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Chapter: Medical Surgical Nursing: Health Assessment

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Physical Health Assessment

Inspection, Palpation, Percussion,Auscultation

Physical Assessment

 

Physical assessment, or the physical examination, is an integral part of nursing assessment. The basic techniques and tools used in performing a physical examination. The examination of specific systems, including spe-cial maneuvers. Because the patient’s nutritional status is an important factor in health and well-being.

 

The physical examination is usually performed after the health history is obtained. It is carried out in a well-lighted, warm area. The patient is asked to undress and draped appropriately so that only the area to be examined is exposed. The person’s physical and psychological comfort is considered at all times. Procedures and sensations to expect are described to the patient before each part of the examination. The examiner’s hands are washed before and immediately after the examination. Fingernails are kept short to avoid injuring the patient. The examiner wears gloves when there is a possibility of coming into contact with blood or other body secretions during the physical examination.

 

An organized and systematic examination is the key to obtain-ing appropriate data in the shortest time. Such an approach en-courages cooperation and trust on the part of the patient. The individual’s health history provides the examiner with a health pro-file that guides all aspects of the physical examination. Although the sequence of physical examination depends on the circum-stances and on the patient’s reason for seeking health care, the complete examination usually proceeds as follows:

 

·      Skin

 

·       Head and neck

 

·       Thorax and lungs

 

·       Breasts

 

·       Cardiovascular system

 

·       Abdomen

 

·       Rectum

 

·       Genitalia

 

·       Neurologic system

 

·       Musculoskeletal system

 

In clinical practice, all relevant body systems are tested through-out the physical examination, not necessarily in the sequence de-scribed (Weber & Kelley, 2003). For example, when the face is examined, it is appropriate to check for facial asymmetry and, thus, for the integrity of the seventh cranial nerve; the examiner does not need to repeat this as part of a neurologic examination. When sys-tems are combined in this manner, the patient does not need to change positions repeatedly, which can be exhausting and time-consuming.

 

A “complete” physical examination is not routine. Many of the body systems are selectively assessed on the basis of the individ-ual’s presenting problem. If, for example, a healthy 20-year-old college student requires an examination to play basketball and re-ports no history of neurologic abnormality, the neurologic assess-ment is brief. Conversely, a history of transient numbness and diplopia (double vision) usually necessitates a complete neurologic investigation. Similarly, a person with chest pain receives a much more intensive examination of the chest and heart than the per-son with an earache. In general, the individual’s health history guides the examiner in obtaining additional data for a complete picture of the patient’s health.

 

The process of learning physical examination requires repeti-tion and reinforcement in a clinical setting. Only after basic physical assessment techniques are mastered can the examiner tailor the routine screening examination to include thorough assess-ments of a particular system, including special maneuvers.

 

The basic tools of the physical examination are vision, hearing, touch, and smell. These human senses may be augmented by spe-cial tools (eg, stethoscope, ophthalmoscope, and reflex hammer) that are extensions of the human senses; they are simple tools that anyone can learn to use well. Expertise comes with practice, and sophistication comes with the interpretation of what is seen and heard. The four fundamental techniques used in the physical ex-amination are inspection, palpation, percussion, and auscultation (Weber & Kelley, 2003).

 

INSPECTION

 

The first fundamental technique is inspection or observation. General inspection begins with the first contact with the patient. Introducing oneself and shaking hands provide opportunities for making initial observations: Is the person old or young? How old? How young? Does the person appear to be his or her stated age? Is the person thin or obese? Does the person appear anxious or depressed? Is the person’s body structure normal or abnormal? In what way, and how different from normal? It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful ob-servation; for example:

 

·       “The person appears sick.” In what way does he or she ap-pear sick? Is the skin clammy, pale, jaundiced, or cyanotic; is the person grimacing in pain; is breathing difficult; does he or she have edema? What specific physical features or be-havioral manifestations indicate that the person is “sick”?

