PATIENT

ASSESSMENT (ADULT)
PART 2: PHYSICAL EXAMINATION

PENNY GILL

LECTURER WCCN/CPUT

ECP MARCH 2008

 PATIENT
ASSESSMENT (ADULT)
SUMMARY OF PART 1
ASSESSING A PATIENT
Assess need for an interpreter.
 taking a patient’s history

- approach to the patient

- the interview
- special circumstances
Revision of the interview
 demographic information

 reason for visit

 history of the presenting problem

 other health information/review of systems

Revision of the interview

 previous health history

 family health history

 information related to lifestyle

 activities of daily living

 PHYSICAL EXAMINATION
 preceded by history taking (subjective)

 nurse examines patient in order to collect

(objective) data about him/her
 APPROACH TO PATIENT
 ensure privacy

 exposure to a minimum only

when absolutely necessary

 explain procedure to
patient

 make sure patient is

comfortable
 APPROACH TO PATIENT
 continue to build on trust
established during history
taking
 talk to patient, reassure
explain steps of
examination
 continue to ask questions
THE PHYSICAL EXAMINATION
Difference between signs and symptoms

 Symptoms: the history tells the nurse

what the symptoms are.

 Signs: the physical examination will

reveal the signs related to the patient’s
health problems.
TECHNIQUES USED DURING THE
PHYSICAL EXAMINATION
 Inspection

 Palpation
TECHNIQUES USED DURING
THE PHYSICAL EXAMINATION
 Percussion

 Ascultation
TECHNIQUES USED DURING
THE PHYSICAL EXAMINATION
INSPECTION IS:

 looking at or observing the

patient

 focused & purposeful top-to-

toe survey of patient using
the senses of vision, hearing
and smell
TECHNIQUES USED DURING
THE PHYSICAL EXAMINATION
INSPECTION CONT:
 beginswith general survey
and ends with a specific
inspection of each area or
part of body: shape,
colour, texture &
movement

 assessment of symmetry
TECHNIQUES USED DURING THE
PHYSICAL EXAMINATION
 Palpation: means examine by touch
TECHNIQUES USED DURING THE
PHYSICAL EXAMINATION:
PALPATION:
 Aspects that can be determined are:
- swelling - present of masses
- spasm - temperature
- tenderness - movement
- stiffness - enlargement
- shape - outline
- texture - presence of
fluid/crepitations
TECHNIQUES USED DURING
THE PHYSICAL EXAMINATION
Percussion: means to strike or
tap (Used by doctors)

 this technique involves light

tapping on the surface of the
body & analysing the sounds
that are produced

 used to determine the amount

of air &/or solid matter in the
lungs & to determine the size,
position & borders of the
other thoracic organs
TECHNIQUES USED DURING
THE PHYSICAL EXAMINATION
Ascultation: means listening by
means of a stethoscope

 This technique is used to listen

directly to the sounds made by the
movement of air or fluid in the
body

 Used to assess movement of air in

the lungs, movement of blood in the
blood vessels & movement of
digestive fluids in the GIT
 MEASUREMENTS
 temperature

 pulse

 respiration
 MEASUREMENTS

 blood pressure
 pain
PRINCIPLE FEATURES OF THE
GENERAL PHYSICAL
ASSESSMENT
 patient’s name, age &
gender
 carry out general
inspection of the
patient
 take vital signs
 carry out systematic
physical assessment
GENERAL EXAMINATION OF
THE PATIENT: INSPECTION
 general appearance of
the patient – grooming/
hygiene: yes/no

 posture & gait: upright

bent
 COMMUNICATION
 need for an interpreter:
yes/no

 language perception:
good/poor

 speech: clear/ unclear

STATUS OF SPECIAL SENSES

 Hearing

 Discharges/pain
 Ear abnormalities
STATUS OF SPECIAL SENSES

 Sight
STATUS OF SPECIAL SENSES

 Sight
STATUS OF SPECIAL SENSES
 Smell

 Taste

 touch
EMOTIONAL STATUS
 cheerful/withdrawn

 calm/fearful
 EMOTIONAL STATUS
mental state of patient
 anxiety
 agitation
 confusion
 withdrawal & aggression
 signs of abuse
 NEUROLOGICAL STATUS
Eyes (perrla)

 Pupils equal, round,

reacting to light and
accomodation
 left & right
 Glasgow Coma Scale
 The Glasgow Coma Scale or GCS, is a
neurological scale

 aims to give a reliable,

 objective way of recording the conscious

state of a person,

 for initial as well as continuing assessment.

