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126 PHYSICAL EXAMINATION
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UNIT 2
FIGURE 5.6 The nurse must select
the appropriate personal protective
equipment for every consumer encounter.
Personal protective equipment
Personal protective equipment or PPE refers to equipment that acts as a barrier
to protect mucous membranes, airways, skin and clothing from contact with
any infectious agent. PPE includes gloves, gowns, masks (surgical/P2 respirator),
eyewear or face shields and gowns (
potential for exposure to body uids and infectious processes when caring for the
consumer. For further information about the following risks and considerations
SHUTTERSTOCK.COM/PORDEE _AOMBOON
that relate to PPE you should refer to the NHMRC’s Australian Guidelines for
the Prevention and Control of Infection in Healthcare, 2019, v.11.10 (2021), Living
guideline (NHMRC, 2019).
Figure 5.6). The selection of PPE is related to the
Handling and disposing of sharps
Healthcare workers are exposed to the risk of injury and blood-borne infectious
agents such as hepatitis B and C virus and human immunodeciency virus (HIV)
(NHMRC, 2019).
Routine management of the physical environment
Evidence supports that healthcare settings contain infectious agents, although
environmental surfaces can be safely decontaminated (NHMRC, 2019). Healthcare
facilities should have a specic policy regarding measures for cleaning and
disinfecting consumer care areas and the surrounding environment. It is good
practice to routinely clean surfaces as follows:
> Clean frequently touched surfaces with detergent solution at least daily, when
visibly soiled and after every known contamination.
> Clean general surfaces and ttings when visibly soiled and immediately after spillage.
NHMRC . (2019). AUS TRALI AN GUIDEL INES FOR IN FECTIO N PREVE NTION, P. 57
Reprocessing of reusable instruments and equipment
If consumer equipment is labelled as reusable, the manufacturer will provide
guidelines on cleaning and disinfecting the equipment. If an item is single use, it
should be disposed of in the specied manner after it is used.
Respiratory hygiene and cough etiquette
Respiratory hygiene and cough etiquette should be a precaution upheld at
all times, such as covering sneezes and coughs to limit the infectious person
dispersing respiratory secretions into the air (Table 5.1). Ensure that hands are
washed with soap and water after sneezing and coughing; use tissues and watch
contact with respiratory secretions or objects that are contaminated by secretions
(NHMRC,2019). When caring for persons with conrmed or suspected infectious
agents disseminated by airborne transmission, the healthcare professional may
likely be required to implement standard and transmission-based precautions,
including the use of a P2 respirator. The person with conrmed or suspected
infectious disease may be required to wear a correctly tted surgical mask to prevent
dispersal of respiratory secretions into the air (NHMRC, 2019, p. 112).
CLINICAL REASONING
Practice tip: Allergies to latex gloves
In line with standard precautions, the use of gloves when dealing with consumers’ bodily
uids is compulsory. Be aware of the possibility that healthcare workers or consumers can
have a latex allergy. The reactions range from eczematous contact dermatitis to the extreme
of anaphylactic shock. It is important therefore, prior to touching consumers when wearing
latex gloves or using other latex products, to check that the consumer does not have any
known allergies to latex.
PHYSICAL EXAMINATION TECHNIQUES 127
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TABLE 5 .1 Steps in respiratory hygiene and cough etiquette
Anyone with signs and symptoms of a respiratory infection regardless of the cause should follow or be
instructed to follow respiratory hygiene and cough etiquette as follows:
Cover the nose/mouth with disposable single-use tissues when coughing, sneezing, wiping
STEP 1
STEP 2
STEP 3 Dispose of tissues in the nearest waste receptacle or bin after use.
STEP 4
STEP 5
STEP 6
STEP 7
SOURC E: NATION AL HEALT H AND MEDIC AL RESE ARCH COU NCIL
and blowing noses.
Use tissues to contain respiratory secretions.
If no tissues are available, cough or sneeze into the inner elbow rather than the hand.
Practise hand hygiene after contact with respiratory secretions and contaminated
objects/materials.
Keep contaminated hands away from the mucous membranes of the mouth,
eyes and nose.
