Physical Assessment Skills

1. Physical Assessment Skills EmtenanAlharbi , MSc. Department of Clinical Pharmacy

2. Pharmacists & Physical Examination • Pharmacists do not perform a complete physical examination • It is important, however, to be familiar with the physical examination in terms of the principles, methods, and data obtained to understand findings documented by other healthcare professionals

3. Basic Principles of Physical Examination • Objective of physical examination (PE): • Obtaining valid info about health status of the patient • This is achieved by: • Identifying ‘’normal’’ state • Identifying any variations from ‘’normal’’ state by: • Validation of patient’s complaints & symptoms • Screening of the patient general well-being • Monitoring of the patient’s current health problems

4. Basic Principles of Physical Examination • The medical record consists of both subjective and objective information. • Subjective: • Subjective information is acquired during patient interview & from the health history. • It alerts the examiner regarding areas on which to concentrate during examination. • Objective: • Objective information is obtained through the physical examination.

5. Methods of Assessment • Four assessment techniques are used during PE: • Inspection • Palpation • Percussion • Auscultation • They should always be accomplished in the order given above, with each technique amplifying the results obtained from the previous one.

6. Methods of AssessmentInspection • Inspection is the visual looking at and evaluating of a person. • Examiner uses the sense of sight to concentrate attention on the thorough, persistent, unhurried visualization of the patient. • It starts from the moment of first meeting through obtaining the patient history & throughout entire physical examination.

7. Methods of AssessmentInspection • Observe the patient’s: • Breathing • Gait • Personal grooming • Body habitus (physical characteristics) • Body position (e.g. sitting comfortably, leaning forward) • Affect (mood) & its appropriateness to the situation • Skin for color, presence of lesions or trauma

8. Methods of AssessmentPalpation • Palpation is touching or feeling with the hand • Palpating individual structures on the surface and within the body cavities, particularly the abdomen: • Elicits important information regarding the position, size, shape, consistency, & mobility of the normal anatomic components • Uncovers crucial clues to the presence of abnormalities such as enlarged organs and palpable masses. • May be effective in assessing fluid within a space.

9. Methods of AssessmentPalpation • Can be performed with the fingertips, palm, or back of the hand • Palpation may be: • Light • Medium • Deep

10. Methods of AssessmentPalpation • Light palpation • Always used first • Superficial, gentle, and useful in assessing for lesions on the surface or within muscles. • Serves to relax the patient in preparation for medium and deep palpation • Performed by pressing the pads of the fingers lightly into the patient’s skin, moving the fingers in a circular motion.

11. Methods of AssessmentPalpation • Medium palpation • Assesses for midlevel lesions of the peritoneum and for masses, tenderness, pulsations, & pain in most structures of the body. • Performed by pressing the palmar surface of the fingers 1-2 cm into the patient’s body, using a circular motion.

12. Methods of AssessmentPalpation • Deep palpation • Assesses organs deep within the body cavities, and it may be performed with one or two hands • At times, it may be necessary to cause the patient some discomfort or pain to fully assess a symptom.

13. Light Vs. Deep Palpation

14. Methods of AssessmentPercussion • Involves striking the body’s surface lightly, but sharply, to determine the position, size, and density of the underlying structures as well as to detect fluid or air in a cavity. • Sound reverberations assume different characteristics depending on the features of the underlying structures. • The resultant sound is described as one of the following: • Flat • Dull • Resonant • Hyper-resonant • Tympanic

15. Methods of AssessmentPercussion • The percussion notes are identified and characterized as follows: • Pitch(also known as frequency) is the number of vibrations or cycles per second (cps). Rapid vibrations produce a higher-pitched tone, whereas slower vibrations produce a lower-pitched tone • Amplitude (also known as intensity) determines the loudness of the sound. The greater the intensity, the louder the sound • Duration is the length of time that the note lingers • Quality a subjective concept used to describe the variance secondary to a sound’s distinctive overtones

