Physical assessment & safety

Starting the exam

The physical assessment gives baseline data for the plan of care and catches changes in the client's condition.

Before you touch anyone

Stethoscope

• Diaphragm (firm pressure): high-pitched sounds; S1, S2, lung and bowel sounds
• Bell (light pressure, whole rim on the skin): low-pitched sounds; murmurs, bruits, S3, S4
• Always on bare skin
• Use both as needed

BMI: under 18.5 underweight, 25 or greater overweight, 30 or greater obese.

Culture: eye contact and facial expression vary between cultures. Get an interpreter for language barriers.

Skin, hair & nails

Inspect and palpate at the same time, head to toe, comparing sides.

Head, face, and arms: inspect the head and scalp (color, hair distribution, wounds, lesions); skin color for cyanosis, jaundice, and erythema (check the palms on the arms); integrity, vascularity, rashes or moles; temperature with the back of the hand, texture, and moisture; turgor; and the nails' shape, color, condition, and capillary refill.

Turgor: pinch a skin fold over the clavicle, sternum, or back of the hand. Back to baseline within a few seconds = normal. Tenting for several seconds = dehydration.

Edema

Excess fluid in the tissues, most often the lower legs. Skin looks shiny and tight, and a fingerprint dent means edema is present.

Lesions and wounds: measure length, width, depth, and describe distribution, shape, size, color, texture, location, characteristics, and exudate.

Nails: expect symmetric nail beds with uniform color. Abnormal: discoloration, curvature over 160°, clubbing (chronic low oxygen from heart or lung disease).

Hair: expect even distribution and symmetric growth or loss; postmenopausal thinning is common. Look for dry patches and infestations. Alopecia = hair loss. Hirsutism = hair on the face or chest in females.

Dark skin: look for color changes on the palms, soles, lips, nail beds, and oral mucosa. Palpate for warmth and firmness to find erythema.

Pressure: press any red area over a bony prominence. Nonblanchable redness means pressure damage.

Also: natural light is best, and ask clients to remove a wig or head covering. Turgor isn't reliable in older adults.

Skin aging: thin, dry, fragile, less elastic, wrinkled; thick, slow-growing nails; thinning hair; less oil and sweat; slow healing. Petechiae and hematomas are not expected with aging.

Head, face & neck

• Assess the surrounding skin and the hair
• Movements should be voluntary
• Neck muscles equal in height
• Neck range of motion: chin to chest, ear to shoulder, chin up, turn side to side

Lymph nodes: normally not palpable, tender, or visible. Feel with the index and middle finger pads in circles, comparing sides. Occipital = base of skull; postauricular = over the mastoid; tonsillar = angle of the jaw; submental = under the chin; anterior cervical = along the sternocleidomastoid.

Thyroid: a normal one isn't visible; it rises when the client swallows. A bruit over an enlarged thyroid suggests hyperthyroidism.

Eyes

Observe for glasses or contacts.

• PERRLA: shine a light into each pupil and note the response
• CN (cranial nerve) II: Snellen visual acuity
• CN III, IV, VI: six cardinal positions of gaze, head held still

Snellen (CN II): 20 ft away; test uncorrected first, then each eye and both. Use a picture or E chart if the client can't read English letters. 20/30 means the client sees at 20 ft what a normal eye sees at 30 ft.

Six cardinal positions of gaze (CN III, IV, VI): the client follows your finger or pen with their eyes in a wide "H" without moving their head. Expect smooth, full movement.

Eye aging: presbyopia (trouble seeing close up), glare intolerance, trouble telling colors apart, slower pupils, cataracts, and arcus senilis (gray-white ring around the cornea).

Other eye tests: Rosenbaum chart (14 in away) for near vision; Ishihara for color vision; cover/uncover test for strabismus; visual fields from 2 ft away; ophthalmoscope for the red reflex.

Ears

CN VIII: whisper test. The client covers one ear; whisper and have them repeat the words. Then test the other ear.

If Weber is louder in one ear: conductive loss is heard best in the bad ear; sensorineural loss is heard best in the good ear. Check for cerumen buildup before documenting hearing loss in an older adult.

Ear aging: hearing loss (presbycusis = high-frequency loss), cerumen buildup, thicker eardrums.

Otoscope: pull the adult auricle up and back and insert 1–1.5 cm without touching the canal.

Nose, mouth & throat

Mouth and throat anatomy: lips, gums, mucous membranes, tongue, teeth, hard palate, soft palate, uvula, tonsils.

Tonsil grades

• +1 = barely visible
• +2 = halfway to the uvula
• +3 = touching the uvula
• +4 = touching each other

Mouth and nose aging: less taste and smell, tooth loss, pale gums, darker teeth, less saliva; voice pitch rises.

