PHYSICAL EXAMINATION:

DEFINATION: It is a thorough inspection or detailed study of the entire body or some part of the body to determine the general physical or mental condition of the body. PURPOSES: To determine the physical & mental well-being of the patient. To detect the diseases in its early stages. To determine the cause & extent of the diseases. To understand any changes in the condition of the disease: any improvement / regression. To determine the nature of the treatment or nursing care needed for the patient. To safeguard the family in terms of noting any early signs especially in case of communicable disease. To contribute to the medical research. To find out whether the patient is mentally or physically fit for particular task.

METHODS OF EXAMINATION:

INSPECTION: Visual examination of the body called inspection. It is the observation with the naked eyes to determine the structure & function of the body.

PALPATION: It is feeling of the body or parts with the hand to note the size & position of the organ.in this finger pads or used not the finger tips. Palpate for texture Masses Fluid crepitus

 Assess skin temperature Superficial palpation Deep palpation

PERCUSSION: It is the examination by tapping with the fingers on the body to determine the condition of the internal organ by the sounds that are produced. It is done by placing the finger of the left hand firmly against the part to be examined & tapping with the finger tips of the right hand.

AUSCULTATION: It is the listening to the sounds within the body with the aid of a stethoscope, fetoscope, or directly with the ear placed on the body. Auscultate for intencity Pitch Duration Quality Position stethoscope between index finger & middle finger

MANIPULATION: It is the moving of the part of the body to note its flexibility. Limitation of the movement is discovered by this method.

TESTING OF THE REFLEXES: The response of the tissue to external stimuli is tested by means of percussion hammer, safety pins, wisp of cotton, hot & cold water.

TYPES OF PHYSICAL EXAMINATION:

I.

PERIODIC HEALTH EXAMINATION: It is the health examination done periodically at definate interval to see that the individual is keeping fit. It is the foundation stone for preventive medicine. The more complite the examination, the greater is its value as a preventive measure. It includes the inspection of the entire body . it is also done for the patients as a follow up measure to watch the progress.

II.

PHYSICAL EXAMINATION FOR DIAGNOSTIC PURPOSES: It is the medical examination done by the physician according to the patients symptoms when illness occurs.

ROLE OF THE NURSE IN PHYSICAL EXAMINATION:

A. PREPARATION OF THE ENVIRONMENT: B. PREPARATION OF THE EQUIPMENT C. PREPARATION OF THE PATIENT D. ASSISTANCE WITH THE EXAMINATION

PREPARATION OF THE ENVIRONMENT: MAINTENANCE OF THE PRIVACY: A separate examination room Doors should be closed Draping of the patient according to the parts are exposed

The room should be warm without draughts.

LIGHTING: Provision of natural light source Adequate lighting facility ,maintenance of good ventilation

COMFORTABLE BED OR EXAMINATION TABLE: Place the patient comfortably throughout the procedure. Maintenance of suitable position Special examination table for certain kind of examination.

PREPARATION OF THE EQUIPMENT:

ARTICLES

PURPOSE

PREPARATION OF THE PATIENT: Physical preparation

Keep the patient clean

POSITIONS FOR THE EXAMINATION:

POSITION Sitting

Supine

AREAS ASSESED Head,neck,posterior thorax,lungs,anterior thorax,breast,axillae, heart, vital signs & upper extremities Head, neck, anterior thorax,breast,axillae, heart, abdomen, extremities pulses Head, neck, anterior thorax,breast,axillae, heart, abdomen Female genitalia & genital tract

RATIONALE It provides full expansion of the lungs & provides better visualization of symmetry of upper parts. This is most normally relaxed position provides easy access to pulse sites

LIMITATION Supine position with head & neck elevated

Dorsal recumbent lithotomy

Sims

Rectum & vagina

Prone

Musculoskeletal system

Lateral recumbent Knee-chest

Heart

Rectum

If patient becomes short of breaths easily, examiner may need to raise the head of bed. used for abdominal Patients with painful assessment because it disorders are more provides relaxation of the comfortable with the abdominal muscles. knee flexed. It provides maximum Lithotomy position is exposure of genitalia & embarrassing & facilitates insertion of uncomfortable, so vaginal speculum examiner minimize time that patient spends in it patient is kept well rapped. Flexion of hip & knee Joint deformity may improves the exposure of hinder the patients the rectal area. ability to bend hip & knees. This position is used only This position poorly to assess extension of hip tolerated in patients joint. with respiratory difficulty This position aids in This position poorly detecting murmurs tolerated in patients with respiratory difficulty This position provides This position is maximum exposure of embarrassing & rectal area. uncomfortable.

