Presented

By: Sandeep
Yadav M.Sc. (N)
1st year KGMU
lucknow
OBJECTIVES
Define the physical examination
Explain the purposes
Discuss the indication
Enlist the articles
Discuss the pre-procedural steps
Explain the procedure and demonstrate
Dicuss the post procedural steps
Discuss about the nursing responsibilities.
INTRODUCTION
 A comprehensive head-to-toe assessment is
done on patient admission or in community
centre, and when it is determined to be
necessary by the patient’s health status. The
head-to-toe assessment includes all the body
systems, and the findings will inform the health
care professional on the patient’s overall
condition.
DEFINITION
 It is the systematic collection of objective
information that is directly observed or
is elicited through examination
techniques.
PURPOSES
To understand the physical and mental well
being of the patient.
To detect diseases in early stages.
To determine the cause of disease.
To understand any changes in the condition of
diseases, any improvement or deterioration.
INDICATIONS
check for possible diseases so they can be
treated early
identify any issues that may become medical
concerns in the future
update necessary immunizations
ensure that you are maintaining a healthy diet
and exercise routine.
ARTICLE
S
GLOVES
SPHYGMOMANOMETER
STETHOSCOPE
FETOSCOPE
TONGUE DEPRESSOR
FLASH LIGHT
TAPE MEASURE
WEIGHING MACHINE
LARYNGOSCOP
E
OPTHALMOSCOPE
OTOSCOPE
TUNNING FORK
NASAL
SPECULUM
PERCUSSION HAMMER
VAGINAL SPECULUM
PRCOTOSCOPE
WATC
H
SCALE WITH HEIGHT
MEASURE
SNELLEN CHART
PULSE OXYMETER
COMMUNITY
BAG
COTTON BALL
COTTON APPLICATOR
LUBRICANT
DISPOSABLE NEEDLE
& SYRINGE
GAUZE, BANDAGES
PAPER TISSUE
SPECIMEN CONTAINER
PRE-PROCEDURAL
STEPS
 Prepare yourself
 Prepare environment
 Prepare the client
 Psychological preparation of client like—Remain calm
,Explain each procedures, Allow client to feel free to
ask questions and mention any discomfort, give
comfortable position like—sitting, prone, supine,
knee chest, lithotomy etc.
 Hand hygiene
 Introduce yourself to patient.
 Confirm patient ID using two patient identifiers (e.g.,
name and date of birth).
 Use appropriate listening and questioning skills.
 Listen and attend to patient cues.
 Ensure patient’s privacy and dignity.
 Make patient comfortable.
 Ensure working condition of equipment.
 Check vital signs.
PROCEDURE
STEPS
IDENTIFICATIO
N
 Full name ----
INFORMATION
 Age ----
 Gender ----
 Father name ----
 Mother name -----
 Education status
-----
 Caste & religion
----
 Address ----
 Occupation -----
EXAMINA
TION
HEAD TO
TOE
GENERAL
APPEARANCE:-
Nourished – well nourished/ undernourished
Body build—thin/obese
Activity—active/dull
Look—anxious/worried/happy
HEAD &
FACE:-
Shape of skull—round in shape/oval/flat/any
injury/any suture
Scalp—cleanliness/hair condition/dandruff /
pediculi /infection like ringworm
Shape & colour of hairs or any other.
Face—colour like pale /flushed / puffiness
/fatigue /pain /fear/anxiety/enlargement of
parotid gland etc.
MOUTH
 Lips—normal (pink or moist) /abnormal (swelling
/crusts/cyanosis/redness/angular stomatitis)
 Odour of mouth—foul smelling or other
smelling
type
 Mucus &Gums—ulceration and
membrane
bleeding/swelling /pus formation
/tongue pale or dry/any lesions/ sores/
/gingivitis
furrows/ tongue tie/ coated
 Throat & pharynx—enlarged tonsils/redness/pus
 Teeth—normal/plague/tarter/dental
caries/pyorrhea/any other
TONGUE FURROWS-TOUNGE TIE
TONSILS --- TARTER TEETH
PYORRHEA --- GINGIVITIS
 EYES
 Eye brows—normal /absent
 Eyelashes—infection/sty
 Eyelids--oedema/ lesion/ ectropion (eversion)/ entropion (inversion)
 Conjunctiva—pale/red/purulent
 Eye ball—sunken/protruded
 Sclera—jaundiced
 Fundus—congestion/hemorrhagic spots
 Eye muscles—strabismus(squint)
 Lens—opaque/transparent
 Cornea—normal/abnormal
 Pupils –dialted/constricted/reaction to light
 Vision—normal/ myopia/ hypermetropia/ any
other/lacrimal obstruction.
INVERSION EVERSION
NOSE
External nares—crusts or discharge
Nostrils—inflammation of the mucus
membrane/septam deviation.
NECK
Lymph nodes—enlarged and palpable
Thyroid gland—enlarged
Range of motion—flexion/extention and
rotation
LYMPH NODES
EAR
Discharge /cerumen obstruction/ perforation/
fungal infection/ any other specify
Hearing—normal /abnormal
PERFORATION OF EAR
SKIN
Colour—pallor/jaundice/cyanosis/flushing etc.
Texture—dryness/flaking/wrinkling or
excessive moisture
Temperature—warm/cold and
clammy
Lesions—macules/papules/vesicles/wound
pastule/any other abnormally specify
FLUSHING SKIN
FLAKING SKIN
NAILS
Normal/clubbing/fungal inection/brittles
nails/soft/whitish/any others specify
BRITTLE NAILS – FUNGAL NAILS
EXTREMITIES