16. Percussion Sounds

17. Methods of AssessmentPercussion • Methods of percussion: • Direct percussion • Tapping patient’s body directly with the distal end of a finger • Indirect percussion • Using either the index & middle finger or just the middle finger of one hand, which strikes against the middle finger of the other hand. • Touch patient only with the finger that is being tapped (to avoid dampening the sound) • Another method: tap middle finger with the rubber head of a reflex hammer

18. Methods of AssessmentIndirect Percussion

19. Methods of AssessmentPercussion • Direct and indirect percussion can also be accomplished with the fist. • Direct fist percussion involves making a fist with the dominant hand and then striking the body’s surface directly. • Indirect fist percussion, one hand is placed firmly on the body while the fist of the dominant hand does the striking.

20. Methods of AssessmentFist Percussion

21. Methods of AssessmentAuscultation • Auscultation is the skill of listening either directly with the ear or indirectly with a stethoscope to sounds that arise spontaneously from the body • Examples: breath sounds, heart sounds, bowel sounds, bruits • The stethoscope end piece has both a diaphragm and a bell

22. Methods of AssessmentAuscultation • The diaphragm is used to amplify high-pitched sounds (e.g. breath, bowel, heart) • The bell is reserved for low pitched sounds (e.g. heart murmurs, arterial (bruits) or venous (hums) turbulence, & organ friction rubs)

23. Preparing For The ExaminationGathering the Equipment

24. Gathering the Equipment • Flashlight • Assess pupillary reflexes, aid in inspection of oropharynx & skin

25. Gathering the Equipment • Ophthalmoscope • Perform fundoscopic examination

26. Gathering the Equipment • Otoscope • Assess external ear canal and tympanic membranes

27. Gathering the Equipment • Tongue Depressor • Move or hold tongue out of the way to inspect oropharynx

28. Gathering the Equipment • Watch (digital or sweep second hand) • Assess heart & respiratory rate

29. Gathering the Equipment • Thermometer • Measure body temperature

30. Gathering the Equipment • Stethoscope • Consists of 2 earpieces, rubber tubing, head with diaphragm & bell or diaphragm only • Diaphragm accentuates high-frequency sounds • Bell transmits low frequency sound • Assess CV, pulmonary, abdominal systems

31. Gathering the Equipment Bulb • Sphygmomanometer • Measures blood pressure (BP) • Consists of: • Cuff • Valved rubber bulb for inflating cuff • Manometer to measure cuff pressure Cuff Valve Manometer

32. Gathering the Equipment • Sphygmomanometer • Cuffs come in variety of sizes to accommodate different arm sizes • Cuffs that are too short or narrow falsely elevate BP and too big cuffs decrease BP • Cuff width should be ~ 40% of limb circumference, length ~ 80% of limb circumference

33. Gathering the Equipment • Sphygmomanometer • Mercury Based Sphygmomanometer • Durable, easy to read, consistent accurate measurement • Bulky, must be upright & at eye level to ensure accuracy, mercury is hazardous substance • Aneroid Sphygmomanometer • Inexpensive, work in all positions • Delicate, recalibated if bumped or dropped • Automatic Sphygmomanometer

34. Gathering the Equipment • Reflex Hammer (Percussion Hammer) • Consists of rubber head attached to handle • Used mainly to elicit superficial & deep tendon reflexes • May be used to create percussion notes • Pointed end of the head is used to strike tendon & elicit reflex

35. Gathering the Equipment • Tuning Fork • Consists of a handle & 2 prongs that form a U-shaped fork • Vibrates at a set frequency after being stuck on heel of hand • Used to assess vibratory sensation & auditory testing Vibratory Sensation Auditory Testing

36. The Examination

37. Performing the Examination • Meet the patient in either a clinic room or a hospital room. • Wash hands in the patient’s presence, if possible. • After the patient history, obtain vital signs. • The examination begins with the practitioner positioned on or toward the patient’s right side. • The patient is in the sitting, Fowler’s, or semi-Fowler’s position.

