Physical Assessment is the subjective and objective data obtained to determine the patient’s state of wellness or illness, physical and health status, limitations, assets and liabilities.
Physical Assessment Techniques (Nettina, 2006)
Inspection – Scrutinize the patient’s body and behavior. Be highly sensitive to visual clues.
Palpation – Touch without or with pressure (as indicated) the region or body part to be observed and note for tenderness and what the various structures feel like.
Percussion – Determine the density of the underlying tissues and whether it is air-filled, fluid-filled or solid with the use of audible sounds and palpable vibrations being produced. Distinguish the different qualities of sound, pitch, duration and intensity.
Auscultation – Use stethoscope to augment the sense of hearing. Use the bell for low-pitched sounds like heart murmurs while the diaphragm screen for low-pitched and high-frequency sounds like breath sounds and pulses.
ASSESSING FROM HEAD-TO-TOE (CEPHALO-CAUDAL) (Nettina, 2006)
Assess vital signs
- Temperature – identify whether hypothermia, normothermia and hyperthermia
- Pulse – assess if the pulse is full, strong, weak, bounding or thready.
- Respiration – note for the rhythm, breath sounds and depth of breathing.
- Blood pressure – measures hypotension, BP within normal range and hypertension.
Obtain the height, weight and BMI of the patient.
Inspect for the General Appearance
- Observe for race, sex, general physical development, nutritional state, mental alertness, affect, evidence of pain, restlessness, body position, clothes, apparent age, hygiene and grooming.
Review of Systems
Neurologic – with the use of GLASGOW COMA SCALE. Assess the mental status, cranial nerve function, cerebellar function, motor function, sensory function and deep tendon reflexes.
Integumentary – Inspect for skin color, pigmentation, lesions (distribution, type, configuration, size), jaundice, cyanosis, scars, superficial vascularity, hydration, edema, color of mucous membranes, hair distribution and nails. Palpate skin for temperature, texture, elasticity and turgor.
Peripheral Circulation – Palpate for jugular vein distention and pulsations. Observe for skin color, temperature, hair distribution, pallor, rubor and swelling. Palpate pulses. Palpate for edema and masses
Head – Inspect for the symmetry of face, configuration of skull, hair color and distribution, scalp. Palpate for hair texture, masses, swelling or tenderness of scalp and configuration of the skull.
Eyes and Vision – Inspect globes for protrusion; palpebral fissures for width and symmetry; lid margins for scaling, secretions, erythema, and position of lashes; bulbar and palpebral conjunctiva for congestion and color; sclera and iris for color; pupils for size, shape, symmetry, reaction to light and accommodation—PERRLA (Pupil Equally Round and Reactive to Light Accomodation); eye movement for extraocular movements, nystagmus and convergence; gross visual fields by donfrontation; and the visual acuity with the use of Snellen chart (with and without glasses). Determine the strength of the upper lids by attempting to open closed lids against resistance. Palpate globes through closed lids for the tenderness and tension.
Ears and Hearing – Inspect for the size, shape, color, symmetry, placement on the head, lesions, tenderness, consistency of the cartilage, swelling and masses. Examine for the presence of discharges, impacted cerumen, inflammation, masses or foreign bodies. Examine hearing by mechanical tests such as whisper or watch tic-tac test, weber and rhine tests.
Nose and Sinuses – Inspect for general deformity, position and perforation, discharges, obstruction, airway patency, color of the mucus membranes and the turbinates for swelling. Palpate sinuses for swelling and tenderness.
Mouth – Inspect for the lips color, moisture, pigment, masses, ulcerations and fissures. Check for the number, arrangement and general condition of the teeth. Observe for gums color, texture, discharge, swelling or retraction. Buccal mucosa should be observed for discoloration, vesicles, ulcers and masses. Pharynx for inflammation, exudates and masses. Tongue for its ability to protrude, size, color, thickness, lesions, moisture, symmetry, deviations from midline, fasciculation. Check for the patency of the salivary glands. Uvula should be symmetry when the patient says “ah”. Check the size, ulcerations, exudates and inflammation of the tonsils. The odor of the breath and the hoarseness of the voice should be examined.
Neck – Inspect for the symmetry and range of motion. Palpate for masses, pulsations and jugular vein distention. Auscultate to listen for bruits over the carotid arteries.
