GENERAL SURVEY, PHYSICAL

EXAMINATION TECHNIQUES

53081 SN2123
LEARNING OBJECTIVES

• List the components of a general survey

• Recognize normal findings in general survey
• Recognize that senses can be sharpened to enhance
the physical assessment process
• Identify the 4 physical assessment techniques and
describe the use of each technique
• Identify the best use of different parts of hands for
assessing different factors
LEARNING OBJECTIVES
• Demonstrate the correct technique used for physical
assessment
• Understand the basic principles of sound
• Name the various notes produced by percussion
• Understand the basic principles for the use of
stethoscope
• Understand the basic principles to determine the
sequence of physical assessment techniques
General Survey
GENERAL SURVEY

• A study of the whole person, covering the

general health and any obvious physical
characteristics.
• Prior physical examination & after history taking.
• Basically: an observation skill
• First encounter, then subsequent findings
• Areas: physical appearance, body structure,
mobility, behavior & vital signs.
PHYSICAL APPEARANCE

• Age - appear as the stated age?

• Sex – sexual development appropriate for gender &
age?
• Level of consciousness – alert, responds
appropriately?
• Skin color – colour tone even, no obvious lesions?
• Facial features – symmetric with movement?
BODY STRUCTURE

• Stature – within normal range for age?

• Nutrition – weight within normal range for height &
body build?
• Symmetry – body parts equal bilaterally?
• Posture – stands comfortably?
• Position – sit or lie comfortably & relaxed?
• Body build, contour – proportion as:
• Arm span equals height
• Body length: crown to pubis ≈ pubic to sole
MOBILITY

• Gait
• Base as wide as shoulder width
• Walk is smooth, even & well-balanced
• Symmetric are swing
• Range of motion
• Full ROM for each joint
• Smooth & coordinated
BEHAVIOR

• Facial expression
• Eye contact
• Expressions appropriate to situation
• Mood and affect
• Cooperative & interact pleasantly
• Speech
• Articulation clear & understandable, fluent stream of talking.
• Dress
• Appropriate, fit & clean
• Personal hygiene
• Groomed appropriately for age, occupation & socioeconomic
groups
VITAL SIGNS

• 5 main vital signs consists of

• Temperature
• Pulse
• Respiration
• Blood pressure
• (Pain)
Physical Examination
PHYSICAL EXAMINATION

• Purposes
• To obtain baseline data about the client’s functional abilities
• To supplement, confirm, or refute data obtained in the nursing
history
• To obtain data that will help the nurse establish nursing diagnoses &
plan the client’s care
• To evaluate the physiological outcomes of health care, & thus the
progress of client’s health problem
• To make clinical judgments on client’s health status
PHYSICAL EXAMINATION

• Definition
 A physical examination is an evaluation
of the body and its functions
• Using inspection, palpation (feeling with
the hands), percussion (tapping with the
fingers), and auscultation (listening)
 An objective type of data
PHYSICAL EXAMINATION

• General Principles
 Physical examination is to be conducted following a
careful comprehensive / problem-focused history
 Conduct in a quiet and well-lit room
 When possible, begin with patient in a sitting-up
position
 Expose only the area to be examined
 Conduct the examination systematically so as to
avoid missing any body system
PHYSICAL EXAMINATION

• General Principles (cont’d)

 Consider underlying anatomical structures, their
functions and possible abnormalities while
performing the examination
 Compare findings with the same area on the
opposite side of body
 Explain the procedure to the client before and
during the examination
PHYSICAL EXAMINATION

• Planning
Nurse
 Perform hand washing before approaching client
 Warm hands
Equipment
 Prepare and organise necessary requisites such as
stethoscope, pen-light, tendon hammer, etc.
PHYSICAL EXAMINATION

Client
• Explain the procedure before and during examination
• Ensure client empties bladder or bowel before
examination
• Ensure client is appropriately dressed or draped
• Assist client to a comfortable position
• Avoid unnecessary changes in position
PHYSICAL EXAMINATION

Environment
 Ensure privacy
 Ensure good lighting
 Quiet examination room
eliminate sources of noise
 Ensure that the room is warm enough for client’s
comfort
PHYSICAL EXAMINATION

• Technique
• Inspection, Palpation,
Percussion, and Auscultation (
IPPA)
• Head-to-toe examination
INSPECTION

• Begins the moment you first

meet the client as in general
survey
• The first step of physical
examination
• Watching without some
instruments or with instruments
to enlarge the view (otoscope,
ophthalmoscope)
• Adequate lighting.
INSPECTION

• Make comparison of both sides of the body

• Client as control
• Symmetry
• general survey
• review of systems
• What should be inspected?
• size
• color
• shape
• lesion, would, scar
• pigmentation
PALPATION

• Second step
• May help to confirm what you see
• Touching with various parts of the hands: fingertips, dorsa,
pads of fingers, palmer or ulnar surface of the hand,
• Fingertips: for fine tactile discrimination eg skin texture,
swelling, pulsation;
• Pads of fingers: organ location and size, consistency;
• Dorsal of hands: best for determining temperature;
• Base of fingers (MCPJ) or Ulnar surface of the hand:
vibration
PALPATION

