Introduction to Physical Assessment
Transcript of Introduction to Physical Assessment
Introduction to the Physical
Assessment
Madeline GervaseMSN,CCRN,FNP,RN
Assessment Systematic & continuous
collection, validation, and communication of client data
Nursing process Initial and ongoing Medical vs Nursing Essential components
Purposes of Assessment Obtain Baseline Date regarding functional
abilities Supplement, confirm, or refute date
obtained in nursing history Obtain data that helps establish nursing
diagnoses and plan care Evaluate physiologic outcomes of health
care and thus client progress Screen for presence of risk factors
Types of Assessment
Initial Focused Emergency Ongoing
Types of DataObjective Data
“signs” info perceived by
the senses
Ex: T 101, moist skin
Subjective Data “symptoms” info perceived
only by affected person
Ex: feeling nervous, tired
Characteristics of Data Complete
Factual & Accurate
Relevant
Problems r/t Data Collection
Organization Omission Irrelevant or
Duplicate Data Misinterpretatio
n Too little data Documentation
Why is a health history taken? Patterns of
wellness/illness Physical &
Behavioral risk factors
Deviations from norm
Nurse as a resource
Functional Health Patterns Health Perception/
Management Nutritional-Metabolic Elimination Activity-Exercise Sexuality-
Reproduction Sleep-Rest
Sensory-Perceptual Cognitive Role-Relationship Coping-Stress
Tolerance Value-Belief
Nursing Health History Chief Complaint Present Problem
Usual health status Chronological story Impact on functioning Medications
Past Medical History Family History Personal & Social
History Review of Systems or
Functional Patterns
Client Profile – UK Clinical Setting Biographical Data Chief Complaint History of Present
Illness Current Medications
Current Treatments Past Illnesses or Past
Hospitalizations Allergies
General Survey – Clinical Setting Age/Sex/Race Mental Status Behavior Mood Appearance Body Type Posture Body Mechanics
Speech Use of language Thought Process Reliability as historian
Height/Weight Vital Signs
Explanation- Affect/Mood Affect – observable behaviors which
indicate the feelings or emotional status of the client.
Mood – term which refers to the client’s emotional state as described by the client.
Documentation Terms Affect
Broad Restricted Blunted Flat Labile
Mood Appropriate Inappropriate Depressed Anxiety Agitated Elated Manic Euphoric Euthymic (normal) irritable
General Principles - History Explain purpose Communication techniques Utilization of data sources Document Avoid interruptions or tiring the
client Consider client’s developmental
level
Developmental Principles Pediatric
Parent/child interactions
Integrate child Respect
adolescent, give choices
Geriatric Do not
stereotype Assess and
accommodate: sensory &
physical functioning
Psychosocial Considerations - History Avoid stereotypes Healthcare beliefs Language differences Eye contact Non-judgmental Stressors/Coping Mechanisms
Cultural Awareness Considerations Time Orientation Activity Orientation Human Nature Orientation Human-Nature Orientation Relational Orientation
Seidel, 2003, pp. 43.