Cranial nerves

Taste: CN VII = front of the tongue (salt, sweet); CN IX = back (sour, bitter). Swallowing = CN IX and X. CN V motor: clench the teeth while you feel the jaw muscles.

Mental status & level of consciousness

Orientation (A&O × 4, alert and oriented): person, place, time, and situation. Ask: Who are you? Where are you? What day or time is it? Why are you here? Then verbalize your neuro findings.

Glasgow Coma Scale: scores eye opening, verbal response, and motor response. Minimum 3, maximum 15. The bigger the number, the better.

Neuro aging: short-term memory decline, slower reflexes and reaction time, decreased senses, poorer balance.

Cognition: recent memory (repeat 3 words), remote memory (birth date), calculation (100 minus 7s), abstract thinking (explain a cliché), judgment ("locked your keys in the car?").

Sensory tests (eyes closed): sharp/dull, hot/cold, cotton, vibration, position, stereognosis (key in hand), graphesthesia (number on palm).

Reflexes: graded 0–4+, with 2+ expected. Biceps → elbow flexes; triceps → elbow extends; patellar → leg extends; Achilles → foot plantar flexes. Abnormal adult Babinski = toes fan out.

Thorax & lungs

Use all four techniques: inspection, palpation, percussion, auscultation.

Palpation

• Tenderness, lumps, bumps, deformities
• Chest excursion: thumbs move apart evenly on a deep breath
• Tactile fremitus (client says "99"): should be symmetric; increased = pneumonia; decreased = pneumothorax

Auscultation

Stethoscope on bare skin, quiet room, client doesn't talk. Tell the client: "Take deep breaths with your mouth open each time I move my stethoscope."

Anatomy: the right lung has 3 lobes (listen to the middle lobe at the axilla); the left has 2. Other landmarks: anterior and posterior axillary lines and scapular lines.

Chest shape: AP (anteroposterior) diameter is a third to half the side-to-side width. Barrel chest (AP equals width) comes with aging and COPD (chronic obstructive pulmonary disease).

Lung aging: barrel chest, less expansion, weaker cough, slower cilia, higher infection risk, kyphosis.

Breast exam: self-exam monthly, 4–7 days after the period starts. Palpate with the pads of three fingers in a circular, wedge, or vertical strip pattern. Report peau d'orange (orange-peel skin), recent nipple inversion, dimpling, or one-sided dilated veins.

Heart

Use the bell and diaphragm as needed. Listen for a carotid bruit; if you hear one, palpate for a thrill. Then verbalize your respiratory and cardiovascular findings.

Abnormal findings

• Bruit: blowing or swishing from blocked blood flow; bell
• Thrill: palpable vibration, often with a murmur
• JVD: blood backing up from the right atrium; right-sided heart failure
• Heaves or lifts: visible chest wall rise at the left sternal border or PMI = heart failure

Bruit sites (bell): carotid arteries, abdominal aorta, renal arteries, iliac arteries, femoral arteries.

Technique tips: find the 2nd ICS from the angle of Louis (where the manubrium meets the sternum). Listen sitting forward, supine, and on the left side (best for extra sounds). Check JVD with the head of the bed at 30–45°. The PMI is no bigger than a nickel.

Cardiovascular aging: higher systolic BP, stiffer vessels and valves, lower cardiac output, harder-to-feel PMI.

Peripheral vascular

• Head and neck: temporal, carotid (one side at a time)
• Arms: brachial, radial
• Legs: femoral (verbalize), popliteal, pedal, posterior tibial; check every site
• Inspect legs and feet: color, hair, nails, edema, muscle mass, varicose veins, lesions
• Capillary refill on fingers and toes

Grading: 0 absent (try a Doppler), 1+ diminished (weak and thready), 2+ brisk (normal), 3+ increased, 4+ bounding.

Capillary refill: press the nail bed until it blanches, then release. Color should return in under 3 seconds. It can be slower in older adults.

Compare pulses on both sides at the same time (never the carotids). Purpura = petechiae larger than 3 mm.

Abdomen

• Inspect: color, contour, pulsations, umbilicus, surface characteristics
• Bowel sounds: diaphragm, RLQ (right lower quadrant) → RUQ (right upper) → LUQ (left upper) → LLQ (left lower)
• Normoactive 5–35/min; hypoactive <5; hyperactive >35; absent = no sounds after at least 5 min
• Bruits with the bell: aorta, renal, iliac, femoral (verbalize femoral)
• Percuss RLQ → RUQ → LUQ → LLQ: tympany over bowel, dullness over organs or a mass
• Light palpation about 1 cm (0.4 in) to 1.3 cm (0.5 in) deep for tenderness
• Verbalize abdominal findings

Percussion: tympany over most of the abdomen; dullness over a full bladder, the liver, or the spleen.