 

·      “The person appears chronically ill.” In what way does he or she appear chronically ill? Does the person appear to have lost weight? People who lose weight secondary to muscle-wasting diseases (eg, AIDS, malignancy) have a dif-ferent appearance than those who are merely thin, and weight loss may be accompanied by loss of muscle mass or atrophy. Does the skin have the appearance of chronic ill-ness—that is, is it pale, or does it give the appearance of de-hydration or loss of subcutaneous tissue? These important observations are documented in the patient’s chart or health record.

 

Among general observations that should be noted in the ini-tial examination of the patient are posture and stature, body movements, nutrition, speech pattern, and vital signs.

Posture and Stature

The posture that a person assumes often provides valuable infor-mation about the illness. Patients who have breathing difficulties (dyspnea) secondary to cardiac disease prefer to sit and may re-port feeling short of breath lying flat for even a brief time. People with obstructive pulmonary disease not only sit upright but also may thrust their arms forward and laterally onto the edge of the bed (tripod position) to place accessory respiratory muscles at an optimal mechanical advantage. Those with abdominal pain due to peritonitis prefer to lie perfectly still; even slight jarring of the bed will cause agonizing pain. In contrast, patients with abdom-inal pain due to renal or biliary colic are often restless and may pace the room. Patients with meningeal irritation may experience head or neck pain on bending the head or flexing their knees

Body Movements

 

Abnormalities of body movement may be of two general kinds: generalized disruption of voluntary or involuntary movement, and asymmetry of movement. The first category includes tremors of a wide variety; some tremors may occur at rest (Parkinson’s disease), whereas others occur only on voluntary movement (cerebellar ataxia). Other tremors may exist during both rest and activity (alcohol withdrawal syndrome, thyrotoxicosis). Some voluntary or involuntary movements are fine, others quite coarse. At the extreme are the convulsive movements of epilepsy or tetanus and the choreiform (involuntary and irregular) movements of patients with rheumatic fever or Huntington’s disease. Other aspects of body movement that are noted on inspection include spasticity, muscle spasms, and an abnormal gait.

 

Asymmetry of movement, in which only one side of the body is affected, may occur with disorders of the central nervous sys-tem (CNS), principally in those patients who have had cerebro-vascular accidents (strokes). The patient may have drooping of one side of the face, weakness or paralysis of the extremities on one side of the body, and a foot-dragging gait. Spasticity (in-creased muscle tone) may also be present, particularly in patients with multiple sclerosis.

 

Nutrition

 

Nutritional status is important to note. Obesity may be gener-alized as a result of excessive intake of calories or may be specif-ically localized to the trunk in those with endocrine disorders (Cushing’s disease) or those who have been taking cortico-steroids for long periods of time. Loss of weight may be gener-alized as a result of inadequate caloric intake or may be seen in loss of muscle mass with disorders that affect protein synthesis.

 

Speech Pattern

 

Speech may be slurred because of CNS disease or because of dam-age to cranial nerves. Recurrent damage to the laryngeal nerve will produce hoarseness, as will disorders that produce edema or swelling of the vocal cords. Speech may be halting, slurred, or in-terrupted in flow in some CNS disorders (eg, multiple sclerosis).

 

Vital Signs

 

The recording of vital signs is a part of every physical examina-tion. Blood pressure, pulse rate, respiratory rate, and body tem-perature measurements are obtained and recorded. Acute changes and trends over time are documented; unexpected changes and values that deviate significantly from the patient’s normal values are brought to the attention of the patient’s primary health care provider. The “fifth vital sign,” pain, is also assessed and docu-mented, if indicated.

 

Fever is an increase in body temperature above normal. A nor-mal oral temperature for most people is an average of 37.0°C (98.6°F); however, some variation is normal. Some people’s tem-peratures are quite normal at 36.6°C (98°F) and others at 37.3°C (99°F). There is a normal diurnal variation of a degree or two in body temperature throughout the day; with temperature usually lowest in the morning and rising during the day to between 37.3° and 37.5°C (99° to 99.5°F), then decreasing again during the night.