Lymph Nodes – Inspect and palpate for the size, shape, mobility, consistency, tenderness and inflammation.
Breasts – For female, inspect the areola and nipples for position, pigmentation, inversion, discharge, crusting and masses. Check for size, shape, color, symmetry, surface, contour, skin characteristics and level of breast. Observe for retraction or dimpling of the skin. Palpate for the tissue distribution, masses, inflammation and engorgement. Note for skin texture, moisture and temperature. For male, inspect the nipple and areola for ulceration, nodules, swelling or discharge and tenderness.
Thorax and Lungs – Inspect for the ribs mobility, structural deformity, symmetry, bulges or retractions, respiration and impairment of the respiratory movement. Palpate for tenderness, masses and inflammation. Assess respiratory expansion. Elicit vocal and tactile fremitus by asking the patient to say “99”. Percuss the chest and observe the percussion sounds for both sides. Observe for the resonance, tymphanism and dullness of percussion sounds. Auscultate the breath sounds and identify the vesicular, bronchovesicular and bronchial or tubular.
Heart – Inspect the precordium for any bulging, heaving or thrusting and note for any other pulsations. Palpate for the vibrations and pulsations over aortic, pulmonic, tricuspid and mitral. Percussion to identify heart border and area of cardiac dullness. Auscultate for the rhythm and rate of the pulses, heart and the heart sounds.
Abdomen – Observe for the general contour of the abdomen, symmetry, visible peristalsis and aortic pulsations. Inspect the umbilicus for contour or hernia and the skin for rashes, striae and scars. Auscultate for bowel sounds, note the character and frequency of bowel sounds including the pitch and duration. Auscultate the aorta and renal arteries found at the upper quadrants and iliac arteries at the lower quadrants. Percuss the four abdominal quadrants noting its resonance, dullness and tymphanism. Perform light palpation to detect any muscular resistance or guarding, tenderness or superficial organs or masses. Deep palpation to assess location, size, shape, consistency, tenderness, pulsations and mobility of underlying organs and masses.
Genitalia – Inspect for the skin color and temperature, pubic hair distribution, ulcers, masses, scars, redness, swelling and discharges. Also, for the size and shape irregularities. Palpate for lesions, nodules or masses, tenderness, contour, size and induration. Palpate the inguinal area and anterior thigh.
Rectum – Inspect and palpate the anus, perianal region and sacral region for inflammation, nodules, scars, ulcerations, lesions and rashes or for any abnormal opening. Note any bulges after bearing down.
Musculoskeletal – Inspect the upper and lower extremities for size, shape, symmetry, deformity and muscle mass. Check the joints for range of motion, enlargement and masses. Note gait and posture. Check the spine for range of motion, lateral curvature, or any abnormal curvature. Observe for the signs of pain and inflammation. Palpate for tenderness, swelling, warmth, bony overgrowth, deformity and masses. Palpate the muscles for size, tone, strength, any contractures and tenderness. Palpate the spine for bony deformities and crepitation.
LANDMARKS FOR PHYSICAL EXAMINATION
Apices and bases of the lungs
The structural landmarks of the chest are clavicle, midsternal line, right/left anterior axillary line and the midclavicular line. On the sides, are posterior axillary line, midaxillary line and anterior axillary line. The anteroposterior (AP) diameter of the thorax in relation to the lateral diameter is approximately 1:2. Apices of the lungs – the land marks are manubrium, sternal notch and angle of Louis to assess the right/left upper lung lobes. Bases of the lungs – the land marks are xiphoid process, body of sternum and 4-7th ribs to assess the right/left lower lung lobes (Nettina, 2006; Laurente et al., 1997).
Horizontally, thoracic locations are identified according to their proximity to the rib or the intercostal space under the examiner’s fingers. On the anterior surface, identification of a specific rib is facilitated by first locating the angle of Louis. This is where the manubrium joins the body of the sternum in the midline. The second rib joins the sternum at this prominent landmark. Other ribs may be identified by counting down from the second rib. The intercostal spaces are referred to in terms of the rib immediately above the intercostal space; for example, the fifth intercostals space is directly below the fifth rib. Locating ribs on the posterior surface of the thorax is more difficult. The first step is to identify the spinous process. This is accomplished by finding the seventh cervical vertebra (vertebra prominens), which is the most prominent spinous process. When the neck is slightly flexed, the seventh cervical spinous process stands out. Other vertebrae are then identified by counting downward (Smeltzer & Bare, 2004).
