Published on January 11, 2010
Physical Assessment : Physical Assessment Polk State College Department of Nursing Kozier ch 30 Smith/Duell ch 11 Purposes of Physical Assessment : Purposes of Physical Assessment To obtain information about a patient that is needed to plan appropriate care. Establish a therapeutic relationship Identify areas that need more in-depth assessment (review of systems) Communication : Communication Gain insight about patient’s perception of health problems, concerns, goals, cultural expectations for care What is the patient’s chief complaint? Comprehensive health assessment is the first step of the nursing process Interview, observe, document, report Types of Assessment : Types of Assessment Admission Assessment Cephalocaudal, multi-system Initial Shift Assessment Holistic Focused Chief complaint, limited to body system or area Types of Data : Types of Data Primary Secondary Subjective Objective The Interview : The Interview Directed Non-directed Major Stages Opening Body Closing The Health History : The Health History Biographic Data Chief Complaint History of Present Illness Past History Family History Review of Systems Lifestyle Social History Psychological Data Patterns of Health Care Nursing vs Medical History : Nursing vs Medical History Nursing History Medical History The Physical Examination : The Physical Examination Observation Use standard techniques Supplement, confirm or refute history Equipment for Examination : Equipment for Examination Patient Preparation : Patient Preparation Privacy Safety Personal Comfort Inform the patient Positioning the Patient : Positioning the Patient Considerations Culture, age, gender, disability Types of Positions Sitting, supine, recumbent, lithotomy Physical Examination : Physical Examination Inspection Palpation Percussion Auscultation *except abdomen: 1 inspect, 2 auscultate, 3 percuss, 4 palpate Inspection : Inspection Note general color, attitude, well-being Good lighting to exposed area For any abnormality, note size, shape, color, symmetry, location Palpation : Palpation Note masses, crepitus, tender areas Check tender areas last Percussion : Percussion Note pitch and quality of sound Auscultation : Auscultation Diaphragm for high pitched sounds (bowel & lung) Bell for low pitched (vascular) Note quality and characteristics of sounds General Appearance : General Appearance Age, Gender & Race Any signs of acute distress Body Structure Posture & gait Hygiene & grooming Mental Status : Mental Status Level of consciousness Orientation Attitude Affect/Mood Speech Thoughts Vital Signs : Vital Signs Basic Indicators of health status measured early in examination Signs Measured Temperature Pulse Respirations Blood Pressure Height/ weight/ BMI The Skin (Integument) : The Skin (Integument) Protection Homeostasis Thermoregulation Sensory perception (pain, temp, touch) Vitamin D production Immune Function Cosmetics Inspection of Skin : Inspection of Skin Color & uniformity of color Pallor, erythema, cyanosis, jaundice Vascularity Ecchymosis, edema Lesions Size, shape, color, location, distribution Palpation of the Skin : Palpation of the Skin Temperature Edema Moisture Turgor Texture Skin Lesions : Skin Lesions Types Primary Secondary Color Distribution Configuration More later in the semester… The Hair : The Hair Distribution Thickness Texture Infection/Infestation Body Hair The Nails : The Nails Shape/Configuration Texture Color Surrounding Tissue Capillary Refill or Blanch Test Sample Documentation : Sample Documentation Pt is 39 y/o Hispanic male who appears older than stated age. Alert, Ox3, pleasant, answers questions confidently. T 98.8 P 88 R 20 BP 130/82 wt 264# ht 5’10”. Skin is cool and dry with good turgor. No abnormal lesions observed. Nail beds with rapid capillary refill and no cyanosis. The Head and Neck : The Head and Neck Head Eyes Ears Nose Mouth Throat Neck Key Elements: Symmetry Size Shape Color The Head : The Head Size, Shape, Symmetry (normocephalic) Smoothness Facial Features Ex: exophthalmos, periorbital edema Facial Movement Ex: flattened nasolabial fold, ptosis, tics The Eyes : The Eyes Eyebrow hair distribution Eyelashes Eyelids (ptosis, ectropion, entropion) External eye Conjunctiva (color, discharge, lesions) Sclera (color, lesions) Pupils (size, shape, symmetry, reactivity) Cornea (clarity) Sample Documentation : Sample Documentation Head without masses or lesions, nontender to palpation. Facial features symmetric, no deformities noted. Eyes: PERRLA, no erythema or discharge present, corneas clear. Corrected vision 20/20 both eyes. The Ears: anatomy review : The Ears: anatomy review External ear (auricle) funnels sounds into auditory canal toward tympanic membrane Middle ear includes 3 ossicles (malleus, incus, stapes) that transmit sounds through bone and air conduction and sensorineural stimuli Inner ear includes cochlea (sound transmission), vestibule & semi-circular canals (organs of equilibrium) The Ears : The Ears Auricles Color Symmetry Position Texture Elasticity External Canal & TM Hearing The Nose : The Nose External Nose Size, Shape, Color Discharge Palpation Patency The Mouth & Throat : The Mouth & Throat Palate Lips Buccal Mucosa Gums Teeth Tongue Throat (uvula, tonsils) tonsillitis : tonsillitis Sample Documentation : Sample Documentation Ears: Auricles s lesion, canals are patent c small amt brown cerumen noted bilateral. TMs pearly gray and translucent. Mouth s obvious lesions or dental caries. Gums are pink and moist s gingivitis. Tongue c white coating. Throat: Uvula is midline, tonsils 2+ bilateral, erythema present, white exudate on rt tonsil. The Neck : The Neck Head Movement Strength (SCM muscle) Physical Structures Thyroid, trachea, lymph nodes Carotid arteries Sample Documentation : Sample Documentation Neck c full cervical ROM. Trachea is midline. Thyroid not palpable. Cervical lymphadenopathy palpated bilateral. No carotid bruits auscultated. Cranial Nerves : Cranial Nerves Already done! If a person can see, hear, and speak without impediment, is able to swallow without choking, has symmetrical facial features, and moves head and neck freely … then CN II-XII are intact. The Thorax: Chest and Lungs : The Thorax: Chest and Lungs Anatomical Landmarks Front: midclavicular & midsternal lines Side: anterior and mid-axillary lines Back: axillary, scapular lines Sternum: angle of Louis, manubrium Intercostal spaces Spine & vertebral prominences Thorax Landmarks : Thorax Landmarks The Thorax : The Thorax Shape and Size Chest transverse and AP diameter ratio (normal is 1:2) Symmetry and Alignment Kyphosis, lordosis, scoliosis The Lungs : The Lungs Respiratory Rate & Rhythm Ease/Effort Depth and Symmetry Breath Sounds Auscultate & Palpate the Lungs Normal Breath Sounds : Normal Breath Sounds Vesicular Low pitched sound at lung bases heard best in inspiration Broncho-vesicular Moderate (blowing) sound in upper lungs Bronchial High pitched sound heard over trachea Adventitious Breath Sounds : Adventitious Breath Sounds Crackles Air passing thru fluid Gurgles Air passing thru narrowed air passage Wheeze Air passing thru constricted bronchus Friction rub Rubbing of inflamed pleural surfaces More later in the semester… Auscultation of Lungs : Auscultation of Lungs The Heart : The Heart Anatomy/Landmarks Inspect & palpate for lifts, heaves, PMI Auscultate for rate, rhythm, abnormal sounds Auscultation of the Heart : Auscultation of the Heart Point of Maximum Impulse Peripheral Vascular System : Peripheral Vascular System Carotid Arteries Reflects cardiac function Auscultate for bruits Lightly palpate ONE side at a time Jugular Veins Inspect for distention Peripheral Vascular System : Peripheral Vascular System Extremities Inspect skin color, distended veins, edema (unilateral, bilateral) Palpate peripheral pulses, skin temperature Radial, femoral, popliteal, DP, PT Homan’s sign The Abdomen : The Abdomen Anatomy/Landmarks Inspect Skin Integrity Contour & Symmetry Auscultate bowel sounds, vascular sounds listen before you touch the abdomen! Palpate & percuss organs Genitourinary System : Genitourinary System Palpate bladder, inguinal lymph nodes Inspect external genitalia for lesions, hair distribution (if necessary and appropriate) Testicular examination Musculoskeletal System : Musculoskeletal System Tone, symmetry, strength of all extremities Movement/ Range of Motion (passive, active) of spine, extremeties Patient Teaching : Patient Teaching Incorporate teaching as you go! Heart & lung assessment – ask about smoking Chest – teach breast exam Abdomen – ask about colonoscopy GU – ask about Pap, teach testicular exam PRACTICE TIME! : PRACTICE TIME!