PHYSICAL HEALTH ASSESSMENT

LEARNING OBJECTIVES
Define physical examination. List three types of physical examination. Discuss preparation of client and environment in physical examination. Explain three methods of examination. Demonstrate the skill used in physical examination. Appropriate the effective communication skills and maintaining privacy in physical examination.

DEFINITION
Is

an examination of the bodily state of the patient by ordinary physical means, such as inspection, palpation, percussion and auscultation. (Barbara F. Weller 2009)

PURPOSES
Obtain baseline data Identified problem

Screen health problem

Confirm & support data

Help establish nursing diagnosis & plan of care

IMPORTANT ASPECTS OF PHYSICAL EXAMINATION

Inform

procedure aspects. Attend patients need prior to procedure. The examination table/ bed must properly situated. Comfort the patient as possible during the examination. Wash your hand Conducted systematically head to toe.

 Continue

speaking to the patient. Establish good patient nurse relationship.

TYPES OF PHYSICAL ASSESSMENT

Comprehensive physical assessment
Complete head to toe Admission (inpatient) Medical check up Initial home visit

Focused physical assessment Ongoing assessment

Urgent situation focus on presenting problems

Performed as needed to update patients status

Inspection

Palpation

METHODS

Auscultation

Percussion

Teach the eye to see, the finger to feel, and the ear to hear.

INSPECTION
Visual examination Sense of sight Deliberate, purposeful, systemic Additionally olfactory and auditory cues are noted To assess: moisture, color, texture, shape, position, size color, symmetrical

AUSCULTATION
Is a process of listening to sounds procedure within the body. Direct- used unaided ear

Indirect- use of stethoscope (bowel sound, heart sound)

PALPATION
Examination of body using sense of touch.

The pads of the fingers used because of their sensitivity. Determine texture, vibration, mobility of organ or mass, distention, pulsation, pain upon pressure.

PERCUSSION
Act of striking part with short, sharp, blow.

Indicates whether tissues is fluid filled, air filled or solid.

PREPERFORMANCE PHASE
Preparing Greet

the environment

- Time, equipment, privacy, room temperature.

and explain the procedure. Instruct to empty the bladder. Positioning the patient Wash hands

PERFORMANCE PHASE

HEAD
Observe the size, shape and contour of the scalp. Observe scalp in several areas by separating the hair at various locations; inquire about any injuries. Note presence of lice, nits, dandruff or lesions. Palpate the head by using pads of fingers over the entire of skull; inquire about tenderness upon doing so. Observe and feel the hair condition.

EYE
Check sclera, conjunctiva, eye lid and eyebrow Press lower eye lid to expose conjunctiva Ask patient to roll the eye or follow directions showed by nurse

NOSE
Inspects for symmetry Inspects for discharge Ask regarding air flow/ breathing pattern Palpate to feel ant tenderness

EARS
Turn patient head to assess the ears Assess for laceration, discharge Check for symmetry

MOUTH
Observe lip condition (dry, moist) Observe for symmetry Open mouth to assess inner part tongue, tonsils, uvula

NECK
Inspected for position symmetry Inspected for obvious lumps visibility of the thyroid gland and jugular venous distension or nodes

CHEST/BREAST/AXILLA Expose chest area/ both breast, checked for symmetry and skin condition, size Cover one side, elevate and place hand of the other side under the head Palpate breast circular motion, outer to inner Palpate axilla for nodes

ABDOMEN
Use finger pads to run along the abdomen Repeat until all area covered Checked condition of skin

UPPER LIMB
Ask patient to move extremities (ROM) Checked for capillary return and digits Checked skin condition

GENITALIA Check for discharge or redness or odor If not permitted to assess ask questions

LOWER ABDOMEN
Ask patient to move extremities (ROM) Checked for capillary return and digits Checked skin condition

BACK
Expose back and observe skin condition Observe for spine condition (spine should be straight, with slightly curvature in the thoracic area)