In healthcare facilities, patients with symptoms of respiratory infections should sit as far
away from others as possible. If available, healthcare facilities may place these patients
in a separate area while waiting for care.
Transmission-based precautions
The CDC has developed another level of precautions called transmission-based
precautions
precautions. Airborne, droplet and contact transmissions of microorganisms that
are known to exist in a consumer, or are suspected in a consumer, are targeted.
Contact transmission pathogens, such as impetigo, scabies, varicella zoster virus
and multidrug-resistant organisms (e.g. MRSA), can be spread directly from person
to person. Contact precautions must also be implemented when the consumer
has faecal incontinence, excessive wound drainage, or other body secretions,
because of the risk of environmental contamination and subsequent transmission.
Microorganisms can also be spread indirectly from a contaminated inanimate object
to a person. Cohorting of consumers may occur when single rooms are unavailable
to allow implementation of contact precautions. Consumer cohorting may be an
appropriate infection control strategy during a pandemic (Patterson et al., 2020).
Droplet transmission occurs when microorganisms (large-particle droplets >5 microns)
are deposited on susceptible body parts via respiratory secretions (sneezing and
coughing). Typically, the pathogens in the droplet remain infectious for only a
short period of time. Suctioning a consumer can also transmit droplets. Bacillus
pertussis, Haemophilus inuenzae, rhinovirus, adenovirus, group A Streptococcus, and
Neisseria meningitidis are examples of pathogens contracted through this mode of
transmission. Airborne transmission spreads microorganisms (droplet nuclei or
small particles) by air currents and inhalation. These pathogens are infectious over
long distances when they are airborne. They can also be passed through ventilation
systems. Measles (measles virus), Chickenpox (varicella virus) and tuberculosis
(Mycobacterium tuberculosis) can spread in this mode. Transmission-based precautions
are used in every encounter in every healthcare setting in addition to standard
precautions, as some diseases can have more than one mode of transmission (e.g.
SARS-CoV). Additional information can be found in the NHMRC (2019) Australian
Guidelines for the Prevention and Control of Infection in Healthcare, Part 3: Standard
and transmission-based precautions. Also, you can view information on the CDC
website: http://www.cdc.gov/. Refer to your health institution, or the Australian
Government Department of Health: www.health.gov.au within Australia. In New
Zealand, refer to Health and Disability Services (Infection Prevention and Control)
Standards (Standards New Zealand, 2022).
. These precautions are to be used in conjunction with standard
CHAPTER 5
128 PHYSICAL EXAMINATION
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UNIT 2
CLINICAL REASONING
Practice tip: PPE for healthcare workers in the context of COVID-19
Caring for consumers in the COVID-19 environment may create a sense of stress or anxiety.
Consider the following recommendations, with a exible approach guided by healthcare
facility policy, context, healthcare environment and healthcare professional preferences.
> An assessment of risk of transmission of COVID-19 to healthcare professionals should
consider the level of risk (i.e. likely high risk or low risk of SARS-CoV-2 transmission).
> Standard and transmission-based precautions should be following by all healthcare
professionals when providing consumer care in the COVID-19 environment. In addition to
standard and airborne (transmission) based precautions, the following is recommended
when there is likely high-risk SARS-CoV2 transmission:
• A P2/N95 respirator is preferred when providing care for consumers with conrmed
or suspected COVID-19. When a P2/N95 respirator is required, t testing should occur
before the rst use, and a seal check should occur prior to each use.
• Eye protection as described in the guidelines for prevention and control of infection
in health care should be worn when providing direct care for consumers with
conrmed, suspected or asymptomatic COVID-19.
(ICEG, 2021, June; Ministry of Health, 2022; ACSQHC, 2021)
LEGAL CONSIDERATIONS
In today’s litigious society, you must be vigilant when engaging in direct consumer
care. Documentation issues have previously been addressed. Equally important is
how you execute the health assessment and physical examination. Establishing
a trusting and therapeutic relationship that is based on effective communication
is a primary element in avoiding legal issues. While performing each step in the
physical examination process, you need to inform the consumer of what to expect,
where to expect it, and how it will feel. Protests by the consumer need to be
addressed prior to continuing the examination. Otherwise, the consumer may claim
insufcient informed consent, sexual abuse or physical harassment.
