In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of techniques of physical assessment in order to:
Applying the Knowledge of Nursing Procedures and Psychomotor Skills to the Techniques of Physical Assessment
Baseline data that is collected after the health history and before the complete head to toe examination includes a general survey of the client. The general survey includes the patient's weight, height, body build, posture, gait, obvious signs of distress, level of hygiene and grooming, skin integrity, vital signs, oxygen saturation, and the patient's actual age compared and contrasted to the age that the patient actually appears like. For example, does the patient appear to be older than their actual age? Does the patient appear to be younger than their actual age?
Nurses prepare and position clients for physical examinations. Nurses provide privacy, explain and reinforce the procedures to the client and insure that the client is as comfortable as possible during the physical examination.
As with all other aspects of nursing care, all data and information that is collected with the health history and the physical examination are documented according to the particular facility's policies and procedures. Some facilities use special forms for this data and information.
Registered nurses, advanced practice nurses such as nurse practitioners, and doctors typically do the complete head to toe physical assessment and examination and document all of these details in the patient's medical record; however, licensed practical nurses review these details and compare this baseline physical examination data and information to the current patient status as they are providing ongoing care. They also report and document all their significant physical examination results to the supervising registered nurse and/or the patient's health care provider.
The four basic methods or techniques that are used for physical assessment are inspection, palpation, percussion and auscultation. Inspection is a visual examination of the patient; palpation is done when the person doing the assessment places their fingers on the body to determine things like swelling, masses, and areas of pain. Palpation can include light and deep palpation. Deep palpation is cautiously done after light palpation when necessary because the client's responses to deep palpation may include their tightening of the abdominal muscles, for example, which will make the light palpation less effective for this assessment, particularly if an area of pain or tenderness has been palpated.
Percussion is tapping the patient's bodily surfaces and hearing the resulting sounds to determine the presence of things like air and solid masses affecting internal organs. The sounds that are heard with percussion are resonance which is a hollow sound, flatness which is typically hear over solid things like bone, hyper resonance which is a loud booming sound, and tympany which is a drum type sound.
Lastly, auscultation is listening to an area of the body using a stethoscope. For example, bowel sounds, lung sounds and heart sounds are auscultated with a stethoscope. The sounds that are heard with auscultation are classified and described according to their duration, pitch, intensity and quality. For example, the duration of a breath sound can be described in terms of seconds of duration or it can be described as having a longer duration of inspiration than expiration. The intensity can be describe as loud or soft and quiet; the pitch is described as a high pitched sound to a dull and low pitched sound.
A thorough physical assessment consists of the following:
Choosing Physical Assessment Equipment and Techniques Appropriate for the Client
Although the routine and the equipment needed for a complete physical assessment are similar for both the adult and the pediatric client, there are some differences. For example, the pediatric client will require that the nurse use a neonatal, infant or pediatric blood pressure cuff, respectively, and techniques such as the assessment of the vital signs which vary among the age groups.
Performing a Comprehensive Health Assessment
A comprehensive health assessment includes:
The medical history and the general survey were previously detailed. In this section, you will review the components of the complete physical assessment.
The pulse, blood pressure, bodily temperature and respiratory rate are measured and documented.
Assessment of the Thorax
Inspection: The anterior and posterior thorax is inspected for size, symmetry, shape and for the presence of any skin lesions and/or misalignment of the spine; chest movements are observed for the normal movement of the diaphragm during respirations.
Palpation: The posterior thorax is assessed for respiratory excursion and fremitus.
Percussion: For normal and abnormal sounds over the thorax
Assessment of the Lungs
Auscultation: The assessment of normal and adventitious breath sounds.
Percussion: For normal and abnormal sounds. Normal breath sounds like vesicular breath sounds, bronchial breath sounds, bronchovesicular breath sounds are auscultated and assessed in the same manner that adventitious breath sounds like rales, wheezes, friction rubs, rhonchi, and abnormal bronchophony, egophony, and whispered pectoriloquy are auscultated, assessed and documented.
Assessment of the Cardiovascular System
Inspection: Pulsations indicating the possibility of an aortic aneurysm
Auscultation: Listening to systolic heart sounds like the normal S1 heart sound and abnormal clicks, the diastolic heart sounds of S2, S3, S4, diastolic knocks and mitral valve sounds, all of which are abnormal with the exception of S2 which can be normal among clients less than 40 years of age.
Assessment of the Peripheral Vascular System
Inspection: The extremities are inspected for any abnormal color and any signs of poor perfusion to the extremities, particularly the lower extremities. While the client is in a supine position, the nurse also assesses the jugular veins for any bulging pulsations or distention.
Auscultation: The nurse assesses the carotids for the presence of any abnormal bruits.