Vertical landmarks start at the midsternal line passes through the center of the sternum. The midclavicular line is an imaginary line that descends from the middle of the clavicle. The point of maximal impulse of the heart normally lies along this line on the left thorax. When the arm is abducted from the body at 90°, imaginary vertical lines may be drawn from the anterior axillary fold, from the middle of the axilla, and from the posterior axillary fold. These lines are called, respectively, the anterior axillary line, the midaxillary line, and the posterior axillary line. A line drawn vertically through the superior and inferior poles of the scapula is called the scapular line, and a line drawn down the center of the vertebral column is called the vertebral line. Using these landmarks, for example, the examiner communicates findings by referring to an area of dullness extending from the vertebral to the scapular line between the seventh and tenth ribs on the right (Smeltzer & Bare, 2004).
The line between the upper and lower lobes on the left begins at the fourth thoracic spinous process posteriorly, proceeds around to cross the fifth rib in the midaxillary line, and meets the sixth rib at the sternum. This line on the right divides the right middle lobe from the right lower lobe. The line dividing the right upper lobe from the middle lobe is an incomplete one that begins at the fifth rib in the midaxillary line, where it intersects the line between the upper and lower lobes and traverses horizontally to the sternum. Thus, the upper lobes are dominant on the anterior surface of the thorax and the lower lobes are dominant on the posterior surface. There is no presentation of the middle lobe on the posterior surface of the chest (Smeltzer & Bare, 2004).
Auscultating Normal Heart Sounds
- First heart sound
- Second heart sound
To visualize the position of the heart under the sternum and the ribs, locate the intercostals spaces by identifying the angle of Louis felt as a slight ridge approximately 1 inch below the sternal notch where the manubrium and the body of the sternum are joined. The 2nd ribs extend to the right and left of this angle. Locate the 2nd rib, palpate downward and obliquely away from the sternum to identify the remaining ribs and intercostals spaces. Apical impulse can be located on the 5-6th intercostals space or just medial to the midclavicular line. Heart sounds can be auscultated over the pulmonic or aortic area. S1 is caused by the closing of the tricuspid and mitral valves. S2 results from the closing of the aortic and pulmonary valves. Aortic area found at the 2nd right intercostals space, close to the sternum. Pulmonic area is at the 2nd left intercostals space. Mitral area is the apex of the heart found at the 5th intercostals space or just medial to the midclavicular line, the apical beat (the point of maximal impulse). Tricuspid area is at the 5th intercostal space next to the sternum. The Erb’s point can be heard over the 3rd interspace close to the sternum.
S1 and S2 are heard as “lub” “dub”. In the aortic and pulmonic areas, S2 is usually louder than S1. In the tricuspid area, S1 and S2 are of almost equal in intensity and in the mitral area, S1 is often slightly louder than S2 (Nettina, 2006; Laurente et al., 1997).
Auscultating Bowel Sounds
Bowel sounds can be heard like “growling” sounds over the entire four quadrants of the abdomen (Nettina, 2006). The right lower quadrant (RLQ) is the best site to auscultate bowel sounds for immediate examination (Hayes, 2007). All areas (4 quadrants) should be assessed to examine the entire colon and to determine the area of obstruction.
Area of Liver Palpation
Palpate the liver by placing the left hand under the patient’s lower right rib cage and the right hand on the abdomen below the level of liver dullness (Nettina, 2006).
CLINICAL IMPLICATIONS AND RELEVANCE OF PHYSICAL ASSESSMENT PARAMETERS
Level of Consciousness
Level of consciousness is gauged on a continuum with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. The level of consciousness can be an indication of the heart’s ability to propel oxygen to the brain (cerebral perfusion). LOC is a very significant indicator of oxygenation and tissue perfusion. It is also necessary to detect evidence of neurologic problem, infection (sepsis), bleeding, decreased circulating blood, and fluid volume and cardiac output. The level of responsiveness and consciousness is the most important indicator of the patient’s condition (Smeltzer & Bare, 2004).
