Complete Physical Exam
Clinical Setting
n Cleanliness
n Safety – standard precautions, transmission based precautions
n Warm, quiet, private environment
n Good lighting
n Equipment ready
n Explain what you are doing
n Make slow movements
n Organize steps of assessment to prevent unnecessary position changes
General Survey
n Physical appearance
¨ Age
¨ Sex – appropriate development for age and sex
¨ LOC
¨ Skin – color, texture, intact
¨ Facial features – symmetry
n Body Structure
¨ Stature – gigantism, acromegaly, dwarfism
¨ Nutrition – obesity, anorexia
¨ Symmetry
¨ Posture – scoliosis, lordosis, kyphosis
¨ Position – tripod
¨ Body build – arm length compared to height (Marfan’s syndrome – inherited connective tissue disorder)
General Survey
n Mobility
¨Gait – shuffling, limping
¨ROM – paralysis, jerky and uncoordinated
n Behavior
¨Facial expression – eye contact
¨Mood and affect – appropriate emotions
¨Speech – articulation
¨Clothing
¨Personal hygiene
Measurements and Vital Signs
n Weight and Height
¨ Developmental considerations
n Vital signs
¨ Temp
n Thermometer types
¨ Mercury
¨ Electronic
¨ TMT – tympanic membrane thermometer
n Routes (must be recorded, why?)
¨ Oral
¨ Axillary – add 0.5 C (0.9 F) to reading if don’t record route
¨ Rectal
¨ Tympanic
n Other variations
¨ diurnal cycle – higher temp in the evening 1 to 1.5 C
¨ menstrual cycle – increases temp immediately after ovulation
¨ exercise
¨ age
Vital Signs
n Pulse – normal varies with age
¨ Sites
n Radial
n Carotid
n Dorsal pedal
n Posterior tibial
¨ Rate
n Tachycardia
n Bradycardia – when is it normal?
¨ Rhythm
n Arrhythmias – when is it normal?
¨ Force
n Range from 0 to +3
¨ 0 = absent
¨ +1 = weak, thready
¨ +2 = normal
¨ +3 = bounding
¨ Elasticity
n Respirations
¨ Also vary with age
¨ 10-20 resp/min in adults
Assessing the Pulse
n Pulse is the pressure felt in the periphery with each heartbeat.
¨ Palpating the radial pulse
n Use pads of your first three fingers and palpate along the flexor side (anterior) along the radial bone (lateral)
n Press down until a pulsation is felt
n Count pulsations for 30 seconds and multiply by 2 if the rhythm is regular. Count for full 60 seconds if the rhythm is irregular
n Blood pressure
¨ Review of physiology
n Systolic/Diastolic
¨ Systolic – Maximum pressure felt on the artery during left ventricular contraction
¨ Diastolic – Resting pressure that the blood exerts constantly between each contraction
n Pulse pressure
¨ Reflects stroke volume – the amount of blood pumped with every beat
¨ (SP-DP)
n MAP – mean arterial pressure
¨ Average arterial pressure during a single cardiac cycle
¨ Perfusion pressure by organs in the body
¨ (DP + 1/3 PP). Should be greater than 60
How to take BP
• Make sure the person is sitting or lying with palms turned up and the brachial artery at level of heart
• Center cuff above the brachial artery. Wrap the deflated cuff evenly and snugly around the upper arm
• Palpate the brachial a. with fingertips and inflate the cuff 20 to 30 mm Hg above the point where the pulse disappears
• Deflate the cuff and wait 30 sec. Place stethoscope over brachial pulse
• Close the valve on the pressure bulb and inflate the cuff to 30 mm Hg above the palpated systolic pressure. Slowly release the valve and allow the mercury to fall at 2 to 3 mm Hg per second
• Note the manometer pressure reading when the first clear sound (first Korotkoff sound) is heard. This is the SYSTOLIC pressure.
