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Physical Assessment Key Concepts

Two Components of Physical Assessment

  • Health History: Introduces the nurse-patient relationship and gathers essential information through effective communication, active listening, and therapeutic interaction.

    • Provides crucial information for focused assessments by identifying patient priorities, concerns, and perceptions of health and illness.

Components of Health History

  • Biographical Data

  • Chief Concern (CC): The primary reason for seeking care, stated in the patient’s own words, typically in quotes.

  • History of Present Illness (HPI): Provides a chronological account of the CC and its associated history, which may involve forward or backward chronology (must be consistent).

    • Summary of Symptoms includes:

    • Location: Ask patient to point, inquire if the pain radiates and its depth.

    • Character or Quality: Description of symptoms (i.e., "Feels like…").

    • Quality or Severity: Patient grades pain from 1-10.

    • Timing: Includes onset, duration, and frequency of symptoms.

    • Setting: The physical environment or any activities related to symptom onset and mental state.

    • Associated Manifestations: Other symptoms accompanying the CC.

    • Aggravating or Alleviating Factors: Includes self-treatment methods, OTC medications vs. prescribed ones.

    • Impact on Patient: Effects on work and activities.

  • Past Medical History (PMH): Information includes:

    • Childhood Illnesses:

    • Measles, Mumps, Chickenpox, Pertussis, Strep Throat, Rheumatic Fever, Scarlet Fever, Polio, Small Pox, Diphtheria, Chronic Ear Infections (document age, treatment, complications).

    • Immunizations:

    • MMR, Polio, DPT, Flu, Pneumococcal, Varicella, Hepatitis B, Meningitis, PPD, Td.

    • Adult Medical Illnesses:

    • Myocardial Infarction (MI), Cerebrovascular Accident (CVA), Diabetes Mellitus (DM), Hypertension (HTN), Cancer (CA), Peripheral Vascular Disease (PVD), Angina, Stroke, Chronic Obstructive Pulmonary Disease (COPD), Asthma, Gastroesophageal Reflux Disease (GERD), Renal Failure, Liver Disease, Thyroid Problems, Chronic Sinus Disorders, Mental Illness (document diagnosis and treatment).

    • Communicable Diseases:

    • AIDS, STDs, Herpes, Hepatitis (document symptoms, treatments, complications).

    • Surgeries, Serious Injuries, Accidents, or Hospitalizations: Must include dates and sequelae.

    • Medications: Both prescription and OTC, including herbal supplements (document dosages and frequencies).

    • Allergies: Document medications, food, environmental, environmental (include type of reaction and treatment).

    • Disabilities/Handicaps: Document types of limitations and coping mechanisms.

    • Gynecological History: Document relevant GYN history, blood transfusions, emotional status, alcoholism.

  • Family History (FH):

    • Document age, health status, and relationships of blood relatives.

    • Aim to establish a history of at least two generations.

    • Document history of diseases (as reviewed in PMH) and hereditary disorders.

    • Information may be listed or recorded in a pedigree diagram.

  • Current Health Status (CHS):

    • Personal Status: Includes birthplace, ethnic/cultural background, educational level, home environment, marital/relationship status, religious practices, economic status.

    • Occupation: Description of work, conditions, exposure to hazardous substances.

    • Habits: Caffeine, alcohol, drug use, etc.

    • Daily Living Characteristics: Sleep patterns, diet, exercise, use of natural or alternative remedies.

    • Sexual Practices.

    • Hobbies, Interests, Leisure Activities.

    • Stress: Sources and management techniques.

    • Recent Travel History: Including pleasure trips, particularly outside of the U.S. and any military service.

    • Health Habits and Check-ups: Document last physical exams, PAP, PSA tests, chest X-rays, eye, and dental exams, and any other relevant tests performed.

Review of Systems (ROS)

  • This section serves to determine any relationship between the CC and each body system.

  • Employ questions related to each major system while noting either positive or negative responses to avoid overlooking vital information.

Physical Examination

  • Inspection: The process of observation utilizing all senses to gather information throughout the history and physical examination.

    • Areas to inspect must be adequately exposed while ensuring patient and examiner modesty is honored as much as possible.

    • Observations include gait, stance, ease of movement, appropriateness of dress, eye contact, body language, and alignment of verbal and nonverbal cues.

