An Overview
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Part of a general health assessment
Used to gather data about the client
Focuses on functional abilities and responses
to illness/stressor
The nurse performs a physical examination to:
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Establish baseline data
Identify nursing diagnoses, collaborative
problems, or wellness diagnoses
Monitor the status of an identified problem
Screen for health problems
Comprehensive:
 Interview plus complete head-to-toe
examination
Focused:
 “Focused” on presenting problem
Ongoing:
 Performed as needed to assess status
 Evaluates client outcomes
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Head-to-toe
◦ Starts at the head
◦ Progresses “down” the body
◦ System-related data found throughout:
• Heart sounds - chest
• Pulses - periphery
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Body systems
◦ Gathers system-related data all at once
◦ May be done in a predetermined order that mimics
head-to-toe:
• Neurological
• Cardiovascular
• Respiratory
• Gastrointestinal
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Theoretical
knowledge
• A and P, techniques
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Self-knowledge
• Skill and comfort level
• Willingness to seek
help
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Knowledge about
client situation
• Purpose of
examination
• Client diagnosis
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Privacy is key
• Draping
• Use of curtains
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Noise control
• TV/radio off
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Enable visualization
• Adequate lighting
• Flashlight if needed
Promote client comfort:
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Develop rapport
Explain the procedure
Respect cultural differences
Use proper positioning
Four major skills used:
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Inspection
Palpation
Percussion
Auscultation
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Use of sight to gather data
Used throughout physical examination
Tools to enhance inspection
• Otoscope
• Ophthalmoscope
• Penlight
Examples: Skin color, gait, general appearance,
behavior
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Use of touch to gather data
Begin with light pressure, moving to deep
palpation
Use caution with deep palpation
Parts of the hands used:
• Fingertips: Tactile discrimination
• Dorsum: Temperature determination
• Palm: General area of pulsation
• Grasping (fingers and thumb): Mass evaluation
Examples: Edema, moisture, anatomical
landmarks, masses
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Tapping on skin to elicit sound
• Direct
• Indirect
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Useful for assessing abdomen, lungs,
underlying structures
Examples: Distended bladder
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Use of hearing to gather assessment data
Direct auscultation:
• Listening without an instrument
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Indirect auscultation:
• Use of a stethoscope to listen
 Diaphragm - high-pitched sounds
 Bell – low-pitched sounds
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Examples: Heart sounds, lung sounds
Infants:
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Parents hold
Attend to safety
Toddlers:
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Allow to explore
and/or sit on parent’s
lap
Invasive procedure last
Offer choices
Use praise
Preschoolers:
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Use doll for
demonstration
Still may want parental
contact
Allow child to help with
examination
School-Aged Children:
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Show approval and
develop rapport
Allow independence
Teach about workings
of the body
Adolescents:
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Provide privacy
Concerned that they
are “normal”
Use examination to
teach healthy lifestyle
Screen for suicide risk
Young/ Middle Adults:
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Modify in presence of
acute or chronic illness
Older Adults:
 May need special positioning related to mobility
 Adapt examination to vision and hearing
changes
 Assess for change in physical ability
 Assess for ability to perform activities of daily
living
 Provide periods of rest as needed
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Begins at first contact
Overall impression of client
Deviations lead to focused assessments
• Appearance/behavior
• Grooming/hygiene
• Body type/posture
• Mental state
• Speech
• Vital signs
• Height/weight
Integumentary:
 Skin characteristics
• Color
• Temperature
• Moisture
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Lesions
Hair
Nails
• Texture
• Turgor
Head:
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Skull and Face
• Size
• Shape
• Facial features
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Eyes
• External eye
• Sclera
• Pupils
• Visual acuity
• Vision examinations
 Acuity, distance, near,
color, visual fields
• Internal structures
Head:
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Ears/hearing
• External ear
• Inner ear
 Tympanic membrane
• Hearing
 Weber’s test
 Rinne’s test
• Balance
 Romberg’s test
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Nose
• Smell
Mouth
• Lips
• Buccal mucosa
• Teeth
• Hard and soft palates
Neck:
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Musculature
Trachea
Thyroid gland
Cervical lymph
nodes
Breasts:
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Size
Shape
Nipple characteristics
Tissue
Include axillae
Chest and Lungs:
 Describe size and shape of chest
 Relate findings to landmarks
Breath Sounds:
 Bronchial
 Bronchovesicular
 Vesicular
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Adventitious
Diminished or
misplaced
Abnormal vocal sounds
Cardiovascular–
Heart:
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Inspection
• PMI
• Heaves/Lifts
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Palpation
• Thrill
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Heart sounds
Location:
• Aortic, Pulmonic,
Tricuspid, Mitral
Components:
• S1, S2, S3, S4
Murmurs
Cardiovascular–
Vessels:
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Central vessels
• Carotid arteries
 Palpate pulsation
* Special precautions
 Auscultate for bruit
• Jugular veins
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Peripheral vessels
• Blood pressure
• Peripheral pulses
• Signs of inadequate
oxygenation
• Varicosities
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Different order for assessment skills
• Inspect
• Auscultate
• Percuss
• Palpate
Body shape/symmetry:
Joint mobility:
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Posture
Gait
Spinal curvature
Balance:
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Romberg’s test
Coordination:
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Finger-thumb opposition
Movement
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Color change
Deformity
Crepitus
Muscle strength:
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Range of motion
Resistance
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Staff RN Uses Focused Neuro Assessment:
Cerebral Functioning:
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Level of consciousness
• Arousal - response to stimuli
• Orientation - time, place, person
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Mental status/cognitive function
• Behavior, appearance, response to stimuli, speech,
memory, communication, judgment
Reflexes:
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Automatic responses
Responses on a graded
scale
• 0 = No response
• 4 = Clonus
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Example: deep tendon
reflexes
Motor/Cerebellar
Function:
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Movement/coordination
Tone
Posture
Equilibrium
Proprioception
Sensory Function:
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Light touch
Light pain
Temperature
Vibration
Position
Sense
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Stereognosis
Graphesthesia
Two-point
discrimination
Point localization
Extinction
Male:
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Includes reproductive information
External genitalia: penis, urethral opening,
scrotum, lymph nodes, pubic hair
Examine for the presence of a hernia
Female:
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Female external genitalia: labia, clitoris, urethral
opening, vaginal orifice, pubic hair, lymph nodes
Other:
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Kidneys (CVA tenderness)
Bladder (palpation of the abdomen)
NP/MD responsible for anus, rectum, prostate
examination
NP/MD responsible for pelvic examination