Basic Physical Assessment Physical Assessment Part 1.
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Transcript of Basic Physical Assessment Physical Assessment Part 1.
Basic Physical AssessmentBasic Physical Assessment
Physical Assessment Physical Assessment
Part 1Part 1
General AssessmentGeneral Assessment
gathering information about the gathering information about the health status of a person health status of a person
identify concerns and needs that can identify concerns and needs that can be treated or managed by nursing be treated or managed by nursing care.care.
look, listen, touch, look, listen, touch, to make an informed decision about to make an informed decision about
care.care.
Types of AssessmentTypes of Assessment
InitialInitial FocusedFocused OngoingOngoing Shift AssessmentShift Assessment EmergencyEmergency
Health HistoryHealth History
Reason for admission/chief complaintReason for admission/chief complaint Demographic informationDemographic information History of present illnessHistory of present illness Family historyFamily history Other historyOther history
Medical: diabetes, heart disease, renal Medical: diabetes, heart disease, renal diseasedisease
Surgical historySurgical history
Health HistoryHealth History
It’s important to remember:It’s important to remember: General care- more concerned General care- more concerned
with with helping the personhelping the person manage or manage or
function with a health problem function with a health problem Not with Not with
diagnosing and treating illnesses.diagnosing and treating illnesses.
Physical ExamPhysical Exam
Usually follows historyUsually follows history Head to toe approachHead to toe approach Includes (as needed): inspection, Includes (as needed): inspection,
palpation, auscultation, and palpation, auscultation, and percussionpercussion
General SurveyGeneral Survey
How do they look overall?How do they look overall? What can you discern just by looking What can you discern just by looking
at and talking with them?at and talking with them? Are they Are they orientedoriented?? What is their mood?What is their mood? How about nutritional status?How about nutritional status? Vital signs?Vital signs?
General SurveyGeneral Survey
As you introduce your self and As you introduce your self and establish trust with the patient your establish trust with the patient your are beginning the general surveyare beginning the general survey
General SurveyGeneral Survey
Level of consciousnessLevel of consciousness OrientationOrientation ConfusionConfusion MemoryMemory Mood, affectMood, affect Signs of distress: dyspnea, anxietySigns of distress: dyspnea, anxiety
Planes of the BodyPlanes of the Body
Sagittal (through midline)-divides Sagittal (through midline)-divides right and left; medial and lateralright and left; medial and lateral
Frontal plane- divides anterior and Frontal plane- divides anterior and posteriorposterior
Transverse – divides top to bottom Transverse – divides top to bottom through pelvis; superior and inferiorthrough pelvis; superior and inferior
Proximal and distalProximal and distal
InspectionInspection
Visual examination - lookingVisual examination - looking Color, shape, size, symmetry, Color, shape, size, symmetry,
position and movementposition and movement Good lighting is very important Good lighting is very important
PalpationPalpation
Assessment through touchAssessment through touch Temperature, moisture, texture, Temperature, moisture, texture,
tenderness, masses, and edematenderness, masses, and edema May be light or deep, one hand or May be light or deep, one hand or
twotwo Make sure your hands are clean and Make sure your hands are clean and
fingernails short!fingernails short!
PercussionPercussion
Short, sharp strikes to the body Short, sharp strikes to the body surface to produce palpable surface to produce palpable vibrations and soundsvibrations and sounds
Maybe direct (one hand) or indirect Maybe direct (one hand) or indirect (two hands)(two hands)
Can detect size, shape, density and Can detect size, shape, density and location of structureslocation of structures
AuscultationAuscultation
Listening to the sounds in the body Listening to the sounds in the body (usually with a stethoscope)(usually with a stethoscope)
Used to listen to lung sounds, heart Used to listen to lung sounds, heart sounds and abdominal soundssounds and abdominal sounds
Keep your stethoscope clean!Keep your stethoscope clean!
HEENTHEENT
Head, Eyes, Ears, Nose, ThroatHead, Eyes, Ears, Nose, Throat Look at distribution of hair. Are there Look at distribution of hair. Are there
any lumps on the head? any lumps on the head? Discolorations?Discolorations?
Is head normal size? Upright? Are the Is head normal size? Upright? Are the facial structures symmetrical in facial structures symmetrical in shape?shape?
HEENTHEENT
Basically a Cranial nerve assessmentBasically a Cranial nerve assessment You You do notdo not need to check each need to check each
cranial nerve at this point, but be cranial nerve at this point, but be aware of what they are and how to aware of what they are and how to assess them.assess them.