Palpate

• Light: finger pads of one hand, about 1–1.3 cm (0.4–0.5 in) deep
• Deep: advanced practice providers only
• Expected: no pain, soft; bladder felt only if full
• Abnormal: distention, rigidity, rebound tenderness
• A rigid abdomen that stays hard when the client relaxes, especially with absent bowel sounds, points to peritoneal irritation. Voluntary guarding (an anxious client tensing up) relaxes when they exhale

Setup: have the client void first, then lie supine with knees slightly bent. Silver striae are expected.

Rebound tenderness: press firmly, then release; pain on release = peritoneal irritation. Found tenderness? Stop palpating and notify the provider.

Abdominal aging: rounder belly, weaker muscles; peritonitis is harder to spot (less pain, guarding, and fever).

Also: liver span is 6–12 cm. CVA (costovertebral angle) tenderness (fist percussion over the back) = kidney inflammation.

Musculoskeletal

Assess: gait, alignment, symmetry, muscle tone, range of motion, involuntary movements, signs of inflammation, gross deformities, height, posture, spine.

Range of motion

Muscle strength

Graded 0 to 5. Test the shoulder, elbow, and wrist (flex and extend against resistance), grip strength, and ROM.

Hypertrophy = enlarged from strengthening. Atrophy = shrunken from disuse; soft and boggy.

Spine: have the client bend forward and look for curves. Expected is a double S. Kyphosis = exaggerated thoracic curve (older adults). Lordosis = exaggerated lumbar curve (pregnancy). Scoliosis = sideways curve.

Get-up-and-go test: time the client rising from a chair without using the arms, walking 3 m (10 ft), turning, returning, and sitting. Assistive devices are OK.

Musculoskeletal aging: less muscle and bone, height loss, joint changes, limited ROM, kyphosis, wider stance.

National Performance Goals

The Joint Commission (JC) reviews safety every year and accredits facilities that meet its goals. NPGs (National Performance Goals; 14 goals) apply to hospitals; NPSGs (National Patient Safety Goals) apply to other settings, such as ambulatory care and assisted living.

Alarm safety: constant nuisance alarms cause alarm fatigue, so staff respond slower. Don't ignore or silence alarms, prioritize them, and report broken equipment right away. ICUs (intensive care units) are the loudest.

Before surgery: two identifiers, mark the site, and a time-out (everyone pauses). The client states the procedure and points to the site; verify consent. The surgeon or another clinician marks the site when there's more than one possible side. No marking for bilateral organs (tonsils, ovaries); mouth, teeth, or perineum need a signed waiver.

Other goals: pain plans use nonopioid and nonpharmacological options first; informed consent covers the treatment, benefits, risks, side effects, and alternatives, in a way the client understands; screen and report maltreatment; staff for 24-hr care; safe imaging, transplant, and waived (point-of-care) testing.

Suicide prevention: screen clients, and a positive screen always gets a follow-up (Is there a plan? For how long? Any self-injury?).

Equity: JC's goal is care free of discrimination. Assess social needs (transportation, literacy, housing, food) and provide interpreters. The Speak Up initiative encourages clients to report concerns.

Culture of safety & communication

To Err Is Human (1999) made a culture of safety a priority: open communication, confidential reporting, and reporting near misses too. Transforming Care at the Bedside aims for 70% of nurse time at the bedside, plus leadership training, rapid response teams, and standard communication tools.

Hourly rounding: check toileting, position, pain, side rails, bed height, and call light every hour. It reduces falls.

Rapid response team (RRT)

Brings critical care skills to the bedside. Call for:

• Sudden vital sign changes
• Low SpO2 despite oxygen
• Chest pain despite nitroglycerin
• Seizure
• Sudden mental status change
• Any staff concern

Not for: a single high blood glucose.

Handoff report happens at the bedside, written or verbal.

Unexpected events & reporting

Common sentinel events: falls with serious injury, wrong-site surgery, retained objects, suicide in the facility, infant abduction. An expected death from illness is not a sentinel event.

After an incident

Occurrence reports aren't punitive. They track trends and root causes. Report falls, unexpected drug or vaccine reactions, wrong medications, lost property, body fluid exposures, and actions against policy.

Fatigue: under 4 hours of sleep in 24 makes a car crash 11.5 times more likely.

Falls

A fall is an unplanned descent to the floor, with or without injury. It's the main safety risk for older adults (1 in 4 fall each year), and Medicare and Medicaid don't pay for fall injuries.

Do it at admission, regularly, with any change in condition, on transfer, and after a fall.

Morse Fall Scale factors: history of falling, secondary diagnosis, ambulatory aid, IV (intravenous) access, gait, mental status.