• Continue to deflate the cuff, noting the point at which the sound disappears. This is the DIASTOLIC pressure
• Deflate cuff and remove from arm
Common Errors in BP Measurement
n Anxiety (from patient)
n Arm position
n Leg position
n Inaccurate cuff size
¨ In general, a cuff 20% wider than the diameter of the limb must be used in order to obtain correct BP
¨ If the cuff is too narrow, both systolic and diastolic pressures will be falsely high and vice versa
n Pushing stethoscope too hard
n Deflating cuff too slowly or quickly
¨ Too slowly produces venous congestion, which decreases amplitude of Korotkoff sounds
Abnormalities in Blood Pressure
n Hypotension
¨ Less than 95/60
¨ Occurs with acute MI, shock, hemorrhage, vasodilation
¨ Due to:
n ↓ cardiac output
n ↓ total blood volume
n ↓ peripheral vascular resistance
Abnormalities in Blood pressure
n Hypertension
¨ Primary (Essential) HTN
n Has no identifiable cause
¨ Secondary HTN
n Brought on by identifiable causes
n Might actually be cured
Developmental considerations
n Head circumference – up to 6 years
n Vital signs
¨ Infants
n Measure respiration, pulse, then temp.
n Inguinal temp most accurate
n Apical pulse rate most accurate and should be used until 2 years
n Respirations should be monitored by observing abdomen
n Pulse and respirations should be monitored for 1 full minute
¨ Preschoolers
n Try to avoid invasive procedures. Avoid rectal route for temp.
n NCLEX hint: explain procedure and encourage handling of equipment
Developmental Considerations
n The Aging Adult
¨ Posture – general flexion, kyphosis
¨ Weight – deposition of fat on abdomen and hips
¨ Height – shorter due to shortening of spinal column
¨ Temperature – decrease in regulatory mechanisms. Tend to have lower normal temp.
¨ Pulse – rhythm may be irregular. Easier to palpate due to arteriosclerosis.
¨ BP – increase in both systolic and diastolic pressures
Assessment Techniques
• Inspection
¨ To examine critically
¨ Begins immediately after entering the room
¨ Neuromuscular status, mental and emotional status
• Palpation
¨ Use systematic, gentle approach. Warm your hands
¨ Palpate tender areas last
¨ Always start with light palpation before moving to deep palpation
¨ Different parts of hands used to assess different factors:
n Fingertips – Skin texture, swelling, pulsation, lumps or masses, moisture, organ location, tenderness or pain
n Grasping with finger and thumb – to detect position, shape, and consistency of mass
n Dorsa of hands and fingers – temperature since skin is thinner
n Base of fingers or ulnar surface of hands – best for vibration
• Percussion (if needed)
¨ Tapping a person’s skin with short, sharp strokes to assess underlying structures
¨ The vibration and characteristic sound depicts location, size, and density of underlying organ
¨ Done to evaluate the size, borders, and consistency of some internal organs, to detect tenderness, and to determine extent of fluid
¨ Direct – striking the body directly (sinuses)
¨ Indirect – striking the stationary hand (interphalangeal joint) with the middle finger of the striking hand
¨ The resulting sounds vary due to the density of tissues.
¨ The denser the tissue, the quieter the percussion
• Auscultation
¨ Listening to sounds produced by body
¨ Using a stethoscope to eliminate and amplify sounds
Percussion Notes
Other Assessment Tools
n Invasive arterial pressure monitoring
¨ Insertion of a catheter into an artery – most accurate technique of pressure monitoring
¨ Disadvantage – infection, invasive
n Central venous pressure
¨ A catheter inserted by physician into the right atrium measures adequacy of venous return and cardiac filling
¨ Normal 7-12 mm H2O
¨ Elevated CVPs may indicate right ventricular failure
¨ Low CVPs may indicate hypovolemia
Preparing for the Health Assessment
§ Environment
• Ensure privacy
• Quiet, warm room
• Special needs of the client
• Surface for placement of equipment
§ Equipment
• Maintenance
• Isolation precautions
• Adequate number of gloves
§ Positioning
• Ensures accessibility to the body part being assessed.
