King Saud University

College of Nursing

Health Assessment (NUR 224)

General Survey & Health History

Part 2

1

Learning objectives

At the end of this module, the learner should be able to:1.Define the Key terms.2.Understand the concept of physical examination in terms of its requirements. 3.Discuss the concept of general survey in terms of its purpose, skills, and components.4.Discuss the four basic physical examination techniques.5.Identify commonly needed physical examination equipments and their functions.

Physical Examination

Physical examination is a systematic approach of collecting objective data about clients’ health status.

It employs through detailed evaluation of clients’ all body structures, organs, or systems.

It requires the nurse to apply special techniques, use equipments and knowledge base, to physically expose each region of clients’ body and examine it by looking, listening, touching, or smelling.

Purpose of physical ExaminationPhysical examination is performed

in all health care settings, covering healthy and sick clients.

It serves for screening, detection, and prevention of disease.

It also provides an opportunity for health promotion (education & counseling) as well as the evaluation of disease process or treatment results.

Component of Physical Examination:

General survey (the nurses’ initial

observation for the clients’ general

appearance and behavior).

Vital signs measurement

Height and weight measurement

Body systems examination

1 -Physical AppearanceNormal Range of Findings Abnormal Findings

1- Age – the person appears his or her stated age.

Appears older, smaller, or younger, as with chronic disease or retardation.

2- Sex – Sexual development is appropriate for gender and age

Delayed or early puberty, or inappropriate to gender.

3- Level of consciousness – the person is alert and oriented, attends to your questions and responds appropriately.

Alert.Alert. Follow commands and responds completely and appropriately to stimuli

LethargicLethargic. . The patient is sleepy or drowsy and will awaken and respond appropriately to command. Stupor. Stupor. require vigorous stimulation for a response . Semi comaSemi coma. . The patient is not awake but will respond purposefully to deep painComa. Coma. The patient is completely unresponsive.

1 -Physical AppearanceNormal Range of Findings Abnormal Findings

4- Skin color – color tone is even, skin is intact with no obvious lesions

• Pallor, (loss of color) • cyanosis, (bluish discoloration)

• jaundice Yellowish discoloration)

• lesions.

5- Facial features – symmetric with movement.

6- No signs of acute distress are present

• Immobile, masklike, asymmetric, drooping.

• shortness of breath, wheezing.

• facial grimace, holding body part. (Pain)

II- Body STRUCTURE 1- Stature – the height

appears within normal range for age.

• Excessively short or tall

2- Nutritional status – the weight appears within normal range for height and body build.

• Underweight • Obese

II- Body STRUCTURE 3- Symmetry – body parts look equal bilaterally • Unilateral atrophy

• hypertrophy (enlargement of muscles.)

4- Posture – the person stands comfortably erect as appropriate for age.

• Rigid spine and neck (moves as one unit) e.g., arthritis. Stiff and tense.

5- Position – the person sits comfortably in a chair or on the bed or examination table, arms relaxed at sides, head turned to examiner.

•Leaning forward with arms braced on chair arms (chronic pulmonary disease).

•Sitting straight up and resists lying down, (left-sided congestive heart failure).

7- Physical deformities– Absence of any congenital or

acquired defects.

Presence of deformities or congenital defect

III- Mobility 1-Gait: the walk is smooth, even,

and well-balanced; and associated movements, (symmetric arm swing), are present.

Limping with injury.

Difficulty stopping

2-Range of motion – the person has full mobility for each joint.

3- Involuntary movement: absent

Limited joint range of motion. Paralysis – absent movement.

Movement jerky,

uncoordinated

Tics, tremors, seizers

IV- Behavior

1- Facial expression – the person maintains eye contact expressions are appropriate to the situation.

Flat, depressed, angry, sad anxious. However, note that anxiety is common in ill people.

2- Mood and affect – the person is comfortable and cooperative with the examiner and interacts pleasantly.

Hostile, distrustful, suspicious, crying

Vital signs are the key physiologic measures of the person’s general health state. The nurse obtains vital signs to:

a.Establish baseline measurement.

b.Identify physiologic problems.

c.Monitor clients’ response to therapy.

Signs range

Pulse rate 60 - 100 beats/min

Respiratory rate 12 - 20 breath/min

Blood pressure 100/70 to 140/90 mmHg

Temperature 36.5 - 37.5 C

Pain

3- Measuring Height and 3- Measuring Height and weightweight

Body mass index Body mass index __Weight_(kg)____Weight_(kg)____

(Height) 2(Height) 2 Where Where Weight is measured in kilograms.Weight is measured in kilograms. Height is measured in metersHeight is measured in meters BODY MASS INDEX FINDINGBODY MASS INDEX FINDING < 20 PERSON IS UNDER WEIGHT< 20 PERSON IS UNDER WEIGHT =20-25 PERSON IS NORMAL WEIGHT=20-25 PERSON IS NORMAL WEIGHT =25-30 PERSON IS OVERWEIGHT=25-30 PERSON IS OVERWEIGHT >30 PERSON IS OBESE>30 PERSON IS OBESE

EXAMPLE:-EXAMPLE:-

Calculate body mass index of person, Calculate body mass index of person, his weight is 98kg, his height is172 cm his weight is 98kg, his height is172 cm ..

