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ATI Physical Assessment: Physical Assessment of an AdultEquipment
Stethoscope
o Stethoscopes are used to auscultate, or listen to, a variety of sounds generated within the
body. In general, higher quality stethoscopes allow better transmission of sound
o Most nurses use acoustic stethoscopes. With this type, the stethoscope’s head picks up
sounds that are transmitted through hollow tubing to your ears
o Many stethoscopes have rotating heads; thus, you can listen either with the diaphragm,
which is better for listening to high-pitched sounds, or with the bell, which is useful for
hearing low-pitched sounds.
o Stethoscope tubing that is thick, heavy, and no longer than 18 inches is best for transmitting
sound. The earpieces are attached to bendable metal tubing, so that you can insert the
earpieces at an angle toward your nose. This allows the sound to be projected in the
direction of your tympanic membranes. The earpieces should be soft, comfortable, and large
enough to fill your ear canal and block outside sounds.
o To use the stethoscope, place the earpieces in your ears, making sure that they are directed
toward your nose.
To listen to high-pitched sounds, such as heart, lung, or bowel sounds, use the
diaphragm. Gently rub or tap on the diaphragm to ensure that your stethoscope’s
head is rotated correctly. Apply the diaphragm firmly to your patient’s skin, using
your index and middle fingers to apply pressure. Be sure that nothing rubs against
the tubing because that will generate distracting sounds
When listening for low-pitched sounds, such as checking blood vessels for bruits, use
the stethoscope’s bell. Use light pressure, but be sure that the entire rubber ring
around the bell is in contact with the patient’s skin
Penlight
o Used for better visualization when examining body orifices, such as the mouth, or in skin
folds where you need extra illumination.
o Penlights are also used to check pupillary responses and to provide tangential lighting when
examining skin surfaces
Otoscope
o Examine the PTs ear canals and perhaps the tympanic membranes. Make sure the handle of
the otoscope is charged; otherwise, the light source will not function. Attach the otoscope’s
head to the handle and then attach a disposable speculum to the head. Twist the speculum
onto the head and be sure it is rigidly attached.
o Speculae are most commonly available in two sizes: 2-mm for pediatric exams, and 4-mm
for adult exams. The larger speculum affords a wider view of the inner ear. Turn on the light
by pressing the small button and rotating the ring at the top of the otoscope’s handle.
Handle the otoscope carefully and safely and, at the end of the examination, discard the
speculum.
Tongue Depressor
o Hold down PTs tongue while you visualize the throat or to check the gag reflex. Use another
tongue depressor for sharp/dull discrimination in the neurologic exam. Simply break it, and
then use the half with the sharpest point to test sensation
Cotton Ball
o test sensation to light touch, both on the face during cranial-nerve testing, and on the
extremities as part of the neurologic exam.
Fragrance (coffee or mint)
o Testing the first cranial nerve, the olfactory nerve, is often omitted from physical exams. But
you can test it easily by asking your patient, with his or her eyes closed, to identify a non-
noxious odor, such as coffee or mint (as in toothpaste). Test one nostril at a time by
occluding the other nostril. Do not use alcohol wipes to test sense of smell. Irritating odors
can stimulate the trigeminal nerve and produce an incorrect response
Measuring Device
o A disposable ruler is handy for measuring a variety of skin lesions, areas of redness, and
incisions. Use a measuring tape for determining abdominal circumference and edema.
Tuning Forks
o Some clinicians use a tuning fork as part of the neurologic exam. Tuning forks come in a
variety of tones measured in units called Hertz. While high-frequency tuning forks are often
used to test hearing, you’ll want to use a lower-frequency tuning fork to test vibration. Select
, ATI Physical Assessment: Physical Assessment of an Adult
a 128 or 256 Hertz fork. Activate the tuning fork by holding the handle, or base, in your
dominant hand and striking a tine against the heel of your hand. Then place the handle on
your patient’s skin and ask if he or she can feel the vibration. Once the tuning fork is
vibrating, avoid touching the tines, as you will dampen the vibration.
