Introduction to the

Physical
Assessment

Madeline Gervase
MSN,CCRN,FNP,RN
Assessment
 Systematic & continuous
collection, validation, and
communication of client data
 Nursing process
 Initial and ongoing
 Medical vs Nursing
 Essential components
Purposes of Assessment
 Obtain Baseline Date regarding functional
abilities
 Supplement, confirm, or refute date
obtained in nursing history
 Obtain data that helps establish nursing
diagnoses and plan care
 Evaluate physiologic outcomes of health
care and thus client progress
 Screen for presence of risk factors
Types of Assessment

 Initial
 Focused
 Emergency
 Ongoing
Types of Data
 Objective Data  Subjective Data
 “signs”  “symptoms”
 info perceived by  info perceived
the senses only by affected
person
 Ex: feeling
 Ex: T 101, moist
skin nervous, tired
Characteristics of Data
 Complete

 Factual
&
Accurate

 Relevant
Problems r/t Data Collection
 Organization
 Omission
 Irrelevant or
Duplicate Data
 Misinterpretatio
n
 Too little data
 Documentation
Why is a health history
taken?
 Patterns of
wellness/illness
 Physical &
Behavioral risk
factors
 Deviations from
norm
 Nurse as a
resource
Functional Health Patterns
 Health Perception/  Sensory-Perceptual
Management  Cognitive
 Nutritional-Metabolic  Role-Relationship
 Elimination  Coping-Stress
 Activity-Exercise Tolerance
 Sexuality-  Value-Belief
Reproduction
 Sleep-Rest
Nursing Health History
 Chief Complaint  Past Medical History
 Present Problem  Family History
 Usual health status  Personal & Social
 Chronological story History
 Impact on functioning  Review of Systems or
 Medications
Functional Patterns
Client Profile – UK Clinical
Setting
 Biographical Data  Current Treatments
 Chief Complaint  Past Illnesses or Past
 History of Present Hospitalizations
Illness  Allergies
 Current Medications
General Survey – Clinical
Setting
 Age/Sex/Race  Speech
 Mental Status  Use of language
 Thought Process
 Behavior
 Reliability as historian
 Mood
 Height/Weight
 Appearance
 Vital Signs
 Body Type
 Posture
 Body Mechanics
Explanation- Affect/Mood
 Affect – observable behaviors which
indicate the feelings or emotional status of
the client.

 Mood – term which refers to the client’s

emotional state as described by the client.
Documentation Terms
 Affect  Mood
 Broad  Appropriate
 Restricted  Inappropriate
 Blunted  Depressed
 Flat  Anxiety
 Labile  Agitated
 Elated
 Manic
 Euphoric
 Euthymic (normal)
 irritable
General Principles - History
 Explain purpose
 Communication techniques
 Utilization of data sources
 Document
 Avoid interruptions or tiring the
client
 Consider client’s developmental
level
Developmental Principles
 Pediatric  Geriatric
 Parent/child  Do not
interactions stereotype
 Integrate child  Assess and
 Respect accommodate:
adolescent, give
choices  sensory &
physical
functioning
Psychosocial Considerations
- History
 Avoid stereotypes
 Healthcare beliefs
 Language differences
 Eye contact
 Non-judgmental
 Stressors/Coping Mechanisms
Cultural Awareness
Considerations
 Time Orientation
 Activity Orientation
 Human Nature Orientation
 Human-Nature Orientation
 Relational Orientation

 Seidel, 2003, pp. 43.

History - Biographical Data
 Name  Birthplace, date
 Race  Address
 Age  Source of medical
 Gender care
 Marital status  Insurance
coverage
Past Health
 Previous hosp. &
History
surgeries
 Allergies
 Illnesses &
Accidents
 Immunizations
 Medications
 Habits/Lifestyle
 ADLs
Client’s Family History
 Blood relatives