Answer steps: Answer steps: Transfer height from cm to meter Transfer height from cm to meter

=172/100=1.72m=172/100=1.72m Body mass index (BMI) = Body mass index (BMI) =

98/(1.72)2 =3398/(1.72)2 =33 BMI = 33 SO the person is BMI = 33 SO the person is

obeseobese..

4- Body systems examination4- Body systems examination

Body systemsBody systems examination is the examination is the

systematic systematic objectiveobjective evaluation of client’s evaluation of client’s

body structures, parts, and organs, using body structures, parts, and organs, using

the examiners’ sense the examiners’ sense

Review client health history Prepare equipment Examine client in a warm & quiet room Examine client in well- lighted room Consider patients’ privacy and comfort Practice and adhere to standard precaution of

Infection control Explain procedure to client & reassure client

along the examination. Begin examination with the patient in sitting position( if possible). This facilitates front and back examination

Use appropriate Draping, such that only body part being examined is exposed

Physical examination equipments:

Ophthalmoscope Otoscope

Tuning fork

Nasal speculum

Percussion hammer Snellen chart

Basic Physical examination techniques

Physical examination utilizes four techniques Inspection

Palpation

Percussion

Auscultation

1. Inspection

means Observing the client in a close, focused manner using vision, and smell senses.

*It begins during the first contact with client and continues throughout the assessment

*It provides information about body parts’: color, size, location, movement, texture, symmetry, odor, and sound

2. Palpation

Palpation is the use of hands and fingers to feel different body parts for data collection.

The nurse uses pads of the fingers and palms to touch and feel the patient’s body parts with his hands to examine:

size texture location tenderness body temperature lumps or masses

Types of palpation 1.1. Light palpationLight palpation

Using the flat part of the right hand or the pads of the fingers, not the fingertips

The fingers should be together

Depress the skin 1 to 2 cm with your finger

pads, usually the lightest touch possible.

Light palpation

2. Deep palpation

Used to determine organ size as well as the presence of abdominal masses

The flat portion of the right hand is placed on the abdomen

Depress the skin 4 to 5 cm with firm, deep pressure. Pressure should be applied to the abdomen gently but steadily

The patient should be instructed to breathe quietly through the mouth and to keep arms at the sides

3. Percussion

A methods of “ striking” of body parts during physical examination with fingers to evaluate the size, consistency, borders and presence of fluid in body organs

Percussion of a body part produces a sound that indicates the type of tissue within the organ

It is particularly important in examining the chest and abdomen

Methods of Percussion

1.Direct percussion:

Using one or two fingers, tap directly on the body part. Ask the patient to tell you which areas are painful and watch his/her face for signs of discomfort.

Direct percussion is commonly used to assess an adult patient's sinuses for tenderness.

2. Indirect Percussion

Press the distal part of the middle finger (pleximeter) of

your nondominant hand firmly on the body part(left

hand).

Keep the rest of your hand off the body surface.

Flex the wrist of your dominant hand. Using the middle finger (plexor or striking finger) of

your dominant hand, tap quickly and directly over the

point where your other middle finger touches the

patient's skin. The motion of the striking finger should

come from the wrist and not from the elbow

Deliver 2 - 3 quick taps and listen carefully.

Types of soundsSound Quality of

soundWhere it is

heardSource

Tympany Drumlike sound Over enclosed air

Puffed-out cheek, air in bowel

Resonance Hollow sound Over areas of part air and solid

Normal lung

Hyper resonance

Booming sound Over air (child’s lungs) N

(adult) Lung with emphysema

Dullness Thudlike sound Over solid area Liver, spleen

Flatness Flat sound Over dense tissue

Thigh Muscle, bone, over tumor

4. Auscultation

A method used to “listen” to the body sounds.

Various body systems like heart, lungs, and

abdominal organs have characterized sounds

Bowel, breath, heart, and blood movement

sound are heard using a stethoscope

It is important to know the normal sound to

distinguish from abnormal sound

Types of auscultation

1. Direct auscultation: * Uses the ear alone to listen, such as

when listening to the grating of a moving joint.

* Sounds are audible without stethoscope

2. Indirect auscultation:

sounds are audible with stethoscope

3. Bell for low pitched sound and diaphragm for high pitched sound

Question?

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