Palpation: The peripheral veins are gently touched to determine the temperature of the skin, the presence of any tenderness and swelling.
The peripheral vein pulses are also palpated bilaterally to determine regularity, number of beats, volume and bilateral equality in terms of these characteristics.
Assessment of the Musculoskeletal System
Inspection: The major muscles of the body are inspected by the nurse to determine their size, and strength, and the presence of any tremors, contractures, muscular weakness and/or paralysis. All joints are assessed for their full range of motion. The areas around the bones and the major muscle groups are also inspected to determine any areas of deformity, swelling and/or tenderness.
Palpation: The muscles are palpated to determine the presence of any spasticity, flaccidity, pain, tenderness, and tremors.
Assessment of the Neurological System
Of all of the bodily systems that are assessed by the registered nurse, the neurological system is perhaps the most extensive and complex.
Some of the terms and terminology relating to the neurological system and neurological system disorders that you should be familiar with include those below.
Acalculia: Acalculia is the client's loss of ability to perform relatively simple mathematical calculations like addition and subtraction.
Agnosia: Agnosia is defined as the loss of a client's ability to recognize and identify familiar objects using the senses despite the fact that the senses are intact and normally functioning. The different types of agnosia, as based on each of the five senses, are auditory agnosia, visual agnosia, gustatory agnosia, olfactory agnosia, and tactile agnosia.
Agraphia: Agraphia, simply defined, is the Inability of the client to write. Agraphia is one of the four hallmark symptoms of Gerstmann's syndrome. The other symptoms of Gerstmann's syndrome are acalculia, finger agnosia, and an inability to differentiate between right and left.
Alexia: Alexia, which is a type of receptive aphasia, occurs when the client is unable to process, understand and read the written word. This neurological disorder is also referred to as word blindness and optical alexia.
Anhedonia: Anhedonia is a loss of interest in life experiences and life itself as the result of the neurological deficit.
Anomia: Anomia is a lack of ability of the client to name a familiar object or item.
Anosagnosia: Anosagnosia is characterized with the client's inability to perceive and have an awareness of an affected body part such as a paralyzed or missing leg. Anosagnosia is closely similar to hemineglect and hemiattention
Anosdiaphoria: Anosdiaphoria is an indifference to one's illness and disability
Aphasia: Aphasia includes expressive aphasia and receptive aphasia. Expressive aphasia is characterized by the client's inability to express their feelings and wishes to others with the spoken word; and receptive aphasia is the client's inability to understand the spoken words of others.
Asomatognosi: Asomatognosia is the inability of the client to recognize one or more of their own bodily parts.
Astereognosia: Astereognosia is the client's inability to differentiate among different textures with their sense of touch and also the inability of the client to identify a familiar object, like a button, with their tactile sensation.
Asymbolia: Asymbolia is the loss of the client's inability to respond to pain even though they have the sensory function to feel and perceive the pain. Asymbolia is also referred to as pain dissociation and pain asymbolia.
Autotopagnosia: Autotopagnosia is the inability of the client to locate their own body parts, the body parts of another person, or the body parts of a medical model.
Balint's syndrome: Balint's syndrome includes ocular apraxia, optic ataxia and simultanagnosia, which consist of impaired visual scanning, visusopatial ability and attention.
Boston Diagnostic Aphasia Examination: The Boston Diagnostic Aphasia Examination is a standardized comprehensive assessment tool that assess and measures the client's degree of aphasia in terms of the client's perceptions, processing of these perceptions and responses to these perceptions while using problem solving and comprehension skills.
Broca’s aphasia: Broca’s aphasia entails the client's lack of ability to form and express words even though the client's level of comprehension is intact.
Color agnosia: Color agnosia reflects the client's lack of ability to recognize and name different colors.
Conduction aphasia: Conduction aphasia is the client's lack of ability to repeat phrases and/or write brief dictated passages despite the fact that the client has intact speech abilities, comprehension abilities, and the ability to name familiar objects.
Constructional apraxia: Constructional apraxia is the inability of the client to draw and copy simple shapes on paper.
Dressing apraxia: Dressing apraxia occurs when the person is not able to appropriately dress oneself because of some neurological dysfunction.
Dysgraphaesthesia: Dysgraphaesthesia impairs the client's ability to sense and identify a letter or number that is tactily drawn on the client's palm.
Dysgraphia: Dysgraphia is similar to agraphia; however, dysgraphia is difficulty in terms of writing and agraphia is the client's complete inability to write.
Environmental agnosia: Environmental agnosia is the lack of ability of the client to recognize familiar places, like the US Supreme Court, by looking at a photograph of it.
Finger agnosia: Finger agnosia occurs when the person is not able to identify what finger is being touched by the person performing the neurological assessment.