History - Biographical Data Name Race Age Gender Marital status
Birthplace, date Address Source of medical
care Insurance coverage
Past Health History Previous hosp. &
surgeries Allergies Illnesses &
Accidents Immunizations Medications Habits/Lifestyle ADLs
Client’s Family History Blood relatives
Significant others
Health history
Family as resource
Stressors in family
Present Illness/Health Concerns
Onset Duration Location, quality, and intensity Precipitating factors Relief factors Client’s expectations Subjective and Objective data
PQRST – Characterize Symptoms Precipitating factors Quality Radiation Severity Temporal Factors
OLD CARTS – Onset Location Duration Character Aggravating factors Relieving factors Temporal factors Severity
Reasons for Seeking Healthcare Chief complaint Why? Quotes Specify Clarify
Resources Home and outside environment Community resources Financial Family & significant others Consider Basic Human Needs
Medical Diagnostic Data Medical vs
Nursing Diagnosis
Nursing Implications r/t Medical Diagnosis
Contributions of Lab Data Verifies data Provides baseline
information Evaluates
outcomes Identifies problems
missed in history and assessment
Test: Complete Blood Count(CBC) Analysis of peripheral venous blood
specimen Main components:
RBC = red blood cell count (erythrocytes) WBC = white blood cell count
(leukocytes) Hgb = hemoglobin Hct = hematocrit
Test: Urinalysis (UA) Analysis of a urine
specimen Screens for:
urinary infection renal disease diabetes mellitus
Urinalysis Main components
pH- 4.6 - 8.0 Protein- up to 10mg/100ml Specific gravity- 1.003 - 1.030 Glucose- negative Ketones- negative Blood- up to 2 RBCs
Test: Electrolytes (lytes, e-) Inorganic
substances in the body that conduct electrical current
Usage: Assess fluid balance
Electrolytes Main Components:
Na+ sodium K+ potassium Cl- chloride Ca calcium P phosphate Mg magnesium
Test: Chest X-Ray (CXR, PA Chest, PA & LAT Chest) Radiographic
exam of the thorax
Visualizes respiratory & cardiac function
Identifies & follows progression/ remission of dx process
Test: Arterial Blood Gas (ABG) Assesses the
adequacy of ventilation and oxygenation via arterial blood
Use: measures respiratory and metabolic (renal) disturbances
Arterial Blood Gases Main
Components: pH PaCO2 PaO2 HCO3 SaO2
General Nursing Implications Assess client’s readiness to learn Explain procedure to client Assist client in dealing with the
test Provide privacy Prepare client for test Universal precautions Send specimens promptly
Specific Nursing Implications Electrolytes:
Note diet, food and fluid intake Note s/s that could affect fluid
balance (N/V/D) Chest X-Ray:
Transport Remove metal objects Stand clear
Specific Nursing Implications Arterial Blood
Gases Anticoagulants? Time drawn Check site for
bleeding Pressure Sample on ICE STAT to lab
Physical Assessment:Pediatric Principles Assess:
coping ability previous
knowledge readiness
Encourage questions
Explain at developmental level
Physical Assessment:Pediatric Principles Use concrete
terms Small amounts of
info at a time Simple & clear
explanations Only offer choices
that are available Honest
praise/rewards
Physical Assessment Methods
Inspection Palpation Auscultation Percussion
Equipment Stethoscope Pen light Blood Pressure Cuff Thermometer Watch with second hand
Inspection
Assessment process during which the nurse observes the client
Inspection Initial contact and ongoing Use olfaction, touch General appearance, body language Systematic unhurried approach Expose part, respect privacy Examine: color, size, shape, position,
symmetry (compare like areas) Know “normals” Observe “normals/abnormals”
Palpation
The use of the hands and the sense of touch to gather data
Palpation Detects texture, shape, temp,
movement, pain, moisture Short fingernails, warm hands Gentle approach Light palpation first, if pain - STOP! Palpate tender areas last Three types:
Light palpation (1/2 inch) Deep palpation (1 inch) Bimanual deep palpation (2 hands)
Auscultation The act of
listening to sounds within the body to evaluate the condition of body organs
(stethoscope)
Auscultation Stethoscope: bell for low pitch sounds (cardiac
sounds) Diaphragm for high pitch sounds (bowel,
breath, normal cardiac) 4 characteristics of sounds
Frequency/pitch: # vibrations per second
Loudness: soft, medium, loud Quality: types; gurgling, blowing Duration: short, medium, long (specify)
Auscultation Quiet environment Know landmarks Know “normals” PRACTICE! PRACTICE! PRACTICE! Requires concentration, practice,
and application of knowledge
Percussion Tapping of
various body organs and structures to produce vibration and sound.
Documentation - Purpose Communication Quality Assurance Legal Reimbursement Research Planning Client Care
Education Statistics Accrediting/Licensure Historical Document
Principles of Documentation Timing Confidentiality Permanence Signature Accuracy Sequence Appropriateness
Completeness Standard Terminology Brevity Legibility Legal Awareness
Learning OutcomesThe student will be able to:1. State the purposes of the physical exam.2. Name the necessary equipment need to
perform a physical exam.3. Describe the four basic techniques used in
physical examination.4. Describe guidelines for preparing a client and
the environment for a physical examination.5. What are the components of a general survey?