Physical Assessment

1. Physical Assessment PN 103

2. Signs and Symptoms • Signs • Objective data as perceived by the examiner -seen -heard -measured -verified by more than one person Examples: rashes, altered vital signs, visible drainage or exudate • Lab results, diagnostic imaging, and other studies

3. Signs and Symptoms • Symptoms • Subjective data • Perceived by the patient • Examples: pain, nausea, vertigo, and anxiety • Nurse unaware of symptoms unless the patient describes the sensation -full description by the patient -onset -course -character of the problem -any factors that aggravate or alleviate

4. Signs and Symptoms • Disease and Diagnosis • Disease • -disturbance of a structure or function of the body • -a pathologiccondition of the body • -a set of signs and symptoms • -clustered in groups to help the physician to make a medical diagnosis • -nurse also relies on assessment of signs and symptoms to formulate a nursing diagnosis

5. Signs and Symptoms • Origins of Disease • Disease or illness originates from many causes: -hereditary -congenital -inflammatory -degenerative -infectious -deficiency -metabolic -neoplastic -traumatic -environmental Unknown etiology • Diseases that have no apparent cause

6. Signs and Symptoms • Risk Factors for Development of Disease • increases the vulnerability of an individual or a group to illness or accident -situation -habit -environmental condition -genetic predisposition -physiologic condition

7. Signs and Symptoms • Categories of risk factors • Genetic and physiologic • Age • Environment • Lifestyle

8. Signs and Symptoms • Terms Used to Describe Disease • Chronic • develops slowly • persists over a long period • often for a person’s lifetime • Remission • partial /complete disappearance of clinical and subjective characteristics of a disease • Acute • begins abruptly • marked intensity of severe signs and symptoms • often subsides after a period of treatment

9. Signs and Symptoms • Organic disease • structural change in an organ • interferes with its functioning Functional disease • manifested as organic disease • careful examination fails to reveal evidence of structural or physiologic abnormalities

10. Signs and Symptoms • Frequently Noted Signs and Symptoms • Infection • invasion of microorganisms -bacteria -viruses -fungi -parasites that produce tissue damage Inflammation • Protective response of the body tissues -irritation -injury -invasion by disease-producing organisms

11. Signs and Symptoms • Cardinal signs of infection and inflammation • Erythema • Edema • Heat • Pain • Purulent drainage • Loss of function

12. assessment • Process of making an evaluation or appraisal of the patient’s condition • Medical Assessment • Physical examination is conducted by the physician • The nurse is often expected to carry out certain functions

13. assessment • Medical Assessment • Functions that may be expected of the nurse • Equipment and supplies • Preparing the exam room • Assisting with equipment • Preparing the patient • Collecting specimens

14. assessment • Nursing Assessment • Initiating the nurse-patient relationship • -first interview is the most challenging to conduct. • -introduce yourself (name and position) • -purpose of the interview. • Give an estimate of time. • Ask if the patient has any questions and answer them appropriately. • Communicate trust and confidentiality. • Convey competence and professionalism.

15. assessment • Nursing Assessment • The interview • -relaxed, unhurried manner. • -quiet, private, well-lighted setting. • -feelings of compassion and concern. • -what name the patient wishes to be addressed. • -accepting posture • -relaxed • -eye level • -pleasant facial expression.

16. assessment • Nursing Health History • -initial step in assessment process • -information on: -patient’s wellness -changes in life patterns -sociocultural role -mental and emotional reaction toillness

17. assessment • Biographical data • Date of birth • Sex • Address • Family members • Marital status • Religious preference • Occupations • Source of health care • Insurance

18. assessment • Nursing Health History • Reasons for seeking health care • Chief complaint • Document information in patient’s own words. • The nurse can use the PQRST method: P provocative/palliative Q quality/quantity R region/radiation S severity T timing

19. assessment • Nursing Health History • Present illness /health concerns • -relate to the progression of the present illness from the onset of • the current signs and symptoms • Past health history • Previous hospitalizations • Allergies • Habits and lifestyle patterns • Ability to perform ADLs • Patterns of sleep, exercise, and nutrition

20. assessment • Nursing Health History • Family history • Immediate and blood relatives • Health or cause of death, -history of illness -patient’s risk for illnesses of a genetic or familial nature -information about family structure, interaction, and function