• Guidelines for palpation

 Hands should be clean & warm with finger nails
short.
 Gentle, slow and systematic.
 Palpate tender areas last.
 Instruct client to tell any pain or discomfort
during palpation.
PALPATION

Light palpation
• Perform first, 1 to 2 cm.
• Detect surface
characteristics.
• Effectively assess pulsation,
skin turgor, moisture, edema,
areas of tenderness, superficial
tumor or masses.
PALPATION

• Deep palpation
 After light palpation, 2- 4 cm
 Intermittent better than long
continuous palpation
 Effectively assess abdominal
masses, deep tenderness or
enlarged organs
PALPATION

• Bimanual palpation
• Used when deep palpation is
difficult to be performed
• Deep palpation but with
both hands
• Envelope or capture certain
body parts or organs eg
kidney, uterus.
PERCUSSION

• Third step
• Tapping client’s skin with short, sharp strokes to
assess underlying structures
• Yield palpable vibration & characteristic sound that
depict location, size and density of the underlying
organ
• Direct (one hand) and indirect percussion (both
hands).
PROCEDURE (INDIRECT)

• Stationary hand:
• Hyperextend M/F (pleximeter);
• Place DIPJ(distal interphalangeal joint) firmly against the skin;
• Avoid bony parts; (always “DULL”)
• Lift the rest of the stationary hand up off the skin.

• Striking hand:
• Use M/F of your dominant hand (plexor), keep flexed;
• With upper arm & shoulder steady;
• Action in the wrist;
• Spread other fingers, bounce M/F (with finger tip) off the M/F of
stationary hand.
• Percuss twice in each region.
PERCUSSION

• Sounds heard on percussion

• Basic principle: a structure with relatively more air (e.g.
the lung) produces a louder, deeper and longer sound.

• Components of sound:
• Amplitude (intensity)
• Pitch (frequency)
• Quality ( ~ tone)
• Duration (length of time the note lingers)
PERCUSSION: 5 PERCUSSION NOTES

• 5 percussion notes:
• Hyper-resonant
• Resonant
• Tympany
• Dull
• Flat
 PERCUSSION TONES

Air-filled
Air-filled Tones Examples Intensity Duration Pitch
Duratio Quality
Quality
structure
structure of the
of the =amplitude
=amplitude n (Frequen
(Frequen
structure
structure cy)
cy)
More air-filled
More air-filled Hyper-
Hyper- Normal
Normal Louder
Louder Longer
Longer Lower
Lower Booming
Boomin
structure
structure resonant
resonna child
child lung
lung g
nt
Resonant Normal
Normal Medium-
Medium- Moderate Low
Low Clear,
adult
adult lung
lung loud
load long
long hollow
hollow

Tympany Stomach Loud

Loud Long
Long High
High Musical
Musical
and
and and
and
intestinal
intestinal drum
drum like
Dull Liver
Liver and
and Soft Short High
High like
Muffled
Muffled
spleen
spleen bang
thud
Less air-filled
air-filled Flat
Flat Muscles Very
Very soft
soft Very
Very High
high Absolute
Absolute
structure
structure and bone
and bone short
short dullness
dullness
AUSCULTATION

• The last step

• Your ears OR instrument--Stethoscope
• What is the use of the Diaphragm?
• What is the use of the Bell?
• What is the use of auscultation?
• What environmental or client preparation do you
need to ensure the accuracy of the auscultation?
AUSCULTATION:
STETHOSCOPE

• Listening to the sound with a stethoscope

produced by the body
• Such as, the heart, blood vessels, lungs, and
abdomen through a stethoscope
• Stethoscope does not magnify sound but
eliminate extraneous environmental sounds.
AUSCULTATION

• Diaphragm:
• Most often use
• Flat edge.
• Best for high-pitched sounds.
• Breath, bowel, & normal heart sounds.
• Bell:
• Deep, hollow cuplike shape.
• Best for soft, low-pitched sounds.
• Extra heart sounds or murmurs
 AUSCULTATION

• Beware of extraneous  Observe for the

sounds which can be characteristics of
produced by clothing, hair, sounds:
movement of the head of
1. Frequency
stethoscope – these
sounds should be 2. Loudness (auscultation sounds
disregarded! described as loud or soft)
3. Quality (e.g. gurgling, blowing)
4. Duration (short, medium or
long) – layers of soft tissue
dampen duration of sounds
from deep internal organs
SEQUENCE OF 4 PHYSICAL
EXAMINATION TECHNIQUES
• Basic principles: less to more body contact; less
to more stimulative, less to more accuracy
• normal sequence: inspection, palpation,
percussion, & auscultation
• abdominal system: inspection, auscultation,
percussion, & palpation
• special senses & breast examination: no
percussion & auscultation
REFERENCES

• Bickley, L.S. & Hoekelman, R. A. (2007). Bates’ guide to physical

examination and history taking (9th ed.). Philadephia: Lippincott.
• Kozier, B., Erb, G., Berman, A., & Snyder, S. (2008). Fundamentals of
nursing : Concepts, process, and practice (8th ed.). New Jersey:
Pearson.
• Lynn, P. (2008). Taylor’s Clinical Nursing Skills: a nursing process
approach (2nd ed.). Philadephia: Lippincott.