§ Draping
• Prevents chilling.
• Prevents unnecessary exposure.
Conducting the Health and Physical Assessment
§ Aimed at establishing a data base against which subsequent data can be compared.
• Comprehensive Assessment (head to toe)
• Assessment of a body part (focused)
• Assessment of a body system (focused)
§ Conducted in an aseptic, systematic, and efficient manner.
§ Requires the fewest position changes for the client.
General Survey
§ Initial Observations
• Client’s physical appearance
• Mood and behavior
• Speech patterns and voice intonations
• Signs and symptoms of distress
• Vital signs
• Height and weight
§ Special Considerations
• Elderly clients
• Disabled clients
• Abused clients
Measurement of Height and Weight
§ Height
• Height is expressed in inches (in), feet (ft), centimeters (cm), or meters (m).
• A scale for measuring height is usually attached to a standing weight scale.
• Infant’s length is measured from vertex (top) of head to soles of feet while infant is lying with knees extended.
§ Weight
• Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg).
• Daily weights should be obtained at the same time of the day, on the same scale, with the client wearing the same type of clothing.
§ Weight
• Types of scales available include chair, stretcher, bed, and platform scales.
• Infants are weighed on platform or cradle scales.
§ Nursing Considerations
• Accurate recordings are necessary for drug dosage calculations and evaluation of effectiveness of drug, fluid, and nutritional therapy.
§ Documentation
• Height and weight are recorded on the admission assessment form.
• Daily weights are usually recorded on the vital signs record.
• Measurements taken at different times or on different scales should be recorded.
Vital Signs
§ The taking of vital signs refers to measurement of the client’s body temperature (T), pulse (P) rate, respiratory (R) rate, and blood pressure (BP).
§ Vital signs are the first step in the physical examination.
§ Assessment of vital signs provides specific data regarding the client’s current condition.
§ Variations from baseline values may indicate potential problems with the client’s health status.
§ The sequence for recording vital sign measurements in the nurses’ notes is T-P-R and BP.
§ Vital signs are plotted on graphic forms that facilitate data comparison at a glance.
Thermoregulation
§ The body’s physiological function of heat regulation to maintain a constant internal body temperature
Physiologic Function
• The heat of the body is measured in units called degrees.
• The core internal temperature of 98.6 degrees Fahrenheit (F) does not vary more than 1.4 degrees F.
• Core internal temperature is higher than the skin and external temperature.
§ Heat Production
• Basal Metabolic Rate (BMR)
• Vasodilation
• Vasoconstriction
• Piloerection
§ Heat Loss
• Radiation
• Conduction
• Convection
• Evaporation
§ Insensible Heat Loss
§ Behavioral Control of Body Temperature
• The person makes appropriate environmental adjustments in response to the body’s signaling conditions of either being overheated or too cold.
Respiration
§ Respiration is the act of breathing.
§ Terms related to respiratory function are:
• External respiration
• Internal respiration
• Inspiration
• Expiration
• Vital capacity
§ Major physiological pulmonary functions are:
• Ventilation
• Circulation
• Diffusion
• Transport
• Regulation
Hemodynamic Regulation
§ The circulatory system transports nutrients to the tissues, removes waste products, and carries hormones from one part of the body to another.
§ Systemic Circulation
• Arteries
• Arterioles
• Capillaries
• Veins
• Venules
§ Cardiac Cycle
• Systole
• Diastole
§ Stroke Volume
§ Cardiac Output
§ Compensatory Mechanisms
§ Pulse
• The pulse is caused by the stroke volume ejection and distension of the walls of the aorta.
• The bounding of blood flow in an artery is palpable at various points in the body (pulse points).
