INTRODUCTION

TO PHYSICAL
EXAM and
HISTORY
TAKING
CHRISTINAL JEYAPAUL,MSC CRITICAL CARE
NURSING
Learning objectives
At the end of this module, the learner
should be able to:
1.Define the Key terms.
2.State purpose of physical examination
3.Describe components of history taking
skills
4.Discuss the concept of general survey in
terms of its purpose, skills, and
components.
5.Explain the four basic physical
examination techniques.
6.Identify commonly needed physical
examination equipments and their
functions.
Physical Examination

 Physical examination is a systematic

approach of collecting objective data
about clients’ health status.
 Itemploys through detailed evaluation
of clients’ all body structures, organs, or
systems.
 It requires the nurse to apply special
techniques, use equipments and
knowledge base, to physically expose
each region of clients’ body and examine
it by looking, listening, touching, or
smelling.
Purpose of physical
Examination
 Physical examination is performed
in all health care settings, covering
healthy and sick clients.
 It serves for screening, detection,
and prevention of disease.
 It also provides an opportunity for
health promotion (education &
counseling) as well as the
evaluation of disease process or
Component of Physical
Examination:
 General survey (the nurses’ initial

observation for the clients’ general

appearance and behavior).

 Vital signs measurement

 Height and weight measurement

 Body systems examination

 Review client health history
 Prepare equipment
 Examine client in a warm & quiet room
 Examine client in well- lighted room
 Consider patients’ privacy and comfort
 Practice and adhere to standard precaution of
Infection control
 Explain procedure to client & reassure client along
the examination. Begin examination with the
patient in sitting position( if possible). This
facilitates front and back examination
 Use appropriate Draping, such that only body part
being examined is exposed
THE HEALTH HISTORY:
STRUCTURE AND PURPOSES

SUBJECTIVE DATA OBJECTIVE DATA

 EG: Mrs. G is a 54-  EG: Mrs. G is an older
year-old hairdresser white female,
who reports pressure deconditioned,
over her left chest pleasant, and
“like an elephant cooperative. BP
sitting there,” which 160/80, HR 96 and
goes into her left regular, respiratory
neck and arm rate 24, afebrile
seven components of the
Comprehensive Adult Health
History
:
● Identifying Data and Source of the History
Chief Complaint(s)
● Present Illness
● Past History
● Family History
● Personal and Social History
● Review of System
Overview of history taking

 Identifying data—such as age, gender,

occupation, marital status ,religion etc
 ● Source of the history—usually the patient, but
can be a family member or friend, letter of
referral, or the medical record
 ● If appropriate, establish source of referral,
because a written report may be needed.

 RELIABILITY: Varies according to the patient’s

memory, trust, and mood
Overview of history taking

 CHIEF COMPLAINTS
 Reason for the visit to hospital and record as
informed by patient own words
Overview of history taking

 HISTORY OF PRESENT ILLNESS :Amplifies

the Chief Complaint; describes how each
symptom developed
 OLDCART(Onset, Location, Duration,
Characteristics ,Aggravating factor, relieving
factor, Timing)
 ● Includes patient’s thoughts and feelings about
the illness
 ● May include medications, allergies, habits of
smoking and alcohol, which are frequently
pertinent to the present illness
Overview of history taking

 ● Medications should be noted, including name,

dose, route, and frequency of use. Also list home
remedies, nonprescription drugs, vitamins,
mineral or herbal supplements, oral
contraceptives, and medicines borrowed from
family members or friends. Ask patients to bring
in all their medications so you can see exactly
what they take
 . ● Allergies, including specific reactions to each
medication, such as rash or nausea, must be
recorded, as well as allergies to foods, insects, or
environmental factors
Overview of history taking

 ● Note tobacco use, including the type. Cigarettes

are often reported in pack-years (a person who
has smoked 11 ⁄ 2 packs a day for 12 years has an
18-pack-year history). If someone has quit, note
for how long.
 ● Alcohol and drug use should always be
investigated. S
Overview of history taking

 PAST MEDICAL HISTORY

 ● Lists childhood illnesses
 ● Lists adult illnesses with dates for at least four
categories: medical; surgical;
obstetric/gynecologic; and psychiatric
 ● Includes health maintenance practices such as
immunizations, screening tests, lifestyle issues,
and home safety
Overview of history taking

 FAMILY HISTORY
 :● Outlines or diagrams age and health, or age
and cause of death, of siblings, parents, and
grandparents
 ● Documents presence or absence of specific
illnesses in family, such as hypertension, coronary
artery disease, etc
Overview of history taking

 PERSONAL AND SOCIAL

HISTORY:
 Describes educational level,
family of origin, current
household, personal interests,
and lifestyle
REVIEW OF SYSTEMS

 GROUP ASSIGNMENT
Vital signs are the key physiologic measures of the
person’s general health state. The nurse obtains
vital signs to:
a.Establish baseline measurement.
b.Identify physiologic problems.
c.Monitor clients’ response to therapy.