Geographic agnosia: Geographic agnosia is the lack of ability of the client to recognize familiar counties, like Canada or Mexico, when viewing a world map.
Gerstmann's Syndrome: Gerstmann's Syndrome consists of dyscalculia or acalculia, finger agnosia, one sided disorientation and dysgraphia or agraphia.
Hemiasomatognosia: Hemiasomatognosia is the neurological disorder that occurs when the client does not perceive one half of their body and they act in a manner as if that half of the body does not even exist.
Homonymous hemianopsia: Homonymous hemianopsia occurs when the person has neurological blindness in the same visual field of both eyes bilaterally.
Ideomotor apraxia: Ideomotor apraxia is a neurological deficit that affects the client's ability to pretend doing simple tasks of everyday living like brushing one's teeth.
Misoplegia: Misoplegia is a hatred and distaste for an adversely affected limb.
Motor alexia: Motor alexia occurs when the client is not able to comprehend the written word despite the fact that the client can read it aloud.
Musical alexia: Musical alexia is a client's inability to recognize a familiar tune like "The National Anthem" or "Silent Night".
Movement agnosia: Movement agnosia is a neurological deficit that is characterized with a client's lack of ability to recognize an object's movement.
Ocular apraxia: Ocular apraxia is the neurological deficit that occurs when the person is no longer able to rapidly move their eyes to observe a moving object.
Optic ataxia: Optic ataxia is characterized with the client's inability to reach for and grab an object.
Phonagnosia: Phonagnosia is the client's lack of ability to recognize familiar voices such as those of a child or spouse.
Prosopagnosia: Prosopagnosia is a lack of ability to recognize familiar faces, like the face of a spouse or child.
Simultanagnosia: Simultanagnosia is a neurological disorder that occurs when the client is not able to perceive and process the perception of more than object at a time that is in the client's visual field.
Somatophrenia: Somatophrenia occurs when the client denies the fact that their body parts are not even theirs, but instead, these body parts belong to another.
The Two-Point Discrimination Test: This test measures and assesses the client's ability to recognize more than one sensory perception, such as pain and touch, at one time.
Visual agnosia: Visual agnosia is the client's lack of ability to recognize and attach meaning to familiar objects.
Wechsler Memory Scale IV: Wechsler Memory Scale IV: This measurement tool is a standardized comprehensive method to assess verbal and visual memory, including immediate memory, delayed memory, auditory memory, visual memory and visual working memory..
The neurological system is assessed with:
Balance, gait, gross motor function, fine motor function and coordination, sensory functioning, temperature sensory functioning, kinesthetic sensations and tactile sensory motor functioning, as well as all of the cranial nerves are assessed.
Balance is assessed using the relatively simple Romberg test. The Romberg test is the test that law enforcement use to test people for drunkenness. Gait can be assessed by simply observing the client as they are walking or by coaching the person to walk heal to toe as the nurse observes the client for their gait.
Gross motor functioning is bilaterally assessed by having the client contract their muscles; and fine motor coordination and functioning is observed for both the upper and the lower extremities as the client manipulates objects.
Sensory functioning is determined by touching various parts of the body, bilaterally, with a pen or another blunt item while the client has their eyes closed. The client is prompted to report whether or not they feel the blunt item as the nurse touches the area. Similarly, a hot and cold object is placed on the skin on various parts of the body to assess temperature sensory functioning. The client will then report whether they feel heat, cold or nothing at all.
Kinesthetic sensations are assessed to determine the client's ability to perceive and report their bodily positioning without the help of visual cues.
Tactile sensory functioning is assessed for the client's ability to have stereognosis, extinction, one point discrimination and two point discrimination. One and two point discrimination relates to the client's ability to feel whether or not they have gotten one or two pin pricks that the nurse gently applies. Stereognosis is the client's ability to feel and identify a familiar object while their eyes are closed. For example, the nurse may place a pen, a button or a paper clip in the client's hand to determine whether or not the client can identify the object without any visual cues. Extinction is the client's ability to identify whether or not they are being touched by the person doing the assessment with either one or two bilateral touches. For example, the nurse may touch both knees and then ask the client if they felt one or two touches while the client has their eyes closed.
Reflexes are automatic muscular responses to a stimulus. When reflexes are absent or otherwise altered, it can indicate a neurological deficit even earlier than other signs and symptoms of the neurological deficit appear.
Reflexes can be described as primitive and long term. Primitive reflexes are normally present at the time of birth and these reflexes normally disappear as the baby grows older; neurological deficits are suspected when these primitive reflexes remain beyond the point in time when they are expected to disappear. Reflexes, other than the primitive reflexes remain intact and active during the entire life span, under normal conditions.