10-gram monofilament
o Using standardized monofilaments to test for sensation has become common in recent
years, especially for examining the feet of patients who have diabetes. Simply press the tip
of the monofilament against your patient’s skin, causing the filament to bend, and ask if the
patient can feel that touch. For foot exams, test several areas on the plantar aspect, or sole,
of the patient’s foot. Each touch should last 1 to 2 seconds. Vary the interval between
touches and ask the patient to report when he or she feels a touch. Standardized cards with
drawings of feet are helpful for recording your findings.
Gloves
o Have clean gloves available to use in case you encounter any open skin or body fluids and a
measuring device to help you document the size of any incisions, wounds, or lesions.
Level of consciousness, general patient survey and vital signs
Components of level of consciousness include:
o Assess level of consciousness
o Evaluate level of orientation if the patient is alert
Is he is alert and responding appropriately as you greet him? If so, then assess his
orientation.
Can he tell you his name? If so, he is oriented to person.
Does he know where he is? If he does, then he is oriented to place.
Does he know what time or what day it is? If so, he is oriented to time.
Some experts have begun to include orientation to situation as a measure of level of
consciousness, as well. Ask if he knows the reason for the visit. If so, he is oriented to
situation
If he can answer these questions appropriately, he is “oriented times three" (or four if
orientation to situation is included).
o Evaluate level of responsiveness if the patient is not alert
If your patient is not alert but appears to be sleeping or even comatose, does he
respond to your voice? If he does not, see if he will respond to touch by pressing or
rubbing his arm or shoulder.
Some patients who do not respond to gentle touch will respond to pain.
Test for a pain response by pressing a pen across a nailbed or rubbing a
knuckle over the bony part of the patient’s sternum.
The expected response is withdrawal from the painful stimuli. Be sure to
practice on yourself so that you are aware of the level of pain these actions
inflict.
Note whether the patient responds to voice, touch, or pain, and document this
response.
In some practice settings, you will use a standardized scale to assess level of
consciousness.
For example, the Glasgow Coma Scale uses a point system based on the
patient’s responsiveness as indicated by eye opening, as well as verbal and
motor responses to stimulation.
, ATI Physical Assessment: Physical Assessment of an Adult
Another example, the AVPU scale, assigns points according to the patient’s
degree of alertness and response to verbal and painful stimulation. The letters
in “AVPU” correspond to alert, verbal stimulus response, pain stimulus
response, and unresponsive.
General PT Survey
o Components of the general survey include:
Observe skin color, respiratory effort, and presence or absence of distress
After assessing your patient's level of consciousness, begin your general
patient survey. Observe his skin color, respiratory effort, and the presence or
absence of distress. Are the patient’s lips pink and moist or are they bluish or
purple in color?
The bluish discoloration may be cyanosis, which indicates decreased
oxygenation.
Are his respirations regular and unlabored or is he using accessory muscles?
Does the patient appear to be comfortable or does he have other signs of pain
or distress?
Evaluate mood and affect (smiling, pleasant, anxious, apprehensive, depressed,
angry, hostile)
Assess your patient’s mood or affect. Is he smiling and pleasant? Does he
appear anxious or apprehensive? Depressed? Is he angry or hostile? It is
extremely important to consider cultural and ethnic variables during this
portion of the physical assessment. It is easy to conclude that a patient is
withdrawn or has a flat affect because he does not make direct eye contact
and has little emotion in his speech patterns. The nurse must be familiar with
common cultural considerations and demonstrate respect for the patient to
obtain accurate assessment data.
Assess posture and observe hygiene, grooming, and dress, and odors
General appearance
If the PT is standing, is his posture erect?
o If he is seated or in bed, look for evidence that he can change position
independently.
Note his facial expression. Is there any evidence of pain or distress?
Observe hygiene, grooming, and dress
o Is he dressed appropriately for the season and the situation?
Pay attention to any noticeable odors as well
Measure height, weight, and body mass index (BMI)
Finally, assess his general body structure: Is your patient thin? Obese? After
noting your patient’s height and weight, use a BMI calculator to determine his
body mass index, or BMI. If you do not have a BMI calculator and cannot
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