§ Blood Pressure
• Measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole
§ Systolic Pressure
• Maximum pressure exerted against arterial walls during systole
§ Diastolic Pressure
• Pressure remaining in the arterial system during diastole
§ Hemodynamic regulators for blood pressure control are:
• Blood volume
• Cardiac output
• Peripheral vascular resistance
• Viscosity
Factors Influencing Vital Signs
§ Age
§ Gender
§ Heredity
§ Race
§ Lifestyle
§ Environment
§ Medications
§ Pain
§ Exercise
§ Anxiety and Stress
§ Postural Changes
§ Diurnal (daily) Variations
Assessing Body Temperature
§ Temperature Scales
• Centigrade or Fahrenheit scales are used to measure temperature.
• Glass or electronic thermometers are used.
§ Temperature Sites
• Oral
• Rectal
• Axillary
• Rectally
§ Alterations in Body Temperature
• Pyrexia
• Hyperthermia
• Heat Exhaustion
• Heat Stroke
• Hypothermia
• Frostbite
Assessing Pulse
§ Sites
• The most accessible peripheral sites are the radial and carotid sites.
• The carotid site should always be used to assess the pulse in a cardiac emergency.
§ A peripheral pulse is palpated by placing the first two fingers on the pulse point with moderate pressure.
§ A Doppler ultrasound stethoscope is used on superficial pulse points.
§ A stethoscope is used to auscultate the heart’s rate and rhythm.
§ A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate.
§ Pulse Characteristics
• Pulse quality
• Pulse rate (bradycardia, tachycardia)
• Pulse rhythm (dysrhythmias)
• Pulse volume
§ Nursing Considerations
• An irregular pulse rate, if not previously documented, should be reported immediately.
• Clients on certain cardiac medications may need to monitor their pulse rate.
• Routine exercise lowers resting and activity pulses.
Assessing Respirations
§ Sites
• Observation of chest wall expansion and bilateral symmetrical movement of the thorax
• Placement of back of hand next to client’s nose and mouth to feel expired air
Assessing Respirations
§ Rate is counted by number of breaths taken per minute.
§ Observation of thoracic and abdominal movements includes:
• Depth, rhythm, and symmetry
• Costal (thoracic) breathing
• Diaphragmatic breathing
§ A stethoscope is used to auscultate breath sounds throughout the respiratory system.
Assessing Respirations
§ Dyspnea,
§ Bradypnea, tachypnea, apnea
§ Hypoventilation
§ Hyperventilation
Assessing Respiratory Function
§ Cyanosis
• Bluish appearance in the nail beds, lips, and skin
• Reduced oxygen levels in the arterial blood
§ Clients with respiratory alterations require additional nursing assessment.
• Pulse oximetry
• Apnea monitor
Assessing Blood Pressure
§ The direct method of measuring blood pressure requires an invasive procedure.
§ The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed.
§ The most common site for indirect measurement is the client’s arm over the brachial artery.
§ Accurate measurement requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity.
§ Korotkoff sounds are five distinct phases of sound heard with a stethoscope during auscultation.
§ The forearm or leg sites can be palpated to obtain a systolic reading when the brachial artery is inaccessible.
Assessing Blood Pressure
§ Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure.
§ Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg.
Assessing Blood Pressure
§ Orthostatic Hypotension (postural hypotension)
• Sudden drop in systolic pressure when client moves from a lying to a sitting to a standing position
§ False Readings
• Clients who have recently eaten, ambulated, or experienced an emotional upset
• Improper cuff width
• Improper technique in deflating cuff
• Improper positioning of extremity
• Failure to recognize an auscultatory gap
The Physical Examination
§ Techniques
• Inspection
• Palpation
• Percussion
• Auscultation
Integumentary System
§ Skin
§ Hair and Scalp
§ Nails
Skin Assessment
§ Skin assessment provides a noninvasive window to observe the body’s physiological functions.
Skin Assessment
§ Color
§ Lesions
§ Moisture
§ Temperature
§ Texture
§ Mobility and Turgor
§ Edema
§ Hair
• The amount and texture of hair vary with age, sex, race and body part.
• Vellus
• Terminal hair
§ The scalp should be smooth, clean, intact, and free of lumps or tender areas.