38. Performing the Examination • Considering patient privacy and modesty, the examiner must be discreet yet fully expose each area to be examined to ensure accurate findings • The examination should proceed in a methodical, slow, and deliberate manner, with the practitioner asking questions and encouraging the patient to ask questions • Each step should be explained as the examination proceeds, giving advance warning if a maneuver might produce discomfort.

39. Performing the Examination • Continually monitor your level of anxiety and concentrate on achieving effective therapeutic communication. • At the end of the examination, summarize the findings and share the necessary information with the patient. • Thank the person for the time spent, and reinforce your teaching regarding medications and home care or follow-up visit

40. General Assessment

41. General Assessment • The general assessment (general survey) is a quick assessment of the patient as a whole, including the: • Physical appearance • Certain physical parameters (i.e., height, weight, and vital signs). • The general assessment should provide an overall impression of the patient’s health status.

42. Physical Appearance • Note the following characteristics: • Age • skin color • facial features • level of consciousness • signs of acute distress • nutrition • body structure • dress and grooming • behavior • mobility

43. Physical Appearance1) Age • The patient’s facial features and body structure should match his or her stated age. • If the person looks much older than the stated age, it could be a sign of chronic illness, alcoholism, or smoking

44. Physical Appearance2) Skin Color • The patient’s skin tone should be even and pigmentation should be consistent with the patient’s genetic background. • A lesion is an area of tissue with impaired function resulting from disease or physical trauma.

45. Physical Appearance2) Skin Color • Cyanosis is a bluish discoloration resulting from an inadequate amount of oxygen in the blood. • Pallor is an abnormal paleness of the skin resulting from reduced blood flow or decreased hemoglobin level • Jaundice is a yellowing of the skin resulting from excessive bilirubin (a bile pigment) in the blood. • Cyanotic changes can be seen most easily in the lips and oral cavity, whereas pallor and jaundice are detected most easily in nail beds and conjunctiva of the eye.

46. Physical Appearance3) Facial Features • Facial movements should be symmetric, and the facial expressions should match what the patient is saying. • Abnormal facial features examples: • If one side of the face is paralyzed=> the patient may have suffered a stroke or physical trauma. • Aflat affect or mask-like expression (no facial emotion)=> can be associated with Parkinson’s disease and depression. • Inappropriate affect, in which the facial expression does not match what the patient is saying => may be a sign of psychiatric illness.

47. Physical Appearance4) Level of Consciousness • The patient should be alert and oriented to time, place, and person. (A&Ox3) • Disorientation occurs with organic brain disorders, stroke, and physical trauma. • A lethargic patient typically drifts off to sleep easily, looks drowsy, and responds to questions very slowly. • A patient in a stupor responds only to persistent and vigorous shaking and answers questions only with a mumble. • A completely unconscious patient (i.e. a patient in a coma) does not respond to any external stimuli or pain.

48. Physical Appearance5) Signs of Acute Distress • Signs of acute respiratory distress include shortness of breath, wheezing, or use of accessory muscles to assist inbreathing. • Facial grimacing or holding a body part are signs of severe pain. • Emotional distress may appear as anxiousness, nervousness, fidgeting, and/or tearfulness/crying.

49. Physical Appearance6) Nutrition • The patient’s weight should be appropriate for his or her height and build, and body fat should be distributed evenly. • Truncal obesity, in which fat is located primarily in the face, neck, and trunk regions of the body and the extremities are thin, can be caused by: • Cushing’s syndrome or • Taking corticosteroid medication.

50. Physical Appearance6) Nutrition • If the patient’s waist is wider than the hips, then he or she is at increased risk of developing obesity-related diseases (e.g., diabetes, hypertension, coronary artery disease). • A cachectic appearance, in which the patient looks emaciated or very thin and has sunken eyes and hollowed cheeks, is associated with chronic wasting diseases(e.g., cancer, starvation, dehydration).