Shave the part Empty the bladder prior to the examination Empty the bowel by enema , if required Loose the garments & change into the hospital dress, if it is the custom Drape the patient & avoid un necessary exposure.

. Explain the Purpose for the Physical Assessment. The purpose of the nursing assessment is to gather information about the patient's health so that you can plan individualized care for that patient. All other steps in the nursing process depend on the collection of relevant, descriptive data. The data must be factual, not interpretive. Obtain an Informed, Verbal Consent for the Assessment. The chief source of data is usually the patient unless the patient is too ill, too young, or too confused to communicate clearly. Patients often appreciate detailed concern for their problems and may even enjoy the attention they receive. Ensure Confidentiality of All Data. If possible, choose a private place where others cannot overhear or see the patient. Explain what information is needed and how it will be used. It is also important to convey where the data will be recorded and who will see it. In some situations, you should explain to the patient his rights to privileged communication with health care providers.

Mental preparation The patient may be quite new to the hospital situation & he may be Anxious about the illnesses. He may have the false idea about the examination. medical

Explain the sequence of the procedure to allay his anxieties & fear & to gain confidence & co-operation. As far as possible a nurse should remain with a female patient during the physical examination.

ASSISTANCE WITH THE EXAMINATION: To take the height & weight Keep the patient ready for the examination. Stand on the opposite side of the doctor to assist him adjust the position according to the need Handle the equipment as needed. After finishing the examination, keep the patient in comfortable position & replace all articles to its proper place after cleaning them. Send the specimen to the laboratory immediately if any.

NURSING ASSESSMENT: I. INITIATING NURSE PATIENT RELATIONSHIP Introduce yourself

Start with the therapeutic dialogue Meet the patients immediate needs Communicate trust & confidentiality to the patient The final step is enhanced by professionalism & competence conveyed by the nurse THERAPEUTIC DIALOGUE: Good morning MR. ---, I am MS. ---, a student nurse, I will be caring for you today. A portion of my nursing care is to conduct an assessment of you. Your temperature, pulse, blood pressure, heart rate, orientation, lung sounds, abdominal sound, arterial pulses & skin color will be included in my assessment. It will take me 30 minutes. Do you have any question? (Pause). My assessment will help me plan your nursing care. May I begin now?) (Pause) I will start with your vital signs.

II.

THE INTERVIEW:

Conduct in relaxed, unhurried manner, in a quiet, private & well lighted setting. Maintain eye to eye contact with the patient Use non judgmental language NURSING HEALTH HISTORY: o Biographical data: information such as date of birth,sex, address, marital status, religious preference& practice, occupation, o Reasons for seeking health care: chief complaint o Present illness or health concerns: use PQRST LETTERS P: PROACTIVE/PALLIATIVE: what cause it? What cause it better or worse? Q:QUALITY/QUANTITY: R:REGION/RADIATION: S:SEVIARITYSCALE T:TIMING

o Past health history o Family history o Environmental history o Psychosocial /cultural history: patients primary language, cultural group, educational background ,attention span & developmental stage III. PERFORM PHYSICAL ASSEESSMENT:

 Obtain vital signs Measurement of height & weight

Head to toe assessment: Inspect: Hygiene Clothing Body language Body position Skin color Odor Signs of alcohol use Mental status: level of consciousness Response to touch, verbal & painful stimuli Hair & scalp: Hair: Clean, glossy, thick, thin, soft, tengled, dirty, free from pediculi? Scalp: Clean, free from dandruff or any eruption?

 Face: pale, flushed, jaundice, cyanotic, or swollen? Movement of the face normal? Does the face show any fatigue, pain, worry, dissatisfaction, distress or sorrow? Eyes: examination is done in sitting or lying position. Movement of eyes, reaction to light, accommodation to near & far objects, For detail internal examination of eyes ophthalmoscope is used. Check for presence of purulent discharge or watering of eyes Does the patient complain of double vision, photophobia, or loss of vision? Eye brows: normal or absent Eye lashes: infection, sty Conjunctiva: pale, red, purulent Cornea, iris: irregularities, abrasion Pupils: dilated, constricted, reaction to light Lens: opaque,transperant Mouth & throat: Is the breath foul, odourless or alcoholic? Gums: are the gums swollen, inflamed, spongy or ulcerated. Is there any bleeding? Lips: are lips pale, cyanotic, moist, dry, cracked, trembling fissured or swollen? Teeth: are the teeth complete, natural or artificial, free from caries? Are they straight, irregular, protruding? Are they in good condition or loose? Does the patient complain pain? Tongue: is the tongue clean, coated, moist, dry, swollen, fissured, and ulcerated? Throat: is the throat swollen, is there any white patches, ulceration or difficulty in swallowing? Speech: is it normal? is there any hoarseness of voice ? Nose: is there any discharge? if so its nature? Is the nose deformed, any impairment in sense of smell or difficulty in nose breathing? Ears: are they clean? Is there any discharge? Does the patient complains of any pain , impairment of hearing? Neck: is there any swelling, growth, restricted movement? Are the neck veins prominent?