    • Assessment of skin presentation and symmetry of bodily parts is essential.

Components of Inspection

  • Palpation: Using the sense of touch to collect objective information.

    • Light Palpation: Up to 1 cm depth.

    • Deep Palpation: 1-4 cm depth.

    • Evaluate areas of pain last, ensuring hands are warm and clean with short fingernails.

    • Employ palmer and finger pads to determine position, texture, size, consistency, fluid presence, crepitus, and mass structures.

    • Use the ulnar surface to assess vibrations and the dorsal surface to evaluate temperature.

  • Percussion: Striking one object against another to cause vibrations that generate sounds.

    • Tympanic: Drum-like sound (e.g., gastric bubble).

    • Hyperresonance: Boom-like sound (e.g., emphysematous lungs).

    • Resonance: Hollow sound (e.g., healthy lungs).

    • Dullness: Thud sound (e.g., over liver).

    • Flatness: Soft, dull sound (e.g., over muscle).

Types of Percussion

  • Direct: Striking the hand or finger directly against the surface.

  • Indirect: One hand's finger serves as a hammer while the other acts as the striking surface.

  • Auscultation: Listening to body-produced sounds, often utilizing a stethoscope, which augments the ability to hear internal sounds.

    • Use a stethoscope on bare skin to detect sounds accurately.

    • Bell: Used to listen for high-frequency sounds (e.g., blood flow).

    • Diaphragm: Used for low-frequency sounds (e.g., bowel gurgling).

Skin, Hair, and Nail Assessment

Skin Functions

  • Protection from external injury.

  • Acts as a barrier to minimize the loss of body fluids and electrolytes.

  • Facilitates wound repair.

  • Acts as a sensory organ.

  • Provides defense against bacterial and fungal invasion.

  • Regulates body temperature.

  • Produces Vitamin D.

  • Serves as a reservoir for blood.

  • Reflects emotional health.

Skin Layers

  • Epidermis: Outermost layer; thin, with a turnover rate of 3-4 weeks, responsible for skin tone.

  • Dermis: Comprised of blood vessels, nerve fibers, hair follicles, sweat glands, sebaceous glands, with collagen and elastin providing structural support.

  • Subcutaneous Tissue: Made of adipose tissue that provides insulation and adheres the skin to underlying structures.

Hair

  • Types:

    • Vellus: Short, fine, and faint (over most of the body).

    • Terminal: Coarser, thicker, and more visible (e.g., scalp, eyebrows).

  • Color: Determined by melanocytes in the hair shaft.

  • Function: Provides insulation, cushioning, and protection.

Nails

  • Matrix: Active growth area.

  • Nail Plate: Provides protection.

  • Color: Determined by vascular supply.

Glands

  • Sebaceous Glands: Secrete sebum for lubrication, connected to hair follicles.

  • Sweat Glands: Two types:

    • Eccrine: Spread throughout the body for temperature regulation.

    • Apocrine: Functional post-puberty in genital and axillary regions; secretion occurs during emotional stress and sexual stimulation.

Pigments

  • Melanin: Brown pigment; quantity genetically determined by the number of melanocytes.

  • Carotene: Yellowish, influenced by diet.

  • Oxyhemoglobin: Red pigment related to blood flow.

  • Deoxyhemoglobin: Bluish pigment associated with oxygen content in the blood.

Age and Condition Variations

  • Infants: Physiologic jaundice, vernix caseosa for protection, lanugo (downy hair shed), and milia (white papules); subcutaneous layer underdeveloped.

  • Adolescents: Development of terminal hair; enlargement of apocrine glands and sebaceous glands becoming more active.

  • Pregnancy: Increased body temperature, sweat, and sebaceous gland activity; hormonal changes lead to dark pigmentation.

  • Older Adults: May struggle with temperature regulation; epidermis thinning occurs; decrease in collagen and subcutaneous tissue resulting in gray hair due to reduced melanocyte functionality; nails may become thicker and brittle; senile lentigo ("liver spots").

Health History Detail on Skin, Hair, and Nails

Chief Concern (CC)

  • Dermatology-specific issues:

    • Rash, mole/spot, itchiness.

  • Impaired Skin Integrity:

    • Includes wounds, injuries, surgical incisions.

