Physical Examination : Head to Toe

Physical Examination : Head to Toe

Physical examination is a review from head to toe on every body system, which provides information on clients and allows nurses to make clinical judgments. The accuracy of the physical examination affect selection of treatment received by the client and the determination of response to therapy. (Potter and Perry, 2005)

Physical examination techniques used are:

1. Inspection

Inspection is the examination by using the senses of sight, hearing and smell. General inspection done when you first met the patient. An overview or general impression about the state of health in shape. Examination then forward it to a local inspection that focuses on a single system or parts and typically use special equipment such as an ophthalmoscope, otoscope, speculum and others. (Laura A.Talbot and Mary Meyers, 1997)

2. Palpation

Palpation is an examination by using the sense of touch by laying hands on the body that can be reached by hand. (Laura A.Talbot and Mary Meyers, 1997)

It is detected are: temperature, moisture, texture, motion, vibration, growth or mass, edema, crackles and sensation.

3. Percussion

Percussion is the examination that includes; tapping the surface of the body to produce a sound that would be helpful in assisting the determination of density, location, and position of the structure underneath. (A.Talbot Laura and Mary Meyers, 1997)

4. Auscultation

Auscultation is the act of listening to sounds generated by a variety of organs and tissues. (A.Talbot Laura and Mary Meyers, 1997)

In the physical examination, there are principles that need to be noticed, which is as follows:

1. Infection control
Includes washing your hands, put sterile gloves, masks, and help clients check the wear.

2. Environmental control
Make sure the room in a state that is comfortable, warm, and light enough to carry out a physical examination of both the client and for the inspectors themselves. For example, closing the door / window to maintain client privacy.

• Communication (explanation of the procedure).


• Privacy and comfort of clients.


• Systematic and consistent (head to toe, from external to internal, from normal to abnormal).


• Being on the right side of the client.


• Efficiency.


• Documentation.

Physical examination purposes
In general, a physical examination performed aims:

1. To gather baseline data the client’s health.


2. To add, confirm, or deny the data obtained in the history of nursing.


3. To confirm and identify the nursing diagnoses.


4. To make a clinical judgment about the client’s health status changes and management.


5. To evaluate the physiological outcomes of care.

Each examination also has a specific purpose that will be described later in every part of the body that will do a physical examination.

Benefits of Physical Examination

Physical examination has many benefits, both for the nurses themselves, as well as for other health professionals, including:

1. As data to assist nurses in nursing diagnosis.


2. Knowing the health problems experienced by clients.


3. As a basis for selecting appropriate nursing interventions.


4. As the data to evaluate outcomes of nursing care.

Indication
To be conducted on every client, especially on:

1. Clients who had entered into the place for in-patient health care.


2. Routinely to clients who are in care.


3. At any time as per client requirements.

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