Signs range
Pulse rate 60 - 100 beats/min
Respiratory rate 12 - 20 breath/min
Blood pressure 100/70 to 140/90 mmHg
Temperature 36.5 - 37.5 C

 3- Measuring Height and
weight
 Body mass index _Weight_(kg)____
(Height) 2
 Where
 Weight is measured in kilograms.
 Height is measured in meters
 BODY MASS INDEX FINDING
 < 20 PERSON IS UNDER WEIGHT
 =20-25 PERSON IS NORMAL WEIGHT
 =25-30 PERSON IS OVERWEIGHT
 >30 PERSON IS OBESE
 EXAMPLE:-

 Calculate body mass index of person,

his weight is 98kg, his height is172 cm
.
 Answer steps:
 Transfer height from cm to meter
=172/100=1.72m
 Body mass index (BMI) =
98/(1.72)2 =33
 BMI = 33 SO the person is
Physical examination
equipments:
Ophthalmoscope

Otoscope
Tuning fork

 Nasal speculum

Percussion hammer

Snellen chart
Basic Physical examination techniques
Physical examination utilizes four
techniques
Inspection

Palpation

Percussion

Auscultation
1. Inspection
 means Observing the client in a close,
focused manner using vision, and smell
senses.
*It begins during the first contact with client
and continues throughout the assessment

*It provides information about body parts’:

color, size, location, movement, texture,
symmetry, odor, and sound
 2. Palpation
 Palpation is the use of hands and fingers
to feel different body parts for data
collection.

 The nurse uses pads of the fingers and

palms to touch and feel the patient’s
body parts with his hands to examine:
size texture
location
tenderness
body temperature

lumps or masses
 Types of palpation
1. Light palpation

 Using the flat part of the right hand or

the pads of the fingers, not the fingertips

 The fingers should be together

 Depress the skin 1 to 2 cm with your
finger
pads, usually the lightest touch
possible.
Light palpation
2. Deep palpation

 Used to determine organ size as well as the

presence of abdominal masses

 The flat portion of the right hand is placed on

the abdomen

 Depress the skin 4 to 5 cm with firm, deep

pressure. Pressure should be applied to the
abdomen gently but steadily

 The patient should be instructed to breathe

quietly through the mouth and to keep arms
 3. Percussion
 A methods of “ striking” of body parts
during physical examination with fingers
to evaluate the size, consistency, borders
and presence of fluid in body organs

 Percussion of a body part produces a

sound that indicates the type of tissue
within the organ

 It is particularly important in examining

the chest and abdomen
Methods of Percussion
1. Direct percussion:
 Using one or two fingers, tap directly on
the body part. Ask the patient to tell you
which areas are painful and watch his/her
face for signs of discomfort.
 Direct percussion is commonly used to
assess an adult patient's sinuses for
tenderness.
2. Indirect Percussion

 Using the middle finger (plexor or striking

finger) of your dominant hand, tap quickly
and directly over the point where your
other middle finger touches the patient's
skin. The motion of the striking finger
should come from the wrist and not from
the elbow
 Deliver 2 - 3 quick taps and listen carefully.
 4. Auscultatio
n

A method used to “listen” to the body
sounds.

 Various body systems like heart, lungs, and

abdominal organs have characterized sounds

Bowel, breath, heart, and blood movement
sound are heard using a stethoscope


It is important to know the normal sound to
distinguish from abnormal sound
 Types of
auscultation
1. Direct auscultation:
* Uses the ear alone to listen, such as
when listening to the grating of a
moving joint.
* Sounds are audible without
stethoscope

2. Indirect auscultation:
sounds are audible with
stethoscope

3. Bell for low pitched sound and

diaphragm for high pitched sound
References

 https://uodiyala.edu.iq/uploads/PDF%20ELIBRARY
%20UODIYALA/EL95/Bates%20Guide%20to%20Ph
ysical%20Examination.pdf
 https://emedicine.medscape.com/article/123702-
clinical
Question?

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