Past Medical History (PMH)

  • Skin, Hair, and Nails Related Illnesses: Eczema, psoriasis, or rosacea.

  • Allergies: Skin reactions related to allergies.

  • Skin Cancer: Documented instances or concerns.

  • Infections: Fungal infections, blistering sunburns, rashes (e.g., from poison ivy), and viral infections (e.g., shingles, herpes simplex virus I and II).

  • Infestations: e.g., head lice.

Family History (FH)

  • Skin-related cancers and disorders (e.g., psoriasis).

  • Maternal and paternal family history concerning skin-related issues.

  • Conditions affecting family members and/or causes of death, noting risks associated with family history.

Current Health Status (CHS)

  • Risk factors and lifestyle elements:

    • Alcohol use, smoking, physical activity, exercise, nutrition.

    • Use of tanning beds, sun protection, tattoos, piercings.

    • Overexposure to the sun during work or leisure activities.

    • Changes observed in skin/hair/nails such as dryness, bruising, nonhealing areas, lumps, moles, and warts.

    • Document hygiene habits for hair, nails, and skin—includes routines and products used.

Psychosocial Aspects

  • Address stress factors, environmental exposures (sun, wind, chemicals, etc.), and signs of habitual nail-biting or hair loss.

Review of Systems (ROS)

  • Recent changes noticed in skin, hair, and nails, along with chronic diseases that may relate (e.g., liver disease, kidney disease, CAD, COPD).

  • Determine skin cancer risk through factors like age, family history, extensive sun exposure, and previous sunburns.

Physical Examination of Skin, Hair, and Nails

Skin Inspection

  • Evaluate color, symmetry, hygiene, characteristics of lesions, and overall skin condition.

  • Skin Characteristics:

    • Macule: Less than 1 cm, a flat and non-palpable color change (e.g., freckle).

    • Patch: Greater than 1 cm (e.g., vitiligo).

    • Papule: Less than 1 cm, a palpable and elevated solid mass (e.g., wart, mole).

    • Cyst: A solid mass deeper within the skin.

    • Plaque: Greater than 1 cm in size (e.g., psoriasis).

    • Vesicle: Fluid-filled blisters, with larger blisters categorized as bullae.

    • Pustule: Related to acne or pimples.

    • Nodule: Ranges from 0.5 to 2.0 cm, solid and elevated, deeper than a papule.

    • Tumor: Greater than 2 cm, deep (e.g., breast carcinoma).

    • Wheal: Localized edema in the epidermis, size varies (e.g., insect bite).

Grouping of Lesions

  • Clustered: Grouped lesions (e.g., chickenpox).

  • Linear: In a line pattern (e.g., shingles).

  • Annular: Circular with ring patterns (e.g., hives).

Anatomical Location & Distribution of Lesions

  • Generalized vs Localized: Evaluation based on areas affected.

  • Secondary Lesions: Result from primary injury or changes.

Assessment of Ulcers

  • Stages based on depth and severity:

    • Stage I: Red without breakage.

    • Stage II: Damage through epidermis + dermis.

    • Stage III: Damage extends to subcutaneous tissue.

    • Stage IV: Damage includes muscle and potentially bone.

Other Skin Characteristics

  • Fissure: Linear crack extending through to the dermis, varies in size (e.g., chapped lips).

  • Scale: Flaking of keratinized cells (e.g., dandruff).

  • Keloid: A scar from a previous wound.

  • Excoriation: Loss of epidermal layer.

Carcinomas

  • Basal Cell Carcinoma: Most common, spreads locally, rarely metastasizes.

  • Squamous Cell Carcinoma: Second most common, potential for metastasis if untreated.

  • Malignant Melanoma: Arises from melanocytes, curable if caught early; will metastasize.

ABCD(E) Rule for Melanoma Detection

  • A: Asymmetry of lesion.

  • B: Border irregularities.

  • C: Color variation within the lesion.

  • D: Diameter greater than 6mm.

  • E: Evolving characteristics (size, shape, color change).

Palpation of Skin

  • Moisture: Measure hydration.

  • Temperature: Assess warmth.

  • Texture: Determine skin feel (smooth/rough).

  • Turgor: Assess elasticity and hydration.

  • Edema: Evaluate swelling.

