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 will 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 :

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 :

Directed

Non-directed

Major Stages:

Opening

Body

Closing

The Health History :

The Health HistoryBiographic DataChief ComplaintHistory of Present IllnessPast History FamilyHistory Review of SystemsLifestyle Social HistoryPsychological DataPatterns of Health Care

Physical Examination :

Inspection, Palpation, Percussion, Auscultation

*except abdomen:1 inspect, 2 auscultate, 3 percuss, 4 palpate

Inspection : Note general color, attitude, well-being Good lighting to exposed area For any abnormality, note size, shape, color, symmetry, location

Palpation : Note masses, crepitus, tender areas Check tender areas last

Percussion : Note pitch and quality of sound

Auscultation : Diaphragm for high pitched sounds (bowel & lung), Bell for low pitched (vascular), Note quality and characteristics of sounds

General Appearance : Age, Gender & Race Any signs of acute distress Body Structure Posture & gait Hygiene & grooming Mental Status : Level of consciousness, Orientation, Attitude, Affect/Mood, Speech, Thoughts Vital Signs : Basic Indicators of health status measured early in examination: Signs Measured: Temperature, Pulse, Respirations, Blood Pressure, Height/ weight

The Skin (Integument) :

The Skin (Integument) functions: Protection, Homeostasis, Thermoregulation, Sensory perception (pain, temp, touch) Vitamin D production, Immune Function, Cosmetics

Inspection of Skin : Color & uniformity of color, Pallor, erythema, cyanosis, jaundice Vascularity, Ecchymosis, edema Lesions Size, shape, color, location, distribution

Palpation of the Skin : Temperature, Edema, Moisture, Turgor, Texture…

Skin Lesions : TypesThe Hair : The Hair Distribution, Thickness, Texture, Infection/Infestation, Body Hair

The Nails :Shape/Configuration, Texture, Color, Surrounding Tissue, Capillary Refill

Sample Documentation :

Sample Documentation Pt is 39 y/o Hispanic male who appears older than stated age. Alert, 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

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 :

Head without masses or lesions, nontender to palpation. Facial features symmetric, no deformities noted. Eyes: 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 Hearing

The Nose : The Nose External Nose Size, Shape, Color, Discharge, Palpation, Patency

The Mouth & Throat : Palate, Lips, Buccal Mucosa, Gums, Teeth, Tongue, Throat, (uvula, tonsils)

tonsils : tonsillitis

Sample Documentation :

Sample Documentation Ears: Auricles has no lesion, canals are patent with 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, 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 :

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 :

Vesicular Low pitched sound at lung bases heard best in inspiration Bronchial High pitched sound heard over trachea

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

The Heart :

The Heart Anatomy/Landmarks Inspect & palpate for lifts, rhythm, abnormal sounds

Peripheral Vascular System : Peripheral Vascular System Carotid Arteries Reflects cardiac function Auscultate for bruits Lightly palpate ONE side at a timeJugular Veins Inspect for distention Peripheral Vascular System : Extremities Inspect skin color, distended veins, edema (unilateral, bilateral) Palpate peripheral pulses, skin temperature Radial, femoral, popliteal

The Abdomen :

The Abdomen Anatomy/Landmarks Inspect Skin Integrity Contour & Symmetry Auscultate bowel sounds, vascular sounds listen before you touch the abdomen!

Genitourinary System :

Genitourinary System Palpate bladder, inguinal lymph nodes Inspect external genitalia for lesions, hair distribution (if necessary and appropriate)

Musculoskeletal System :

Musculoskeletal System Tone, symmetry, strength of all extremities Movement/ Range of Motion (passive, active) of spine, extremeties

Intake and Output

What you need to know

1) one ounce equals 30 ml or cc

2) 2/3 of the body weight is water

3) must be a balance of what goes in and what is lost.

4) edema is excess fluid retention.

5) dehydration is inadequate fluid intake

Intake

1) includes all liquids taken by mouth.

2) Don’t forget to include food that becomes liquid at room temperature.

3) Artificially such as by intravenous, or gavage.

Output

1) Urine

2) Perspiration

3) Exhalation

4) Diarrhea

5) Vomiting

6) Drainage from all tubes.

Why Record Intake and Output

1) dehydration

2) on intravenous therapy

3) recent surgery

4) urinary catheter

5) perspiring profusely or vomiting

6) have specific diagnoses such as CHF, kidney disease, etc.

Fluid Intake

1) May need to be encouraged in some

2) May need to be restricted.

3) Not all fluids taken by the pt can be measured.

4) An estimate is made and recorded.

5) Learn the fluid content of the containers used at your facility.

Example

Coffee cup = 8 oz. Drank 1/2

Water carafe =16oz. 4oz. left

Soup bowl = 6oz. gone

Jello = 4oz. Didn’t touch it

Pudding = 5oz. gone

Milk glass = 8 oz. 3/4 gone

Fluid Output

1) Measure all fluids excreted from body on your shift.2)List them separately- may be required to add them together to obtain total output.3) Pour excreta into graduate, set on level surface and measure at eye level recording the lower line of themeniscus.