The primitive reflexes are the:
The other reflexes are the:
All reflexes should be done bilaterally in rapid succession so that all differences between the right and the left reflexes can be determined and assessed. For example, when the person who is performing these assessments should assess the biceps reflex of the right arm and then immediately assess the biceps reflex of the left arm so that any differences or inequalities can be assessed and documented.
Lastly, the nurse assesses the twelve cranial nerves. Some of these twelve cranial nerves are only sensory or motor nerves, and others have both sensory and motor functions.
The twelve cranial nerves can be easily remembered using this mnemonic: On Old Olympus Tippy Top, A Fat Armed German View A Hop, as below:
Each of these twelve cranial nerves, their function and their classification as sensory, motor or both sensory and motor are shown in the table below.
Assessment of the Head (The Face and Skull, Eyes, Ears, Nose, Mouth, Throat, Neck, Trachea and Thyroid)
Face and Skull
Inspection: The size, shape and symmetry of the face and skull, facial movements and symmetry are inspected.
Palpation: The presence of any lumps, soreness, and masses are assessed.
Inspection: Pupils in reference to their bilateral equality, reaction to light and accommodation, the presence of any discharge, irritation, redness and abnormal eye movement are assessed.
Standardized Testing: The Snellen Chart for visual acuity
Inspection: The auricles are inspected in terms of color, symmetry, elasticity and any tenderness or lesions; the external ear canal is inspected for color and the presence of any drainage and ear wax; and the tympanic membrane in terms of color, integrity and the lack of any bulging is also assessed.
Standardized Testing: The Rinne test and the Weber test for the assessment of hearing can be done using a tuning fork.
Inspection: The color, size, shape, symmetry, and any presence of drainage, flaring, tenderness, and masses are assessed; the nasal passages are assessed visually using an otoscope of the correct size for an infant, child and adult; the sense of smell is also assessed.
Palpation: The sinuses are assessed for any signs of tenderness and infection.
Inspection: The lips are visualized for their symmetry and color; the buccal membranes, the gums and the tongue are inspected for color, any lesions and their level of dryness or moisture; the tongue is inspected for symmetry of movement; teeth are inspected for the presence of any loose or missing teeth; the uvula is assessed for movement, position, size and color; the salivary glands are examined for signs of inflammation or redness; the oropharynx, tonsils, hard and soft palates are also inspected for color, redness and any lesions. Lastly, the gag reflex is assessed. The mouth and the throat are assessed using a tongue blade and a light source.
Inspection: The neck and head movement is visualized; the thyroid gland is inspected for any swelling and also for normal movement during swallowing.
Palpation: The neck, the lymph nodes, and trachea are palpated for size and any irregularities
Auscultation: The thyroid gland is assessed for bruits
Assessment of the Integumentary System (Hair, Skin and Nails)
Inspection: The color of the skin, the quality, distribution and condition of the bodily hair, the size, the location, color and type of any skin lesions are assessed and documented, the color of the nail beds, and the angle of curvature where the nails meet the skin of the fingers are also inspected.
Palpation: The temperature, level of moisture, turgor and the presence or absence of any edema or swelling on the skin are assessed.
Assessment of the Breast and Axillae
Inspection: The breasts are visualized to assess the size, shape, symmetry, color and the presence of any dimpling, lesions, swelling, edema, visible lumps and nipple retractions. The nipples are also assessed for the presence of any discharge, which is not normal for either gender except when the female is pregnant or lactating.
Palpation: The nurse performs a complete breast examination using the finger tips to determine if any lumps are felt. The lymph nodes in the axillary areas are also palpated for any enlargement or swelling.
Assessment of the Abdomen
Inspection: The abdomen is visualized to determine its size, contour, symmetry and the presence of any lesions. As previously mentioned, the abdomen is also inspected to determine the presence of any pulsations that could indicate the possible presence of an abdominal aortic aneurysm.
Auscultation: The bowel sounds are assessed in all four quadrants which are the upper right quadrant, the upper left quadrant, the lower right quadrant and the lower left quadrant.
Palpation: Light palpation, which is then followed with deep palpation, is done to assess for the presence of any masses, tenderness, pain, guarding and rebound tenderness.
Assessment of the Male and Female Genitalia
Inspection: The skin and the pubic hair are inspected. The labia, clitoris, vagina and urethral opening are inspected among female clients. The penis, urethral meatus, and the scrotum are inspected among male clients.
Palpation: The inguinal lymph nodes are palpated for the presence of any tenderness, swelling or enlargements. A testicular examination is done for male clients.
Assessment of the Rectum and Anus
Inspection: The rectum, anus and the surrounding area is examined for any abnormalities.
Palpation: With a gloved hand, the rectal sphincter is palpated for muscular tone, and the presence of any blood, tenderness, pain or nodules.
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