HEENTHEENT
Does the mouth droop? Does the mouth droop? Talk to the patient. Do all the facial muscles Talk to the patient. Do all the facial muscles
move together? move together? Can the person see and hear well?Can the person see and hear well? Pupils equal, round and reactive to light and Pupils equal, round and reactive to light and
accommodation.accommodation. What does this mean?What does this mean? Check the eye muscle function. Have the patient Check the eye muscle function. Have the patient
follow your finger to all eight positions.follow your finger to all eight positions. Inspect the ear and assess hearing by talking to Inspect the ear and assess hearing by talking to
the patientthe patient
Cranial NervesCranial Nerves
examine sensation and movement of examine sensation and movement of the face: the facial nerve--CN VII and the face: the facial nerve--CN VII and the trigeminal nerve--CN Vthe trigeminal nerve--CN V
List the function of each cranial List the function of each cranial nerve. Which ones are used for nerve. Which ones are used for swallowing?swallowing?
Other HEENTOther HEENT
Check the nose for abnormalitiesCheck the nose for abnormalities If warranted, palpate the sinuses for tendernessIf warranted, palpate the sinuses for tenderness Look at mouth and neck. Take a look at the Look at mouth and neck. Take a look at the
tongue. Are there white patches? Red patches?tongue. Are there white patches? Red patches? Check range of motion for the neck (gently!).Check range of motion for the neck (gently!). Look at the neck for jugular vein distention. Look at the neck for jugular vein distention.
This could indicate a heart problem.This could indicate a heart problem.
Other HEENTOther HEENT
Where are these structures?Where are these structures? Lymph nodesLymph nodes Jugular veinsJugular veins Carotid arteriesCarotid arteries TracheaTrachea Trapezius and sternocleidomastoidTrapezius and sternocleidomastoid
Other HEENTOther HEENT
To assess the lymph nodes, place To assess the lymph nodes, place both hands on the neck at the same both hands on the neck at the same time and palpate using the time and palpate using the pads of pads of your fingersyour fingers..
Normal: not palpable or smooth, firm, Normal: not palpable or smooth, firm, less than 1 cm, mobile, and less than 1 cm, mobile, and nontendernontender
Head and NeckHead and Neck
size, symmetry, position and size, symmetry, position and movement of head movement of head
temporomandibular joint temporomandibular joint
SkinSkin
InspectionInspection Intact, free of lesionsIntact, free of lesions Pink toned or underlying healthy glowPink toned or underlying healthy glow
PalpationPalpation Warm, cold, moist, dryWarm, cold, moist, dry Lesion: Hard, firm, feels like fluidLesion: Hard, firm, feels like fluid Movable, fixed, attached to underlying Movable, fixed, attached to underlying
structuresstructures
Skin ColorSkin Color
cyanosis (central, peripheral, cyanosis (central, peripheral, circumoral), circumoral),
jaundice, jaundice, pink tone, glowing, ashenpink tone, glowing, ashen pallor, pallor, erythemaerythema
SkinSkin
TurgorTurgor MoistureMoisture TemperatureTemperature
Skin DisruptionsSkin Disruptions
macules, papules, nodulesmacules, papules, nodules vesicles, bullavesicles, bulla scales, plaque, patches (vitiligo)scales, plaque, patches (vitiligo) petechiae, necrosis, keloid petechiae, necrosis, keloid linear, annularlinear, annular
Describing LesionsDescribing Lesions
Size, color, type (primary, Size, color, type (primary, secondary), location, distributionsecondary), location, distribution local vs. generalizedlocal vs. generalized Annular, linearAnnular, linear Abrasion, lacerationAbrasion, laceration
HairHair
DistributionDistribution TextureTexture Cleanliness, groomingCleanliness, grooming Scalp for lesionsScalp for lesions InfestationsInfestations
NailsNails
Capillary refillCapillary refill Abnormal shapeAbnormal shape ClubbingClubbing
Acronyms and DefinitionsAcronyms and Definitions
LOC – Level of ConciousnessLOC – Level of Conciousness PERRLA – Pupils Equal Round Reactive PERRLA – Pupils Equal Round Reactive
to Light and Accommodation to Light and Accommodation JVD – Jugular Vein DistensionJVD – Jugular Vein Distension Skin Turgor- The resilience of normal Skin Turgor- The resilience of normal
skin after being pinched or distorted skin after being pinched or distorted which demonstrates normal cellular which demonstrates normal cellular tension and level of hydrationtension and level of hydration
Acronyms and Definitions Acronyms and Definitions contdcontd
Homan’s Sign – Pain when extending Homan’s Sign – Pain when extending the leg, can indicate Deep Vein the leg, can indicate Deep Vein Thrombosis (DVT)Thrombosis (DVT)
Claudication – Pain and/or Limping Claudication – Pain and/or Limping with walking that is alleviated with with walking that is alleviated with restrest