Hair Inspection

  • Examine hair type, color, distribution, quantity, and signs of infestation. Palpate to assess texture.

Nail Inspection

  • Assess color, shape, presence of lesions, palpatability, thickness, adherence to the nail bed, and tenderness.

  • Measure base angle of the nail: Expected angle is 160 degrees; clubbing presents an angle greater than 180 degrees.

Assessment of the Lymphatic System

Lymphatic System Overview

  • Part of the immune system, responsible for fluid movement within a closed circuit, producing lymphocytes and antibodies, performing phagocytosis, and absorbing fats from the intestinal tract.

  • Relies on blood vessels in all areas except the placenta and the brain, functioning to drain and filter lymph fluid throughout the body.

Functions of the Lymphatic System

  • Moves fluids to maintain fluid balance.

  • Forms lymphocytes for immune response.

  • Functions in immune processing and absorption of dietary fats.

  • Provides a pathway for cancer spread.

Nodes

  • Numerous nodes, often less than 1 cm in diameter and found in groups; serve as early indicators of infection or malignancy.

  • Main Lymphatic Pathways:

    • Right Lymphatic Duct: Drains the right side of the body (head, neck, arm and thorax).

    • Thoracic Duct: Drains lymph from the rest of the body into the left subclavian vein.

Lymphatic System in Different Age Groups

  • Infants: Immune and lymphatic systems develop significantly by 20 weeks gestation, leading to vulnerability at birth. Full competency is reached in childhood.

  • Pregnancy: Hormonal changes can alter immune function.

  • Older Adults: Decreased lymphocyte counts may lead to a more fibrotic and fatty lymphatic system, resulting in a diminished capacity to combat infections.

History Taking in Assessment

  • Chief Concern (CC): may often be nonspecific, such as indicating enlarged nodes or related pain.

  • History of Present Illness (HPI): Symptoms related to potential infections should be documented.

  • Past Medical History (PMH): Document immunizations, recurrent infections, antibiotic use, blood transfusions, chronic illnesses, and cancers presented.

  • Family History (FH): Document relevant family history related to malignancies, infections, or immune disorders.

  • Current Health Status (CHS): As previously discussed for social aspects.

  • Review of Systems (ROS): Inquire about fatigue, anorexia, infection symptoms, and lymph node enlargements.

Physical Examination

Inspection Areas

  • Head, neck, supraclavicular, axillary, elbows, and inguinal regions for signs of erythema, red streaks, enlargement, edema, or skin lesions.

Palpation Techniques

  • Utilize the pads of the second, third, and fourth fingers to palpate for superficial lymph nodes, employing gentle to firmer pressure in circular patterns for assessment.

  • Observations:

    • Small nodes (<1 cm) that are movable and discrete may be palpated; normally not found in healthy adults.

    • Enlarged, hard, tender, or immobile nodes are suggestive of pathology.

Lymph Node Assessment

  • Palpate for superficial lymph nodes:

    • Head: Occipital, Pre-auricular, Post-auricular, Tonsillar, Submaxillary, Submental.

    • Neck: Anterior and Posterior cervical chains, Supraclavicular (often indicating malignancy).

    • Axillary Region: Lateral (brachial), Central, Posterior (subscapular), Epitrochlear nodes.

  • Inguinal Nodes: Position patient supine with knees slightly flexed; normal size is <2 cm. In males, drainage from testes leads to abdominal nodes, while females drain into pelvic nodes.

Summary of Findings

  • Easily palpated lymph nodes are typically not found in healthy adults.

  • Small, non-tender nodes under 1 cm represent a normal variation.

  • Enlarged, hard, immobile nodes require evaluation for potential causes.

  • Enlarged, warm, tender nodes may indicate inflammation or infection.

Assessment of the Abdomen

Functions of the Digestive System

  • Eat: Ingest food for energy and nutrients.

  • Absorb: Nutrients from food are absorbed into the bloodstream.

  • Eliminate: Waste products from metabolism are excreted.

Anatomy Overview

  • Esophagus: Approximately 10 inches long.

  • Stomach: Composed of Fundus, Body, and Pylorus.

  • Small Intestine: Approximately 21 feet long, divided into:

    • Duodenum: 12 inches long.

    • Jejunum: 8 feet.