 Significant others

 Health history

 Family as resource

 Stressors in family
Present Illness/Health
Concerns
 Onset
 Duration
 Location, quality, and intensity
 Precipitating factors
 Relief factors
 Client’s expectations
 Subjective and Objective data
PQRST – Characterize
Symptoms
 Precipitating factors
 Quality
 Radiation
 Severity
 Temporal Factors
OLD CARTS –
 Onset
 Location
 Duration
 Character
 Aggravating factors
 Relieving factors
 Temporal factors
 Severity
Reasons for Seeking
Healthcare
 Chief complaint
 Why?
 Quotes
 Specify
 Clarify
Resources
 Home and outside environment
 Community resources
 Financial
 Family & significant others
 Consider Basic Human Needs
Medical Diagnostic Data
 Medical vs
Nursing
Diagnosis
 Nursing
Implications r/t
Medical
Diagnosis
Contributions of Lab Data
 Verifies data
 Provides baseline
information
 Evaluates
outcomes
 Identifies problems
missed in history
and assessment
Count
(CBC)
 Analysisof peripheral venous
blood specimen
 Main components:
 RBC = red blood cell count
(erythrocytes)
 WBC = white blood cell count
(leukocytes)
 Hgb = hemoglobin
 Hct = hematocrit
Test: Urinalysis (UA)
 Analysis of a urine
specimen
 Screens for:
 urinary infection
 renal disease
 diabetes mellitus
Urinalysis
 Main components
 pH- 4.6 - 8.0
 Protein- up to 10mg/100ml
 Specific gravity-1.003 - 1.030
 Glucose- negative
 Ketones- negative
 Blood- up to 2 RBCs
Test: Electrolytes (lytes, e-)
 Inorganic
substances in the
body that conduct
electrical current
 Usage:
 Assess fluid balance
Electrolytes
 Main Components:
 Na+ sodium
 K+ potassium
 Cl- chloride
 Ca calcium
P phosphate
 Mg magnesium
Test: Chest X-Ray (CXR,
PA Chest, PA & LAT Chest)
 Radiographic
exam of the
thorax
 Visualizes
respiratory &
cardiac function
 Identifies &
follows
progression/
remission of dx
process
Test: Arterial Blood Gas
(ABG)
 Assesses the
adequacy of
ventilation and
oxygenation via
arterial blood
 Use: measures
respiratory and
metabolic (renal)
disturbances
Arterial Blood Gases
 Main
Components:
 pH
 PaCO2
 PaO2
 HCO3
 SaO2
General Nursing
Implications
 Assess client’s readiness to learn
 Explain procedure to client
 Assist client in dealing with the
test
 Provide privacy
 Prepare client for test
 Universal precautions
 Send specimens promptly
Specific Nursing
Implications
 Electrolytes:
 Note diet, food and fluid intake
 Note s/s that could affect fluid
balance (N/V/D)
 Chest X-Ray:
 Transport
 Remove metal objects
 Stand clear
Specific Nursing
Implications
 Arterial Blood
Gases
 Anticoagulants?
 Time drawn
 Check site for
bleeding
 Pressure
 Sample on ICE
 STAT to lab
Physical Assessment:
Pediatric Principles
 Assess:
 coping ability
 previous
knowledge
 readiness
 Encourage
questions
 Explain at
developmental
level
Physical Assessment:
Pediatric Principles
 Use concrete
terms
 Small amounts of
info at a time
 Simple & clear
explanations
 Only offer choices
that are available
 Honest
praise/rewards
Physical Assessment
Methods

 Inspection
 Palpation
 Auscultation
 Percussion
Equipment
 Stethoscope
 Pen light
 Blood Pressure Cuff
 Thermometer
 Watch with second hand
Inspection
 Assessment
process during
which the nurse
observes the
client
Inspection
 Initial contact and ongoing
 Use olfaction, touch
 General appearance, body language
 Systematic unhurried approach
 Expose part, respect privacy
 Examine: color, size, shape, position,
symmetry (compare like areas)
 Know “normals”
 Observe “normals/abnormals”
Palpation

 Theuse of the hands and the

sense of touch to gather data
Palpation
 Detects texture, shape, temp,
movement, pain, moisture
 Short fingernails, warm hands
 Gentle approach
 Light palpation first, if pain - STOP!
 Palpate tender areas last
 Three types:
 Light palpation (1/2 inch)
 Deep palpation (1 inch)
 Bimanual deep palpation (2 hands)
Auscultation
 The act of
listening to
sounds within
the body to
evaluate the
condition of
body organs
 (stethoscope)
Auscultation
 Stethoscope:
 bell for low pitch sounds (cardiac
sounds)
 Diaphragm for high pitch sounds
(bowel, breath, normal cardiac)
4 characteristics of sounds
 Frequency/pitch: # vibrations per
second
 Loudness: soft, medium, loud
 Quality: types; gurgling, blowing
 Duration: short, medium, long
(specify)
Auscultation
 Quiet environment
 Know landmarks
 Know “normals”
 PRACTICE! PRACTICE! PRACTICE!
 Requires concentration, practice,
and application of knowledge
Percussion
 Tapping of
various body
organs and
structures to
produce
vibration and
sound.
Documentation - Purpose
 Communication  Education
 Quality Assurance  Statistics
 Legal  Accrediting/Licensure
 Reimbursement  Historical Document
 Research
 Planning Client Care
Principles of Documentation
 Timing  Completeness
 Confidentiality  Standard Terminology
 Permanence  Brevity
 Signature  Legibility
 Accuracy  Legal Awareness
 Sequence
 Appropriateness
 Learning Outcomes
The student will be able to:
1. State the purposes of the physical exam.
2. Name the necessary equipment need to
perform a physical exam.
3. Describe the four basic techniques used in
physical examination.
4. Describe guidelines for preparing a client and
the environment for a physical examination.
5. What are the components of a general survey?