§ Nails
• Clubbing
• Koilonychia (spoon nail)
• Beau’s line
• Paronchia
Physical Examination
§ Head
• Skull and face assessment involves inspection and palpation.
• The client’s face has its own unique characteristics related to race, state of health, emotions, environment.
Physical Assessment
§ Eyes
• Conjunctive and sclera are assessed for color, redness, swelling, exudate, foreign bodies
• Visual acuity
• Fundoscopy
§ Ears
• Auditory screening
• Inspection and palpation of external ear
• Placement, symmetry
• Otoscopic assessment
§ Nose and Sinuses
• Inspection and palpation
• Use of a penlight
§ Mouth and Pharynx
• Breath
• Lips
• Tongue
• Buccal mucosa
• Gums and teeth
• Hard and soft palate
• Pharynx
§ Neck
• Neck muscles
• Lymph nodes of head and neck
• Thyroid gland
• Trachea
§ Thorax and Lungs
• Landmarks for inspection, auscultation, and percussion
• Anterior and posterior examination
• Shape and symmetry
• Thoracic expansion
• Tactile fremitus
§ Auscultation of Normal Breath Sounds
• Vesicular sounds
• Bronchovesicular sounds
• Bronchial sounds
§ Auscultation of Adventitious Breath Sounds
• Crackles
• Rhonchi
• Wheezes
• Pleural friction rub
• Stridor
Heart and Vascular System
§ Heart
• Landmarks for inspection, palpation, auscultation
• Heart sounds
• Palpation for thrills and heaves
• Abnormal auscultatory findings
– Murmurs
– Bruits
§ Vascular System
• Blood perfusion of peripheral vessels
– Peripheral pulses compared bilaterally
– Skin temperature, color
§ Lymphatic System
• Lymphatic drainage
• Lymph nodes
Breasts and Axillae
§ Palpation of four quadrants of breasts
§ Palpation of supraclavicular, infraclavicular, and axillary nodes
§ Education and encouragement of questions about breast self-examination (BSE)
§ Breast cancer can also occur in males.
§ Drainage patterns of the left breast.
Abdomen
§ Inspection
• Contour
• Symmetry
• Umbilicus
• Surface motion
• Scars
§ Auscultation
• All four quadrants in a systematic fashion
• Beginning with the RLQ
– Tympany
– Dullness
– Bruits
– Hyperactive or hypoactive bowel sounds
Abdominal Quadrants
§ Light palpation in all four quadrants beginning with the RLQ
• Resistance
• Tenderness
• Rebound tenderness
• Organ enlargement
Female Genitalia and Anus
§ Cultural Considerations
§ Inspection and Palpation
• Mons pubis and vulva
• Labia majora, labia minora
• Clitoris
• Urethral meatus and vaginal introitus
• Perineum and anus
Male Genitalia, Anus, and Rectum
§ Testes and male gonads
§ Seminal vesicles and bulbourethral glands
§ Epididymis, vas deferens, ejaculatory ducts
§ Scrotum, penis, spermatic cord
§ Anorectral exam including the prostate
§ Monthly testicular self-examination (TSE)
Musculoskeletal System
§ Inspection
§ Palpation
§ Range of Motion (ROM)
§ Bilateral Comparison
§ Muscle
• Hypertrophy
• Atrophy
• Hypertonicity
• Hypotonicity
§ Joints
• Arthritis
• Osteoarthritis
• Crepitus
Neurologic System
§ Mental Status
• Physical appearance and behavior
• Communication
• Level of consciousness
Mental Status
§ Cognitive Abilities and Mentation
• Attention
• Memory
• Judgment, insight
• Spatial perception
• Calculation
• Abstraction
• Thought process and content
Neurological Assessment
§ Sensory Assessment
• Exteroceptive sensations
• Proprioceptive sensations
• Cortical sensations
• Dermatome map
§ Cranial Nerves Assessment
§ Motor Assessment
§ Cerebellar Assessment
§ Reflex Assessment