    • Ileum: 12 feet.

  • Appendix: Located at the base of the cecum.

  • Large Intestine (Colon): 4.5-5 feet long, structured into:

    • Ascending, Transverse, Descending, and Sigmoid sections.

  • Liver, Gallbladder, Pancreas, Spleen, Kidneys, Bladder, and Aorta are also significant anatomically.

Quadrant Contents

  • RUQ: Liver and gallbladder, pylorus, duodenum, head of pancreas, right adrenal gland, upper right kidney, portions of ascending and transverse colon.

  • LUQ: Portion of liver, spleen, stomach, body of pancreas, left adrenal gland, upper left kidney, portions of transverse and descending colon.

  • RLQ: Lower right kidney, cecum and appendix, ascending colon, distended bladder, right ureter, right ovary, right spermatic cord.

  • LLQ: Lower left kidney, sigmoid colon, distended bladder, left ureter, left ovary, left spermatic cord.

Age & Condition Variations

  • Infants & Children: Round bellies, thin skin; audible percussion and bowel sounds, may observe umbilical hernias; feeding patterns frequent (2-3 hours).

  • Pregnancy: Vomiting and nausea changes, with space restrictions affecting bowel sounds; potential for constipation and hemorrhoids; skin changes such as stretch marks.

  • Older Adults: Common development of constipation from decreased peristalsis, hydration issues, declines in liver size, and changes in taste perception affecting appetite.

History Assessment

  • Chief Concern: Document any gastrointestinal symptoms present.

  • HPI: Includes all relevant symptoms related to digestion.

  • Past Medical History (PMH): Surgeries, illnesses such as Crohn’s disease or ulcerative colitis, cancers affecting the GI tract.

    • Document gastrointestinal bleeding history (e.g., upper bleeding as coffee grounds, lower as bloody stool).

    • Any allergies related to food or medications.

  • Family History (FH): Gather details about colon cancer, Crohn’s disease, allergies, diverticulitis, polycystic kidney disease, and obesity prevalence.

  • Current Health Status (CHS): Conduct a 24-hour diet recall, evaluate elimination patterns, discuss stress responses, and document the first day of the last menstrual period.

  • Review of Systems (ROS): Assess known GI or GU issues and chronic illness histories, while screening for colon cancer risk via age, family history, dietary habits, and lifestyle factors.

Physical Exam Preparation

Landmarks

  • Quadrants: Recognize RUQ, LUQ, LLQ, RLQ for effective assessment.

Inspection Techniques

  • Evaluate skin characteristics: color, tattoos, piercings, stretch marks, and scars.

  • Examine contour for stomach shape (flat, round, distended) and surface motion for observable movement.

Auscultation Techniques

  • Use diaphragm for bowel sounds and bell for vascular sounds, assessing each quadrant.

Bowel Sounds Evaluation

  • Active Bowel Sounds: Gurgling 5-35 times a minute.

  • Hyperactive Bowel Sounds: Indicates increased motility of bowel (e.g., diarrhea, vomiting).

  • Hypoactive Bowel Sounds: Suggest decreased motility (e.g., constipation).

  • Absent Bowel Sounds: Associated with bowel obstruction, requiring immediate verification and addressing.

  • Borborygmi: Loud, growling sounds that can be audible beyond the stethoscope.

Vascular Sounds Assessment

  • Bruit: Wooshing sounds detected above the belly button that indicates turbulent blood flow, which may suggest plaque accumulation.

  • Use the Bell of the Stethoscope: For optimal assessment of vascular sounds in this region.

Percussion Techniques

  • General assessment across all four quadrants.

  • Liver: Upper edge should be found at the 5th intercostal space, lower edge less than 2-3 cm below the costal margin (document as “liver of expected size”).

  • Kidneys: Use fist percussion at the back to assess kidney tenderness.

  • CVA: Assess for kidney tenderness through careful percussion.

Palpation Techniques

  • Always assess painful areas last, while being mindful of nonverbal cues.

  • Light Palpation: Up to 1 cm, utilizing fingertips effectively.

  • Deep Palpation: 2-3 inches to detect any masses.

  • Rebound Tenderness: Noteworthy experience where pain is more pronounced upon release than with direct push, indicating potential pathological concerns.