 Chest: any abnormality in size, shape? Pretense of cough, or expectoration, any abnormalities of breathing? Breast: presence of lump, or growth. Nipples normal or inverted in case of females? Abdomen: whether distended, rigid, soft or bulging in certain area? The extremities: appearance of skin (marks, discolouration, shiny) emesis with abdominal disturbances? Appetite good or poor? Is the fluid intake normal? The extremities: are the fingers long, tapering, clubbing. Nails: pale, cyanotic, brittle, broken? Hands: moist, dry, edematous, trembling, any in ability to move, pain in hands & joints? Joints: enlarged, swollen, deformed or tender. Legs: varicose veins, deformities, edema? Feet: deformities, presence of corns, symptoms of circulatory disturbances? Skin: presence of abrasion, ulcers, scratches, wounds, scars, rashes, edema, or pressure sores? Whether warm, dry, hot, cold, clammy? Abnormal color Postures: any unusual postures or attitude of the body should be observed & reported. Discharges & excretion: vaginal discharges-amount, color & consistency. Genitalia: clean rubber gloves, vaginal speculum, a good source of light, & a lubricant are necessary. Abnormality of vulva, vagina, and cervix are detected. Examination of the rectum: Lateral position/ dorsal recumbent position Anus is observed for hemorrhoids, fissures, cracks. If the patient is asked to bear down, as if to defecates, the internal hemorrhoids may become visible. To examine the rectum, a clean glove(a figure cot may be sufficient), proctoscope, Vaseline as lubricant & good source of light are necessary. The rectum is palpated for the presense of masses on the anterior or the posterior wall in female, on the anterior wall of the rectum, the cervix will be palpated. In males, the prostate gland can be palpated. SYSTEM WISE PHYSICAL ASSESSMENT: NEUROLOGICAL ASSESSMENT:

A reflex is an automatic response of the body to a stimulus. Reflexes are tested using a percussion hammer & a pin. Biceps reflex: this is tested with the doctors thumb on the biceps tendon & gently tapping with a percussion hammer. The contraction of the muscle is noted.

Triceps reflex: the patients arm is supported in relaxed position & tapped with a hammer just above olecranon process. Normally the forearm will be straighten.

Patellar reflex: the patient is seated at the edge of the examination table with the legs to dangle(hanging freely). Tap the area just below the patella. Normally the lower leg will kick forward.

Achilles reflex: again in the same position, the foot is supported with one hand & the Achilles tendon is tapped. The normal response is downward jerk of the foot.

Planter reflex(babinski reflex): the sole of the foot is stroked with a sharp instrument such as pin. Normally all toe bend downward (negative babinski). In abnormal response, the toe spread outwards & the big toe moves upwards.

Co-ordition test: this includes finger to nose test, heel to shin test. In finger to nose test, the patient is asked to abduct & extend the arms at shoulder height & rapidly touch the nose alternatively with one index finger, then with h is the other. In abnormal response , the patient will miss the nose

Equilibrium test: abnormalities of gait or posture can be detected by this test. The patient is asked to stand with the eyes open & the feet together. If he does not loose balance or does not fall(with the eye open) the test is repeated with the eyes closed. It is important to help the patient , should he begin to fall.

Test for the sensation: sensation of touch is tested with the wisp of cotton. The patient is asked to close the eyes & to respond whenever the cotton touches the skin. The vibratory sense is tested by tuning fork which is held firmly against bone . sensation of temperature

difference is tested by touching the skin with test tubes filled with hot & cold water . the patient identifies the test tube that feels hot or cold. Muscles strength: muscle strength is tested by asking the patient to move a particular joint & the examiner opposes the motion

Maneuver to assess the muscle strength: MUSCLE GROUP Neck(sternocleido muscle) Shoulder(trapezious) ELBOW: Biceps Triceps HIP: Quadriceps Gastrocnemius MANEUVER Place the hand firmly against clients upper jaw. Ask client to turn head laterally against resistant Place the hand over midline of clients shoulder, exerting firm pressure. Have client raise shoulder against resistance. Pull down on forearm as client attempts to flex arm as clients arm is flexed, apply pressure against forearm. Ask client to straighten arm When client is sitting , apply downward pressure to thigh. Ask client to raise leg up from table Client sits, holding shin of flexed leg. Ask client to straighten leg against resistence.