Movements of joints/tremors/clubbing of
fingers/ankle oedema/varicose
vein/reflexes
ANKLE OEDEMA—VERICOSE VEIN
ABDOMEN
Skin rashes /scar /hernia /ascitis/ distension
/palpable spleen/tenderness/presence
of gas/fluid or masses present
POSTURE
Body curve—lardosis/kyphosis/scoliosis
Back—spina bifida/curves
Gait—normal/abnormal
CARDIOPULMONARY
SYSTEM
Cough/wheezing/crackles/tachycardia/bradycar
dia/palpitation/cardiac murmur/any other
specify
GASTROINTESTINAL
SYSTEM

Normal/diarrhea/constipation/ulcer/nausea/
vom iting/acidity/spasm/abdominal
distention/bowel movements/any other
FUNDAMENTAL SIGNS
Height
Weight
Temperature
Pulse/heart rate(per minute)
Respiration(beats per minute)
Blood pressure(mm/hg)
ACTIVITIES OF DAILY
LIVING
PERSONAL HYGIENE HABITs
 Bathing pattern—daily/alternate/no fix/less
frequent
 Water preference for bathing—
hot/cold/lukewarm
 Oral care—one time in a day/morning and
evening/more frequent
 Oral care method—uses finger
cleaning/toothbrush/neem stick
 Oral care content—use
SLEEPING
PATTERN
Type of sleeping—sound /disturbed
No. of sleeping hours—at night/during day
ILL
HABITS
Smoking—yes/no if yes-no. of cigarette/Biri
per day
Drinking—yes/no, if yes,
habitual/social/occasional/addicted
/
Chews(tobacco)—yes/no,if yes,
specify brand
Any other habit affecting health
NUTRITIONAL HABITS
Like/dislike of food
Food pattern—veg/nonveg/eggtarian
Frequency in a day
Appetite—good/moderate/poor
Any other important information about
nutrition
ELIMINATIO
N
ACTIVITIES
Bowel pattern—no. of bowel movement/day
Any other difficulty (as constipation,diarrhea
ets)
Urinary pattern—friquency of micturition
times/day or times/night any other difficulty
(as nocturia,dysuria,incontinence etc)

REPRODUCTION
(FOR FEMALE)
Menstruation—
regular/irregular/dysmenorrhoe
a
If amenorrhea LMP
If abnormal, specify sexual
disorder/dysfunction
FOR MALE
•Lesions, pain, prostate problems, infections,
discharge, testicular pain
•Pubic region: Assess for normal hair distribution
and presence of body lice and see any
tenderness, masses present in pubic region.
•Penis: identified if patient circumcised or
uncircumcised. If uncircumcised , ask the pt
to retract the foreskin himself
Contd..
•Palpate the testes for tenderness or masses
•testes are normally equal in size, however
when the male is standing, it is normal for one
testicle to be lower in the scrotal sac than the
other. Observe the penis and testes for any
lesions or rashes.
 LABORATORY
INVESTIGATION/CLINICA
L DIAGNOSTIC REPORT
Description of the investigation

TREATMENT
REPORT
Description of the treatment
PERSON HEALTH
CONDITION(ON THE BASIS
OF PHYSICAL
EXAMINATION,DIAGNOSI
S AND TREATMENGT
HISTORY)
POST PROCEDURAL
STEPS
Record findings and assessment performa
Make patient comfortable
Replace all articles back in utility room after
cleaning and disinfection
Give relevant health education according to
history and physical assessment.
NURSING
RESPONSIBILITIES
Provide the psychological support to the patient
Provide comfortable position
Identify the patient for the procedure
Take care of all articles before examination
check all articles are working correctly or
not
Provide comfortable environment to the client
like- light, temperature etc.
Maintain privacy for the patient
CONCLUSION
Physical Examination is important for everyone.
It is an assessment in which we judge the
physical quality of the person. It is an evaluation
in which we detect a disease in the person who
look and feel well by taking a physical exam.
The technique of assessment involves
inspection, palpation, percussion and
auscultation.
Evaluation/recapitalization
Define the physical examination
Explain the purposes
Discuss the indications
Enlist the articles
Discuss the pre-procedural steps
Explain the procedure
Discuss the post procedural steps
Discuss about nursing responsibilities
Bibliography
Ghai Sandhya, Textbook of Clinical Nursing
Procedures, CBS Publishers & Distributors
Pvt. Ltd., Page No. 204 to 212