Adult physical assessment

Adult assessment items reward the nurse who uses the right sequence, hears the finding that means airway or belly catastrophe, and reports perfusion or neuro change before finishing a checklist. Vital-sign measurement craft (temperature routes, cuff size, orthostatics, SpO2 traps) lives in Vital signs and physical assessment. This chapter owns technique order and the findings that change the plan.

Set the stage, then take a history

Privacy, introductions, and a clear explanation make the exam usable. Sit when you can. Avoid talking across a computer as a wall. Culture and religion shape what you uncover and how you touch. Screen for domestic violence in a private moment with the client alone when the stem allows it.

Health history still matters on exams: chief complaint in the client’s words, present illness timeline, medications and allergies, past surgery, family history for blood relatives, and social history (tobacco, alcohol, drugs, support, living situation). SOAP thinking (subjective, objective, assessment, plan) keeps charting honest: do not put your guess in the subjective line.

Technique order

Four skills build every system exam: inspection, palpation, percussion, and auscultation. Inspection costs nothing and finds color, symmetry, effort of breathing, devices, and wounds. Palpation starts light for temperature, tenderness, and masses. Percussion maps air versus dullness. Auscultation hears air, bowel, and blood flow through a stethoscope.

1. Inspect first everywhere.
2. Abdomen exception: inspect → auscultate → percuss → palpate.
3. Elsewhere: inspect → palpate → percuss → auscultate.
4. Save deep palpation of tender or surgical abdomens for last / as ordered.

Why the abdomen flips the order: percussion and palpation stir the bowel and create false sounds. If you poke first, you can no longer trust what you hear. Count bowel sounds thoughtfully; many protocols expect a full listen (often up to 5 minutes per quadrant) before you chart “absent.” Painful areas come last so guarding does not shut down the rest of the exam.

Cardiopulmonary and perfusion

Look at work of breathing before you chase a single SpO2 digit. Count rate, depth, and pattern. Note accessory muscle use, cyanosis, and position of comfort.

Heart exam on this chapter: apical impulse and auscultation at the left midclavicular line, fifth intercostal space. S1 (mitral/tricuspid closure) and S2 (aortic/pulmonic closure) are the baseline pair. Listen in a quiet room on skin; compare rate to the radial pulse when the rhythm is irregular. New murmurs, friction rubs, or gallops (S3/S4 patterns as tested) get reported with vitals and symptoms, not filed as “probably old.” Pulse checks compare rate, rhythm, amplitude, and equality. Pedal pulse hard to feel may need Doppler (technique detail in the vitals chapter).

Perfusion bedside checks

Neurologic and pain assessment

Mental status can ride along with history: appearance, behavior, speech, mood, orientation to person/place/time, and memory. A falling LOC is not a documentation delay. New confusion, hard-to-arouse sleepiness, or a sudden change from baseline means escalate while you protect airway.

PERRLA is the pupil shorthand the exam still expects: Pupils Equal, Round, Reactive to Light and Accommodation. Darken the room, bring light from the side for direct and consensual constriction, then check near focus for accommodation. Unequal, fixed, or newly sluggish pupils with a LOC change are report-now, not a “recheck next shift” note. Pair pupils with a quick cranial-nerve scan when the stem asks (smile symmetry, tongue midline, shoulder shrug, eye movements in the six cardinal fields).

Pain assessment is part of every meaningful set: onset, location, duration, character, aggravating/relieving factors, radiation, and severity. Reassess after interventions. Infants and nonverbal clients need a behavioral tool (FLACC) or a faces scale. Detailed Wong-Baker teaching sits with vitals; here the rule is: do not invent a number when the client cannot give one. Use the right tool.

Abdomen and other high-yield findings

After the correct sequence, the finding that matters most is the rigid, board-like abdomen with severe pain or rebound tenderness. That picture is peritoneal irritation until proven otherwise. Soft, nontender exams still get documented, but the exam loves the emergency abdomen distractor where the nurse keeps pressing for “completeness.”

• Inspect for distention, scars, devices, and pulsations before you touch.
• Listen in all quadrants; hypoactive after surgery can be expected early, but sudden silence with pain is not “normal recovery.”
• Percuss for tympany versus dullness when the stem asks about fluid or air patterns.
• Palpate lightly first; deep last; stop and escalate if the wall boards up.

Skin turgor, mucous membranes, and fontanels (peds chapters) speak to hydration. Adult skin: note breakdown risk, jaundice, petechiae, and surgical wounds. Musculoskeletal: compare limbs, check neurovascular status distal to casts/splints (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia). Those six Ps belong with fracture chapters too; here you only need to know they are report-now.

Priority map