Universal fall precautions

• Nonskid footwear
• Bed low and locked; wheelchair brakes on
• No clutter; good lighting
• Call light and belongings in reach (client does a return demonstration)
• Orient to the room and call light
• Answer call lights quickly; hourly rounding

Higher-risk clients

• Room near the nurses' station
• Color-coded wristband or room sign
• Bed or chair alarms
• Video monitoring or a sitter
• Regular toileting, gait belts
• Orthostatic hypotension: sit a few seconds, stand a few seconds, then walk

Side rails: keep them up for sedated, unconscious, or compromised clients. For a client who tries to get up alone, all four rails up is a restraint and invites climbing over. Two upper rails prevent rolling out while still letting the client exit.

Hospital-acquired injuries: HAIs, burns or shocks, transfusion reactions, falls, unsafe insulin use, DVT, and pressure injuries. Clients with communication disabilities have 3 times more adverse events.

Restraints

Restraints protect the client or others. They are a last resort, for the shortest time possible, and never for staff convenience, punishment, or short staffing.

Try first

Indications: pulling at tubes, IVs, catheters, or drains; unsafe movement; aggression; danger to self or others, once alternatives fail.

Many facilities don't use vest restraints because of strangulation risk.

Orders

• Written by the provider after a face-to-face assessment
• Must state the reason, type, location, duration, and behavior
• Adult: 4 hours, renewable up to 24 consecutive hours
• No PRN (as-needed) restraint orders

Problems: impaired circulation → remove the restraint immediately, reassess, and notify the provider. Skin change → notify, treat, and replace a wet restraint. Don't reapply either way without an order. A death in restraints is a sentinel event.

Document: what happened before, alternatives tried, times on and off, type and location, behavior, care given, condition of the limb, response at removal, and medications.

Seizures

A seizure is a sudden surge of abnormal electrical activity in the brain. Focal (partial) affects one hemisphere; generalized affects both. Status epilepticus (prolonged seizure) is an emergency.

Before → during → after

Before (precautions)

• Suction and oxygen at the bedside
• Oral airway available
• Padded side rails
• Baseline vital signs and SpO2
• IV access (saline lock)
• Remove tight clothing and jewelry
• Ask about an aura (client warns you, removes dentures)

During

• Stay with the client; call for help (call light)
• Side-lying; protect the head; suction as needed
• Move furniture away; loosen clothing
• Note the start time, duration, body parts, eyes, incontinence
• Benzodiazepine IV (or IM [intramuscular]) as prescribed; check glucose

After

Check mental status, vital signs, and SpO2. Check the gag reflex and that they can follow directions before food or fluids. Reorient, reassure, quiet room. Possible labs: toxicology, anticonvulsant level, EEG (electroencephalogram), imaging. Document the triggers, aura, movements, injuries, duration, and postictal state.

Fire, electrical, chemical & radiation

Evacuation: lateral (same floor) is preferred over vertical (another floor). Move those closest to the fire first, close doors, cover clients with blankets, stay low, and don't run. Fire needs heat, oxygen, and fuel; take one away and it stops.

Radiation: reduce time, increase distance, use shielding (lead apron). CT (computed tomography) gives more radiation than an x-ray. Ask about pregnancy and last period first. Wear PPE for urine and blood from clients with radioactive implants.

Mass casualty: radiation exposure causes nausea, vomiting, diarrhea, and sometimes hair loss and burns. Decontaminate by removing clothing and washing; potassium iodide keeps the thyroid from absorbing radioactive iodine. Biological or chemical: full PPE if the agent is unknown, cut off and double-bag clothing, decontamination shower. Many people with the same symptoms suggests a biological event.

Disasters: CMS (Centers for Medicare & Medicaid Services) requires a plan, training at orientation and yearly, and drills. Know your role and the chain of command.

Home & community safety

Home safety assessments use a risk tool, a history and physical, and a home hazard appraisal, often with PT (physical therapy) and OT (occupational therapy).

Water heater: no higher than 120°F (49°C).

Home fire safety: smoke alarms on every floor, tested monthly, batteries changed every 6 months. Two exits per room; practice escape twice a year. Stop, drop, and roll. Space heaters 3 ft from anything flammable. Cooking causes the most home fires.

First aid

Primary survey (≤60 sec)

Airway comes first because nothing else works without it. Do first aid after the primary survey.

CPR (cardiopulmonary resuscitation) / BLS (basic life support) = CAB: compressions, airway, breathing. Check response and breathing (gasping counts as not breathing), call for help and an AED (automated external defibrillator), check the pulse, start compressions.

Body mechanics & positioning

Assess mobility before moving a client. Many facilities have no-manual-lift and no-solo-lift policies, and lift equipment is the safest way to move clients.

Transfer priority: first decide whether the client can bear weight, help, and cooperate.