All examinations and procedures, including any injury that may have been
caused during the physical examination, must be completely documented. The
institutional policy regarding consumer injury in the workplace must be followed.
REFLECTION IN PRACTICE
Consent: Challenging situations
In the following situations think about the strategies you could implement to decrease your
legal liability.
> You are preparing to perform a genital exam when the consumer says, ‘I’ve changed my
mind. I don’t want to do this.’ What is your best course of action?
> While performing a breast exam on a consumer, the consumer shrieks, ‘What do you
think you are doing?’ How would you respond to this consumer?
> During deep palpation of the abdomen, your consumer responds, ‘Ouch, you hurt me!’
How would you respond?
> You are auscultating the lungs of a 42-year-old man. He tells you that he is thinking of
suing his previous healthcare provider. The consumer tells you, ‘The real problem these
days is that no one bothers to listen to the consumer any more.’ What would be an
appropriate response?
PHYSICAL EXAMINATION TECHNIQUES 129
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PHYSICAL EXAMINATION TECHNIQUES
Physical examination ndings, or objective data, are obtained through the use of
four specic diagnostic assessment techniques: inspection, palpation, percussion
and auscultation. Usually, these assessment techniques are performed in this order
when body systems are assessed. An exception is in the assessment of the abdomen,
when auscultation is performed after inspection. Percussion and palpation can alter
bowel motility, so they are performed after auscultation. These four techniques
validate information provided by a consumer through the health history, or they
can verify a suspected physical diagnosis.
Usually, the easiest assessment skills to master are inspection and basic
auscultation. Percussion and palpation may take more time and practice to master.
With time and practice, the physical examination techniques become second
nature, and you will develop your own rhythm and style. You may not perform
all examination skills in the order in which they are presented in this text. This
practice is acceptable as long as basic guidelines are observed.
Infection control and prevention strategies implemented in response to the
COVID-19 pandemic have shifted policy and practice. To safely manage COVID-19
environments, a variety of changes are evident in persons requiring physical
examination. Physical examination may require additional infection prevention
strategies, time-efcient assessment techniques (Gelfman, 2021), or implementation
of telehealth (Monaghesh & Hajizadeh, 2020).
CHAPTER 5
EXAMINATION IN BRIEF
Physical assessment techniques
Inspection
> Vision
> Smell
Palpation
> Light palpation
> Deep palpation
Percussion
> Direct percussion
> Indirect percussion
> Recognising percussion sound
> Fist percussion
Auscultation
> Direct auscultation
> Indirect auscultation
Equipment
General approach to physical examination
1. Ensure you are appropriately dressed and act in a professional manner.
Ensure your workplace identication is visible.
2. Remove all bracelets, necklaces and earrings that can interfere with the
physical examination.
3. Be sure that your ngernails are short and your hands are warm for
maximum consumer comfort.
4. Be sure your hair will not fall forwards and obstruct your vision or touch
the consumer.
5. Arrange for a well-lit, warm and private room when possible.
6. Ensure all necessary equipment is ready for use and within reach.
7. Introduce yourself to the consumer: for example, ‘My name is Sam Annbel.
I am the nurse who is caring for you today. I need to assess how your lungs
are today.’
130 PHYSICAL EXAMINATION
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UNIT 2
8. Clarify with the consumer how he or she wishes to be addressed: Miss
Jones, Clara, Dr Casey, Rev. Grimes, and so on.
9. Explain what you plan to do and how long it will take; allow the consumer
to ask questions.
10. Instruct the consumer to undress; their underwear can be left on until the
end of the examination. Provide a gown and drape for the consumer and
explain how to use them.
11. Allow the consumer to undress privately; inform the consumer when you
will return to start the examination.
12. Have the consumer void prior to the examination.
13. Wash your hands in front of the consumer to show your concern for
cleanliness.
14. Observe standard precautions and transmission-based precautions, as indicated.
15. Ensure that the consumer is accessible from both sides of the examining
bed or table.
16. If a bed is used, raise the height so that you do not have to bend over to
perform the examination.
17. Position the consumer as dictated by the body system being assessed;
Figure 5.7 illustrates positioning and draping techniques.
