The nurse uses physical assessment for the following reasons:
- To gather baseline data about the client’s health
- To supplement, confirm or refute data obtained in the nursing history
- To confirm and identify nursing diagnoses
- To make clinical judgments about a client’s changing health status and management
Preparation of Examination
- Environment – A physical examination requires privacy. An examination room that is well equipped for all necessary procedures is preferable
- Equipment – Hand washing is done before equipment preparation and the examination. Hand washing reduces the transmission of microorganisms
- Psychological Preparation – clients are easily embarrassed when forced to answer sensitive questions about bodily functions or when body parts are exposed and examined. The possibility that the examination will find something abnormal also creates anxiety so reduction of this anxiety may be the nurse’s highest priority before the examination
- Physical Preparation – the client’s physical comfort is vital to the success of the examination. Before starting, the nurse asks if the client needs to use the toilet.
- Positioning – during the examination, the nurse asks the clients to assume proper positions so that body parts are accessible and clients stay comfortable. Client’s abilities to assume positions will depend on their physical strength and degree of wellness.
Order of Examination
- General Survey – includes observation of general appearance and behavior, vital signs, height and weight measurement
- Review of systems
- Head to toe examination
Skills in Physical Examination
- Inspection – to detect normal characteristics or significant physical signs. To inspect body parts accurately the nurse observes the following principles:
- Make sure good lighting is available
- Position and expose body parts so that all surface can be viewed
- Inspect each areas fro size, shape, color, symmetry, position and abnormalities
- If possible, compare each area inspected with the same area of the opposite side of the body
- Use additional light (for example, a penlight) to inspect body cavities
- Palpation – the hands can make delicate and sensitive measurements of specific physical signs, so palpation is used to examine all accessible parts of the body. The nurse uses different parts of the hand to detect characteristics such as texture, temperature and the perception of movement.
- Percussion – examination by striking the body’s surface with a finger, vibration and sound are produced. This vibration is transmitted through the body tissues and the character of the sound depends on the density of the underlying tissue
- Auscultation – is listening to sound created in body organs to detect variations from normal. Some sounds can be heard with the unassisted ear, although most sounds can be heard only through a stethoscope.
- Bowel sounds
- Breath sounds:
Examples of Adventitious Breath Sounds
- Crackles (previously called rales)
- Friction rub