
“rule out myocardial infarction.” Of the following
alterations found on the initial assessment, which is of
greatest concern to the nurse?
 A. Supine BP is 150/86
 B. Respirations are 28 and labored
 C. Temperature is 99.8 F
 D. There are infrequent, missed apical beats
Case Study