18. Enlist the consumer’s cooperation by explaining what you are about to do,
where it will be done, and how it may feel.
19. Warm all instruments before using them (use your hands or warm water).
20. Examine the unaffected body part or side rst if a consumer’s complaint is
unilateral.
21. Explain to the consumer why you may be spending a long time performing
one particular skill: ‘Listening to the heart requires concentration and time.’
22. If the consumer complains of fatigue, continue the examination later
(if possible).
23. Avoid making crude or negative remarks; be cognisant of your facial
expression when dealing with malodorous and dirty consumers, or with
disturbing ndings (infected wounds, disgurement, etc.).
24. Conduct the examination in a systematic approach every time. (This
decreases the likelihood of forgetting to perform a particular assessment.)
25. Thank the consumer when the physical examination is concluded; inform
the consumer what will happen next.
26. Document examination ndings in the appropriate section of the consumer
health record.
CLINICAL REASONING
Practice tip: Key considerations for physical examination
> Stand on the right side of the consumer; establishing a dominant side for examination will
decrease your movement around the consumer.
> Perform the examination in a head-to-toe approach.
> Always compare the right and left sides of the body for symmetry.
> Proceed from the least invasive to the most invasive procedures for each body system.
> Always perform the physical examination using a systematic approach. If it is performed
the same way each time, you are less likely to forget some part of the examination.
PHYSICAL EXAMINATION TECHNIQUES 131
I. Prone
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A. SKIN, head and neck; eyes, ears, nose, mouth and
A. Semi-Fowler’s 45° angle
B. Sitting (High Fowler’s) 90° angle
throat; thorax and lungs; heart and blood vessels;
musculoskeletal; neurological; patients who cannot
tolerate sitting up at a 90° angle
B. SKIN, head and neck; eyes, ears, nose, mouth and
throat; back; posterior thorax and lungs; anterior thorax
and lungs; breasts; axillae; heart and blood vessels;
musculoskeletal; neurological
CHAPTER 5
C. Horizontal recumbent (supine)
D. Dorsal recumbent
E. Side lying
F. Lithotomy
G. Knee-chest
C. BREASTS; heart and blood vessels; abdomen;
musculoskeletal
D. FEMALE genitalia; anterior thorax and lungs;
breasts; axillae; heart and blood vessels; abdomen;
musculoskeletal
E. SKIN; thorax and lungs; bedridden patients who cannot
situp
F. FEMALE genitalia and rectum
G. RECTUM and prostate (in men)
H. Sims’
FIGURE 5.7 Positioning and draping techniques and areas examined
H. RECTUM and female genitalia
I. SKIN; posterior thorax and lungs; hips
132 PHYSICAL EXAMINATION
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UNIT 2
Inspection
Inspection is usually the rst examination technique used during the assessment
process. It is an ongoing process that you use throughout the entire physical
examination and consumer encounter.
vision and smell to consciously observe the consumer. Observing the consumer for
even a brief period of time enables you to establish aspects that will help inform
your overall consumer assessment, and can be done while you are undertaking
other activities with the consumer.
Vision
Use of sight can reveal many facts about a consumer. Visual inspection of a
consumer’s respiratory status, for example, might reveal a rate of 38 breaths per
minute and cyanotic nail beds. In this case, the consumer is tachypnoeic and
possibly hypoxic, and would need a more thorough respiratory examination.
The process of visual inspection necessitates full exposure of the body part being
inspected, adequate overhead lighting and, when necessary,
(light that is shone at an angle on the consumer to accentuate shadows and
highlight subtle ndings).
Smell
The nurse’s olfactory sense provides vital information about a consumer’s health
status. The consumer may have a fruity breath odour characteristic of diabetic
ketoacidosis. The classic odour emitted by a Pseudomonas infection is another
well-recognised smell to the experienced nurse.
Inspection is the use of one’s senses of
tangential lighting
Palpation
The second examination technique is palpation. This is the act of touching a
consumer in a therapeutic manner to elicit specic information. Prior to palpating
a consumer, some basic principles need to be observed. You should have short
ngernails to avoid hurting the consumer as well as yourself. Also, you should
warm your hands prior to placing them on the consumer; cold hands can make
a consumer’s muscles tense, which can distort examination ndings. Encourage
the consumer to continue to breathe normally throughout the palpation. If pain
is experienced during the palpation, discontinue the palpation immediately. Most
signicantly, inform the consumer where, when and how the touch will occur,
especially when the consumer cannot see what you are doing. In this way, the
consumer is aware of what to expect in the examination process.