NEUROLOGICAL STATUS

LEVEL OF CONSCIOUSNESS (LOC)

 A frequent tool in evaluating LOC is the

Glasgow coma scale (GCS) . This scores a
patient’s response to voice and deep
pressure using eye opening and verbal and
motor responses .
 Glasgow Coma Scale
 A patient is assessed against the
criteria of the scale,
 and the resulting points give a patient
score between 3 (indicating deep
unconsciousness)
 and either 14 (original scale) or 15 (the
more widely used modified or revised
scale).
 GLASGOW COMA SCALE

Eyes open Best verbal response Best motor response*

Obeys commands (6)
Spontaneously (4) Orientated (5) Localizes pain (5)
To speech (3) Confused (4) Withdraws to pain (4)
To pain (2) Inappropriate words (3) Flexion (abnormal) to pain (3)
None (1) Incomprehensible sounds (2) Extension to pain (2)
None (1) none(1)

Glasgow coma scale = /15

 NUTRITIONAL & ORAL
STATUS
 build & general nutritional state
state/well nourished
NUTRITIONAL & ORAL STATUS
 mass: normal for age,
overweight/underweight

 appetite: good/poor
 food restriction: no/yes
NUTRITIONAL & ORAL STATUS

 fluid intake normal/restricted

 ability to chew/swallow
NUTRITIONAL & ORAL
STATUS LYMPH GLANDS 

 1. SUBMENTAL
 2. SUBMANDIBULAR
 ability to chew/swallow  3. PAROTID
 4. PREAURICULAR
 5. POSTAURICULAR
 6. OCCIPITAL
 7. ANTERIOR CERVICAL
 8. SUPRACLAVICULAR
 9. POSTERIOR CERVICAL
NUTRITIONAL & ORAL STATUS
 condition of oral cavity

 mucosa

 mouth/lips
NUTRITIONAL & ORAL STATUS
 record dentures/crowns/bridges

 teeth
 MOTOR ABILITY STATUS
 current mobility: ambulant/non
ambulant easy/difficult
 movements: coordinated/
uncoordinated
 prosthesis no/yes
 STATUS OF PHYSICAL REST &
COMFORT
 sleep & rest pattern: good/poor

 substances: unnecessary/required

 pain
absent/present
ELIMINATION STATUS
 bowel habits: regular/ changed
 incontinent: faeces no/yes

 medication needed: no/yes

ELIMINATION STATUS
 stoma: no/yes

 haemorrhoids
ELIMINATION STATUS
 micturition: normal/abnormal
 urinary output: normal/abnormal
 incontinent: urine no/yes
 urinary stoma
REPRODUCTIVE SYSTEM: Male

 urinary stream
 continuous/broken
 past STI: no/yes

 current symptoms: no/yes

REPRODUCTIVE SYSTEM: FEMALE

 breasts: present/absent

 menstrual cycle: regular

absent/irregular

 contraceptive use: no/yes/method

REPRODUCTIVE SYSTEM: Female

 pregnant: no/yes/gestation

 past STI: no/yes

 current symptoms STI

STI sexually transmitted infections

SELF EXAMINATION OF THE
BREAST
BREAST EXAMINATION:CHANGES
PHYSIOLOGICAL STATUS
 respiratory status
 chest shape: normal/abnormal
 PHYSIOLOGICAL STATUS

 character of respiration

 regular/irregular
 easy some difficulty
 cough: absent/present

 Tracheostomy: no/yes
PHYSIOLOGICAL STATUS
 circulatory status

 perfusion adequate/poor

 pulses: all extremities: present/ absent

 rhythm regular/irregular
 volume: strong/weak

 extremities: warm/cold L R
 Pacemaker no/yes
PHYSIOLOGICAL STATUS
 oedema: no/yes

 fluid balance status

 skin turgidity normal/ loss of turgidity

 hydration: adequate/ inadequate
PHYSIOLOGICAL STATUS
 skin turgidity normal/ loss of turgidity

 hydration: adequate/ inadequate

STATUS OF SKIN & APPENDAGES
 skin integrity: intact/ broken
areas/lesions/wounds
STATUS OF SKIN & APPENDAGES

 pressure sores: no/yes

STATUS OF SKIN & APPENDAGES

 scars: no/yes

 bruises:no/yes
STATUS OF SKIN & APPENDAGES

 rash:no/yes
STATUS OF SKIN & APPENDAGES

 skin feels: warm/cold

 skin colour: normal/abnormal

STATUS OF SKIN & APPENDAGES

 hair –texture,
parasites
STATUS OF SKIN & APPENDAGES

 Arms/hands
STATUS OF SKIN & APPENDAGES

 Legs/feet
 GENERAL EXAMINATION
2nd YEAR NURSE
 cardiovascular
system

 respiratory system

 lower limbs
 BIBLIOGRAPHY
Uys.L.R.Ed.1999.Fundamental Nursing. Pinelands:
Maskew Miller Longman

Young,A.Ed.2003.Juta’s Manual of Nursing.

Lansdowne:Juta & Co.

http://images.google.co.za/images

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