physicalassessment-100608183419-phpapp01

7/28/2019 physicalassessment-100608183419-phpapp01

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Physical Assessment

Acute Care Nursing Program 2005


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OutlineAssessment Process

Respiratory Assessment

Cardiac Assessment

Neurological Assessment

Abdominal Assessment Neurovascular Assessment


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Assessment Process Inspection

Palpation

Percussion

Auscultation

Gather information base line

Record trends


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Respiratory Assessment Inspection

Palpation

Percussion

Auscultation


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Respiratory Assessment Inspection

General appearance,

colour Scaring

Symmetry

Shape

Position of trachea

Work of breathing

Rate

Rhythm Cough productive?


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Respiratory Assessment Palpation

Chest excursion

Tactile and vocal fremitus


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Respiratory Assessment Percussion

Normal resonant, hollow sound

Solid - dull

Percussion is done in the intercostal spaces

Percussion is done both on the posterior

chest and lateral chest


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Respiratory AssessmentAuscultation

Systematic approach

Note adventitious (extra)

Crackles

Wheeze

Friction rub


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Respiratory Assessment


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Cardiac Assessment Inspection

Palpation

(Percussion)

Auscultation


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Cardiac Assessment Inspection

JVP

Oedema

Colour


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Cardiac Assessment Palpation

Pulse

Oedema

Capillary refill

Blood pressure


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Cardiac AssessmentAuscultation

Normal

S1

S2

Abnormal

S2 split S3

S4


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Cardiac Assessment


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Neurological Assessment

Glasgow Coma Scale

Cranial Nerves


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Glasgow Coma Scale

Assess neurological status

Assessment of best response

Eyes

Verbal

Motor


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Glasgow Coma Scale

Score Best Eye Best Verbal Best Motor

6 ----------- ----------- Obeys

5 ---------- Orientated Localisespain

4 Spontaneous Confused Withdraws

3 To speech Inappropriate Flexion

2 To Pain Incomprehensible Extension

1 None None None


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Cranial Nerves

12 cranial nerves

3rd 12th within brainstem

(Midbrain, Pons, Medulla)


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Cranial NerveFunction:

Sensory

Smell

Assessment:

Recognition ofodor

IOlfactory


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Sensory

Information from

the retina

Assessment:

Visual acuity

IIOptic


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Motor

Four of the six

extra-ocularmuscles

Assessment:

Response to light

Moves eye

Elevates uppereyelid

IIIOculomotor


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Motor

Controls the

oblique eyemuscle

Assessment:

Moves eye right,left, up and down

IVTrochlear


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Mixed

Three sensory

Corneal Reflex

One motor

Assessment:

Normal facialsensation

Blinks

Clenches teeth

VTrigeminal


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Motor

Lateral rectus

muscle of eye

Assessment:

Moves eye

laterally

VIAbducens


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Mixed

Sensory

Tongue

Motor

Eyelids

Assessment: Elevates

eyebrows

Puffs checks

Recognizes tastes

VIIFacial


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Sensory

Hearing

Assessment:

Whisper in eachear

VIIIVestibulocochlear


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Mixed

Sensory

Taste buds

Motor

Gag reflex

Assessment: Taste testing

Test gag

IXGlossopharyngeal


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Mixed

Motor branches

to the pharyngealand laryngealmuscles

Viscera of the

thorax andabdomen

Assessment:

Same as IX

XVagus


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Motor

Innervates the

sternocleidomastoidand trapeziusmuscles

Assessment: Shrugs shoulders

XIAccessory


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Motor

Tongue muscles

Assessment:

Sticks out tongue

XIIHypoglossal


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Abdominal Assessment

Inspection

Auscultation

Percussion

Palpation


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Inspection

Asymmetry

Engorged veins

Intestinal movements

Lesions

Scars Swelling


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Auscultation

Systematic

Bowel sounds


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Percussion

All four quadrants

Tympanic- air filled structures Dull solid structures

Bowel

Liver Bladder


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Palpation

Light and Deep

Tenderness, guarding, rigidity

Define organs

Kehrs sign

McBurneys point Murphys sign


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Neurovascular Assessment

Colour

Temperature

Capillary Refill

Peripheral Pulses

Swelling

Movement

Sensation


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References

A Practical guide to clinical assessmenthttp://medicine.ucsd.edu/clinicalmed/

Smith SF, Duell DJ & Martin BC, 2005, ClinicalNursing Skills, Prentice Hall, New Jersey.
http://medicine.ucsd.edu/clinicalmed/http://medicine.ucsd.edu/clinicalmed/

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