Your hands are the tools used to perform the palpation process. Different
sections of the hands are best used for examining certain areas of the body. The
dorsum of the hand is most sensitive to temperature changes in the body. Thus, it is
more accurate to place the dorsum of the hand on a consumer’s forehead to assess
the body temperature than it is to use the palmar surface of the hand. The palmar
surface of the ngers at the metacarpophalangeal joints, the ball of the hand, and
the ulnar surface of the hand best discriminate vibrations, such as a cardiac thrill
and fremitus. The nger pads are the portion of the hand used most frequently in
palpation. The nger pads are useful in assessing ne tactile discrimination, skin
moisture and texture; the presence of masses, pulsations, oedema and crepitation;
and the shape, size, position, mobility and consistency of organs (Figure 5.8).
Remember to observe standard precautions when you are performing palpation.
Gloves must be worn when examining any open wounds, skin lesions or a body
part with discharge, as well as internal body parts such as the mouth and rectum.
There are two distinct types of palpation: light and deep palpation. Each of
these techniques is briey described here and covered in greater detail in chapters
describing body system examinations in which palpation is specically used.
PHYSICAL EXAMINATION TECHNIQUES 133
A. Palmar surface
B. Dorsal surface
C. Ulnar surface
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Fingertip
Finger pad
Metacarpophalangeal
joints
(vibration)
Finger pads
assess:
ne tactile
discrimination
moisture
texture
masses
pulsations
oedema
crepitus
organ size,
shape, position,
mobility and
consistency
FIGURE 5.8 Parts of the hand used in palpation
Ball of
hand
(vibration)
Palmar surface
Dorsal surface
Back of
hand
(temperature)
Fingertips
CLINICAL REASONING
Practice tip: Sequence of physical examination
When sequencing examination procedures you should progress from the least intrusive
to the most intrusive to minimise interference with data. Examinations that may cause
discomfort should be performed last whenever possible, in order to prevent consumer
anxiety, fear and muscle guarding. For example, palpation of a tender area in the abdomen
should be performed last. In the paediatric consumer, the assessment of the ears and throat
is usually performed last because these are the most uncomfortable for a child and may
cause crying.
CHAPTER 5
Ulnar surface
(vibration)
Light palpation
Light palpation is performed more frequently than deep palpation and is always
done before deep palpation. As the name implies,
delicate and gentle. In light palpation, the nger pads are used to gain information
from the consumer’s skin surface to a depth of approximately 1 cm below the
surface. Light palpation reveals information on skin texture and moisture; overt,
large or supercial masses; and uid, muscle guarding and supercial tenderness.
Perform light palpation by the following steps:
1. Keep the ngers of your dominant hand together, place the nger pads
lightly on the skin over the area that is to be palpated. The hand and forearm
will be on a plane parallel to the area being assessed.
2. Depress the skin 1 cm in light, gentle, circular motions.
3. Keeping the nger pads on the skin, let the depressed body surface rebound
to its natural position.
4. If the consumer is ticklish, lift the hand off the skin before moving it to
another area.
5. Using a systematic approach, move the ngers to an adjacent area and repeat
the process.
6. Continue to move the nger pads until the entire area being examined has
been palpated.
7. If the consumer has complained of tenderness in any area, palpate this area
last. Figure 5.9 shows how light palpation is performed.
light palpation is supercial,
134 PHYSICAL EXAMINATION
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UNIT 2
Deep palpation
Deep palpation can reveal information about the position of organs and masses,
as well as their size, shape, mobility and consistency, and areas of discomfort. Deep
palpation uses the hands to explore the body’s internal structures to a depth of 4–5cm
or more (
and the male and female reproductive organs. Variations in this technique are singlehanded and bimanual palpation, and are discussed in Chapter15.