PALPATION

 

Palpation is a vital part of the physical examination. Many struc-tures of the body, although not visible, may be assessed through the techniques of light and deep palpation (Fig. 5-3). Examples include superficial blood vessels, lymph nodes, the thyroid, the organs of the abdomen and pelvis, and the rectum. When the ab-domen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds.


 

Sounds generated within the body, if within specified fre-quency ranges, also may be detected through touch. Thus, cer-tain murmurs generated in the heart or within blood vessels (thrills) may be detected. Thrills cause a sensation to the hand much like the purring of a cat. Voice sounds are transmitted along the bronchi to the periphery of the lung. These may be per-ceived by touch and may be altered by disorders affecting the lungs. The phenomenon is called tactile fremitus and is useful in assessing diseases of the chest.

 

PERCUSSION

 

The technique of percussion (Fig. 5-4) translates the application of physical force into sound. It is a skill requiring practice but one that yields much information about disease processes in the chest and abdomen. The principle is to set the chest wall or abdominal wall into vibration by striking it with a firm object. The sound produced reflects the density of the underlying structure. Certain densities produce sounds as percussion notes. 

These sounds, listed in a sequence that proceeds from the least to the most dense, are called tympany, hyperresonance, resonance, dullness, and flatness. Tym-pany is the drumlike sound produced by percussing the air-filled stomach. Hyperresonance is audible when one percusses over in-flated lung tissue in someone with emphysema. Resonance is the sound elicited over air-filled lungs. Percussion of the liver produces a dull sound, whereas percussion of the thigh results in flatness.

 

Percussion allows the examiner to assess such normal anatomic details as the borders of the heart and the movement of the di-aphragm during inspiration. One may determine the level of pleural effusion (fluid in the pleural cavity) and the location of a consolidated area caused by pneumonia or atelectasis (collapse) of a lobe of the lung. The use of percussion is described further with disorders of the thorax and abdomen.

 

AUSCULTATION

 

Auscultation is the skill of listening to sounds produced within the body created by the movement of air or fluid. Examples in-clude breath sounds, the spoken voice, bowel sounds, cardiac murmurs, and heart sounds. Physiologic sounds may be normal (eg, first and second heart sounds) or pathologic (eg, heart mur-murs in diastole, or crackles in the lung). Some normal sounds may be distorted by abnormalities of structures through which the sound must travel (eg, changes in the character of breath sounds as they travel through the consolidated lung of the patient with lobar pneumonia).

 

Sound produced within the body, if of sufficient amplitude, may be detected with the stethoscope, which functions as an ex-tension of the human ear and channels sound. Two end pieces are available for the stethoscope: the bell and the diaphragm. The bell is used to assess very-low-frequency sounds such as diastolic heart murmurs. The entire surface of the bell’s disc is placed lightly on the skin surface to avoid flattening the skin and reducing audible vibratory sensations. The diaphragm, the larger disc, is used to as-sess high-frequency sounds such as heart and lung sounds and is held in firm contact with the skin surface (Fig. 5-5). Touching the tubing or rubbing other surfaces (hair, clothing) during ausculta-tion is avoided to minimize extraneous noises.


 

Sound produced by the body, like any other sound, is charac-terized by intensity, frequency, and quality. Intensity, or loudness, associated with physiologic sound is low; thus, the use of the stethoscope is needed.

Frequency, or pitch, of physiologic sound is in reality “noise” in that most sounds consist of a frequency spectrum as opposed to the single-frequency sounds that we as-sociate with music or the tuning fork. The frequency spectrum may be quite low, yielding a rumbling noise, or comparatively high, producing a harsh or blowing sound. Quality of sound re-lates to overtones that allow one to distinguish between different sounds. Sound quality enables the examiner to distinguish be-tween the musical quality of high-pitched wheezing and the low-pitched rumbling of a diastolic murmur.

 

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