21. assessment • Nursing Health History • Environmental history • -patient’s home environment • Psychosocial and cultural history • -primary language • -cultural groups • -educational background • -attention span • -developmental stage • Coping skills and family support • -major beliefs • -values • -behaviors

22. assessment • Nursing Health History • Review of systems • Systematic method • Collection of data on all body systems • Record in clear and concise manner • Appropriate terminology • Ask specific questions relating to functioning of each system

23. assessment • Nursing Physical Assessment • Determine the patient’s state of health or illness • Initial step of the nursing process • Forms the nursing care plan • When to perform a physical assessment • -as soon after admission as possible. • -initial assessment is done by an RN. • -ongoing assessment • -LPN and RN

24. assessment • Nursing Physical Assessment • Where to perform a nursing assessment • Comfortable, private setting • -patient’s own room works • -convenient • Methods of nursing physical assessment • -Head-to-toe • -System-by-system • -Focused

25. assessment • Nursing Physical Assessment • Performing the nursing physical assessment • Items needed: • Penlight • Stethoscope • Blood pressure cuff • Thermometer • Gloves • Tongue blade

26. assessment • Senses of touch, smell, sight, and hearing • Wash your hands before beginning assessment. • Documentation of the interview and assessment • -utilize facility forms • Telephone consultation

27. assessment • Performing the Nursing Physical Assessment • Head-to-toe assessment • Neurologic • Level of consciousness • Level of orientation • Hand grips

28. assessment • Skin • -color, • -temperature • -moisture • -texture • -turgor • -injury or skin lesions. • -color of sclera • -mucous membranes • -tongue, • -lips • -nail beds • -palms • -soles.

29. assessment • Hair • -quantity • -quality • -distribution of hair. • Hair should be: • -smooth • -not oily or dry. • Scalp should be free of: • -dandruff • -lesions • -parasites.

30. Skin turgor

31. assessment • Head and neck • -facial expression. • -symmetry of features. • -palpate arteries, veins, and lymph nodes • -feel for enlarged lymph nodes. • -carotid arteries. • -jugular vein distention. • -auscultate the carotids for bruits.

32. assessment • Mouth and throat • Inspect the lips and mucous membranes • -tongue blade and penlight. • -condition of teeth and gums. • -breath odor. • Eyes • -symmetry. • -exudates. • -sclera. • -pupillary reflex.

33. assessment • Ears • -symmetry. • -ear canals. • -hearing and follow commands. • -use of hearing aids • Nose • -symmetry • -nares patent. • -bleeding or drainage.

34. assessment • Chest, lungs, and heart and vascular system • -bilateral chest expansion. • -rate and rhythm of respirations. • -breathing should be QUIET. • -posture. • Breasts • -examine • -encourage monthly self-exams.

35. assessment • Lung sounds • -breath through mouth quietly • -deeply and slowly • -stethoscope firmly but not tightly on the skin • -listen for one full inspiratory/expiratory cycle at each point. • -auscultate using a zigzag pattern.

36. assessment • Spine • -curvature -sitting and a standing position. • Heart sounds • Auscultate • -intensity of the sound • -faint to strong. • -regularity of the rhythm.

37. Auscultating Cardiac sounds

38. assessment • Peripheral vascular system • Palpate peripheral pulses. • -strength on a 0-to-4+ scale. • Extremities • -symmetry • -color • -varicosities. • -temperature • -hands and feet. • -capillary refill or blanch test.

39. Peripheral Pulses

40. assessment • Abdomen • -shape • -contour • -lesions • -scars • -lumps • -rashes. • Auscultate • -bowel sounds in all quadrants. • Palpation • Percussion

41. Abdominal assessment • Palpation of the liver using moderate palpation. • Palpation of the abdomen to assess for distention, masses, or tenderness using light palpation.

42. assessment Genitourinary system Inspect labia/genitalia and pubic hair. Palpate the scrotum. Palpate suprapubic area. Rectum -assess for hemorrhoids or lesions.

43. assessment • Legs and feet • Palpate; • -femoral, dorsalis pedis, popliteal, and posterior tibial pulses. • -edema. • Range of motion. • Color • Motion • Sensation • Temperature