The rate and depth of respiration or the breathing pattern is a simple but important aspect of assessment. The normal breathing pattern is called eupnea. Bradypnea (slow breathing) is associated with increased intracranial pressure, brain injury and drug overdose. Tachypnea (rapid breathing) is commonly seen in patients with pneumonia, pulmonary edema, metabolic acidosis, septicemia, severe pain, and rib fracture. Hypoventilation has shallow and irregular breathing. An increase in depth of respirations is called hyperpnea. An increase in both rate and depth that a result in a lowered arterial PCO2 level is referred to as hyperventilation. With rapid breathing, inspiration and expiration are nearly equal in duration. Hyperventilation that is marked by an increase in rate and depth, associated with severe acidosis of diabetic or renal origin, is called Kussmaul’s respiration. Apnea describes varying periods of cessation of breathing. If sustained, apnea is life-threatening. Cheyne-Stokes respiration is characterized by alternating episodes of apnea (cessation of breathing) and periods of deep breathing. Cheyne-Stokes respiration is usually associated with heart failure and damage to the respiratory center (drug-induced, tumor, trauma). Biot’s respirations, or cluster breathing, are cycles of breaths that vary in depth and have varying periods of apnea. Biot’s respirations are seen with some central nervous system disorders. Certain patterns of respiration are characteristic of specific disease states (Smeltzer & Bare, 2004).
Breath sounds vary according to proximity of the large bronchi. Breath sounds are louder and coarser near the large bronchi and over the anterior. It is softer and much finer (vesicular) at the periphery over the alveoli. Vesicular breath sound has low pitch with soft intensity and located all over the lungs. Bronchovesicular has medium pitch with medium intensity heard near the main stem bronchi (below the clavicles and between the scapulae, especially on the right). Bronchial or tubular has high pitch and loud heard over the trachea. A disease will alter the normal bronchial, bronchovesicular and ventricular breath sounds. Adventitious sounds may indicate crackles, wheezes and ronchi. Sounds may normally decrease in obese patients (Nettina, 2006; Laurente et al., 1997).
Assessing peripheral perfusion such as skin color, capilly refill, temperature and sensations are indicators of peripheral oxygenation and venous / arterial blood flow. This will also detect if the blood vessels are constricted or dilated. This helps to assess the peripheral system blood flow and its ability and capacity to maintain an adequately circulating blood volume for tissue oxygenation. Also, this will help to assess not only the blood volume of the body but the ability of the heart to pump blood and test the functions of the cardio-pulmonary and hematologic system (Smeltzer & Bare, 2004).
Assymetrical Chest Expansion
Chest movement should be symmetric and without lag or impairment (Nettina, 2006). It is quite normal to see a slight retraction of the intercostal spaces during quiet breathing of thin patient. Bulging during expiration implies obstruction of expiratory airflow as seen in emphysema. Marked retraction on inspiration, particularly if asymmetric, implies blockage of a branch of the respiratory tree. Asymmetric bulging of the intercostal spaces, on one side or the other, is created by an increase in pressure within the hemithorax. This may be a result of air trapped under pressure within the pleural cavity where it does not normally appear (pneumothorax) or the pressure of fluid within the pleural space (pleural effusion). Respiratory excursion is an estimation of thoracic expansion and may disclose significant information about thoracic movement during breathing. This movement is normally symmetric. Decreased chest excursion may be due to chronic fibrotic disease. Asymmetric excursion may be due to splinting secondary to pleurisy, fractured ribs, trauma, or unilateral bronchial obstruction (Smeltzer & Bare, 2004).
Jugular Vein Distention
Jugular vein distention can be an indication for a suspected compromise cardiac function (Nettina, 2006). When the right ventricle fails, congestion of the viscera and the peripheral tissues predominates. This occurs because the right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation. The increase in venous pressure leads to jugular vein distention (JVD). JVD is associated with fluid volume overload and pulmonary congestion or edema. Also, it is associated with right-sided heart failure. Jugular vein distention is a sign of fluid and electrolyte imbalances and compromised regulatory mechanisms such as renal failure, heart failure, and cirrhosis and overzealous administration of sodium-containing fluids. Prolonged corticosteroid therapy, severe stress, and hyperaldosteronism augment fluid volume excess (Smeltzer & Bare, 2004).