Figure 5.10). This technique is most often used for examination of the abdomen
FIGURE 5.9 Technique of light palpation
FIGURE 5.10 Technique of deep palpation
Percussion
Percussion is the technique of striking one object against another to cause
vibrations that produce sound. The density of underlying structures produces
characteristic sounds. These sounds are diagnostic of normal and abnormal ndings.
The presence of air, uid and solids can be conrmed, as can organ size, shape and
position. Any part of the body can be percussed, but only limited information can
be obtained in specic areas such as the heart. The thorax and abdomen are the
most frequently percussed locations.
Percussion sound can be analysed according to its intensity, duration, pitch
(frequency), quality and location.
softness of the sound. It is also called the amplitude.
describes the time period over which a sound is heard when elicited. Frequency
describes the concept of
the highness or lowness of a sound. Frequency is measured in cycles per second
(cps) or hertz (Hz). More rapidly occurring vibrations have a pitch that is higher
than that of slower vibrations. The quality of a sound is its timbre, or how one
perceives it musically. The
produced and heard.
The process of percussion can produce ve distinct sounds in the body: atness,
dullness, resonance, hyperresonance and tympany. Specic parts of the body
elicit distinct sounds when percussed. Therefore, when an unexpected sound is heard in
a particular part of the body, the cause must be further investigated.
Table 5.2 illustrates each of the ve percussion sounds in relation to its respective
intensity, duration, pitch, quality, location and relative density. In addition,
examples are provided of normal and abnormal locations of percussed sounds.
pitch. Frequency is caused by the sound’s vibrations, or
location of a sound refers to the area where the sound is
Intensity refers to the relative loudness or
Duration of percussed sound
PHYSICAL EXAMINATION TECHNIQUES 135
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TABLE 5.2 Characteristics of percussion sounds
ABNORMAL
SOUND INTENSITY DURATION PITCH QUALITY NORMAL LOCATION
Flatness
Soft Short High Flat Muscle (thigh) or bone Lungs (severe
LOCATION DENSITY
Most dense
pneumonia)
CHAPTER 5
Dullness
Resonance
Hyperresonance Very loud Long Very low Boom No normal location in
Tympany Loud Long High Drum Gastric air bubble Lungs (large
Moderate Moderate High Thud Organs (liver) Lungs
(atelectasis)
Loud Moderate–long Low Hollow Normal lungs No abnormal
location
Lungs
adults; normal lungs in
children
(emphysema)
pneumothorax)
Sound waves are better conducted through a solid medium than through an
air-lled medium because of the increased concentration of molecules. The basic
premises underlying the sounds that are percussed are listed.
1. The more solid a structure, the higher the pitch, the softer the intensity, and
the shorter the duration of the sound.
2. The more air-lled a structure, the lower the pitch, the louder the intensity,
and the longer the duration of the sound.
There are four types of percussion techniques: direct (immediate), indirect
(mediate), direct st percussion, and indirect st percussion. It is important
to keep in mind that the sounds produced from percussion are generated from body
tissue up to 5cm below the surface of the skin. If the abdomen is to be percussed,
the consumer should have the opportunity to void before the examination.
Least dense
Direct percussion
Direct percussion or immediate percussion is the striking of an area of the
body directly. To perform direct percussion:
1. Spread the index or middle nger of the dominant hand slightly apart from
the rest of the ngers.
2. Make a light tapping motion with the nger pad of the index nger against
the body part being percussed.
3. Note the sound that is produced.
Percussion of the sinuses (Figure 5.11) illustrates the use of direct percussion in the
physical examination.
Indirect percussion
Indirect percussion is also referred to as mediate percussion. This is a skill that
takes time and practice to develop and use effectively. Most sounds are produced using
indirect percussion. Follow these steps to perform indirect percussion (
1. Place the nondominant hand lightly on the surface to be percussed.
2. Extend the middle nger of this hand, known as the pleximeter, and press
its distal phalanx and distal interphalangeal joint rmly on the location
where percussion is to begin. The pleximeter will remain stationary while
percussion is performed in this location.
3. Spread the other ngers of the nondominant hand apart and raise them
slightly off the surface. This prevents interference, and thus dampening, of
vibrations during the actual percussion.
Figure 5.12).
FIGURE 5.11 Technique of direct
percussion
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