Respiratory system:

Thoracic palpation: Palpate for tenderness, masses, lesion, and respiratory excursion Respiratory excursion: it gives significant information about thoracic movement during breathing. The nurse assess for the range & symmetry of excursion.

The patient is instructed to inhale deeply while the movement of the nurses thumbs during the inspiration & expiration is observed. This movement is normally symmetric. Posterior assessment is performed by placing the thumb adjacent to the spinal column at the level of tenth rib. The hands lightly grasp the lateral rib cage. Sliding the thumb medially about 2.5 cm raises the small skin fold between the thumb. The patient is instructed to take a full inspiration & to exhale fully. The nurse observes for normal flattening of the skin folds & feels the symmetric movement of thorax. Thoracic percussion: It usually begins with the posterior thorax. With the patient in a sitting position, symmetric areas of the lungs are percussed at 5 cm intervals. This progression starts at the apex of each lungs & concludes with percussion of each lateral chest wall. Thoracic auscultation: the sequence of auscultation & position of the patient are similar to those used for the percussion. It is necessary to listen to two full inspiration & expiration at each anatomic location for valid interpretation of sound heard.

CARDIO VASCULAR SYSTEM:

The heart is examined indirectly by inspection, palpation, & auscultation of chest wall. For most of examination, the patient lies supine , with the head slightly elevated.the apical impulse normally is located at the fifth intercostals space to the left of the sternum at the mid clavicular line. The nurse locates the impulse with the palm of the hand & palpates with the finger pads. Chest percussion: Normally the left boarder of the heart can be detected by percussion. It extends from the sternum to the mid clavicular line in the third to fifth intercostals spaces

Cardiac auscultation: Auscultation of below areas to be carried out: 1. Aortic area: second intercostals space to the right of the sternum 2. Pulmonic area: second intercostals space to the left of the sternum 3. Erbs point: third intercostals space to left of the sternum 4. Tricuspid area: fourth or fifth inercostal space to the left of the sternum 5. Apical area: point of maximum impulse 6. Inspection of the extremities:the hands ,arms, legs & feet are observed for skin & vascular changes Check for capillary refill time: it is performed by pressing firmly for 5 seconds on the finger nail & estimating the speed at which the blood returns.it should take less than 3 seconds. Check for peripheral edema: it is assessed by pressing firmly for 5 seconds with the thumb over the dorsum of the each medial malleolus Clubbing of fingers & toes: Palpation of arterial pulses:

Gastrointestinal system:

Inspection: the patient lies supine with the knees flexed . The nurse should performs auscultation before percussion & palpation(which can increase intestinal motility).the nurse should assess the bowel sound in all four quadrant using the diaphragm of the stethoscope. It is important to document the frequency of the sound Normal: sound heard every s-20 seconds Hypoactive:one or two sounds in two minutes Hyperactive: 5-6 sound heard in less than 30 seconds After auscultation , the nurse can then palpate the underlying structures.both light & deep palpation are used. Beginning with light palpation, the nurse notes the texture, temperature & moisture of the skin in all regions. The hand should be warm & conversation can be used to distract the patient. Light palpation can detect superficial lession just below the skin.deep palaption is used to detect tenderness or masses of the abdomen. The examiner places one hand under the lower rib cage & press dounwrds with light pressure with the other hand.

Percussion is used on the abdomen to note the density of underlying tissue. It is also used to locate the margins of internal organs. The abdomen has a tympanic (drum like)sound,with dullness noted over the liver. A hallow sound heard over the stomach or intestine indicate flatus. Inspection of anal & perineal area.

Genito-Urinary system: Palpating the right kidney: Place the one hand under the lower rib . place the palm of the other hand anterior to the kidney with fingers above the umblicus.push the hand on top forward as the patient inhales deeply . the left kidney is palpated similarly by reaching over to the patients left side & placing the right hand beneath the patients lower left rib. Percussion: the bladder should be percussed after the patient voids to check for the residual urine.percussion of the bladder begins at the midline just above the umblicus & proceeds down wards The inguinal area is examined for enlarged node. In women the vulva, urethral meatus ,& vagina are examined Valsalva maneuver: to assess the urethral system of muscular & ligament support. Patient is assesssd for edema & weight gain. Nurses do not perform the vaginal examination with a speculum . when inspecting the genitalia on both male & female , the nurse can palpate the femoral artery in that area.

Intengumentary system: Skin condition, Color, Temperature, Turgor, Skin impairments

IV.

Documenting the interview & assessment:

Once a physical examination has been completed, the person being examined and the examiner should review what laboratory tests have been ordered, why they have been selected, and how and with whom the results will be shared. A health professional should discuss any recommendations for treatment and follow-up visits. Special instructions should be put in writing. This is also an opportunity for persons to ask any remaining questions about their own health concerns.