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Physical Assessment

Physical Assessment . Trisha Economidis Lake-Sumter Community College. Purpose of Physical Assessment in Nursing Practice . Establish baseline data To identify and assign priorities of care Monitor status of previously identified problems Screen for health problems.

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Physical Assessment

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  1. Physical Assessment Trisha Economidis Lake-Sumter Community College

  2. Purpose of Physical Assessment in Nursing Practice • Establish baseline data • To identify and assign priorities of care • Monitor status of previously identified problems • Screen for health problems

  3. Types of Physical Exams • Comprehensive – includes health history and complete head-to-toe exam • Focused – Focuses on the presenting problem or complaint • System-specific – Focused exam that’s limited to one body system • Ongoing – performed as needed. Adds to the data base

  4. Exam Preparation • Prepare yourself – know your client’s history and chief complaint; gather supplies • Prepare environment – provide privacy, lighting; eliminate distractions • Prepare client – develop rapport BEFORE exam; explain your purpose; respect cultural differences; use simple language

  5. Rules of Assessment • Proper positioning • Organization • Least intrusive to most intrusive • Privacy is essential • Warm hands & equipment • Record results in specific scientific and anatomical terms

  6. Physical Assessment Skills • Inspection • Palpation • Percussion • Auscultation

  7. Inspection • Evaluating what you see in light of your nursing knowledge base, or the process of observation • Begins when you meet the client • Have to know “normals” • General inspection • Systematic inspection • Note gait, hygiene, affect, behaviors

  8. Olfaction (smell) • Speech changes – smell alcohol? • Urine odor – incontinence? • Fruity breath – ketoacidosis?

  9. Palpation • Using your sense of touch to elicit information • Finger tips – skin texture, shape, edema, pulsation • Dorsum of hand – temperature or moisture • Palmar surface – pulsations • Entire hand – strength & grip • Always palpate tender areas LAST

  10. Percussion • Involves tapping or striking the skin surface with your fingers or hands to elicit sounds, reflexes, uncover abnormal mass and detect pain or tenderness • Direct – striking skin directly • Indirect – non-dominant hand is striking surface and middle finger of dominant hand is used to strike

  11. Auscultation • Listening to sounds produced by internal organs • Direct – listening without an instrument • Indirect – listening with stethoscope • Diaphragm – high pitched sounds • Bell – low pitched sounds

  12. General Survey • Narrative statement of what you observe about the client Appearance and behavior – - speech/behavior appropriate to developmental level -General state of health -Exhibiting signs of distress -Facial characteristics

  13. General Survey, cont. • Body type and posture • Speech • Dress, grooming, personal hygiene • Mental state • Hgt, wgt (BMI), vital signs

  14. General Survey Example • Ms. Clements is an alert, neatly dressed, slender, Black female, who looks her stated age of 30. She is relaxed, oriented to time, place and person, and communicative. She speaks clearly and confidently. She shows no signs of distress. • Hgt: 5’6”, Wgt: 120 lbs; BMI: 19.2 • T: 98 degrees C.; P: 78; R: 16; BP: 116/78

  15. Physical Assessment Modifications for Age • Infants • Toddlers • Preschoolers • School-age • Adolescents • Adults • Older Adults

  16. Respiratory Assessment • Inspection • Palpation • Percussion • Auscultation

  17. Respiratory Inspection • Anterior & Posterior • Color • Skin condition • Symmetry • Shape • Respirations: Rate, rhythm, depth, effort • Nail clubbing • http://www.youtube.com/watch?v=Hv68EQ3tCBI

  18. Respiratory Auscultation • Normal Breath Sounds • Vesicular Sounds • Bronchovesicularsounds • Bronchial (or Bronchotrachial) Sounds

  19. Respiratory Auscultation • Abnormal Breath Sounds: Diminished, Misplaced • Adventitious Breath Sounds • Crackles aka Rales • Rhonchi • Wheezes • Stridor

  20. Respiratory Assessment Documentation • Example: Chest expansion symmetrical. No bulging/retraction in intercostal spaces. No tenderness or masses palpated. No scars, lesions seen. Lungs with rhonchi posterior lobes bilateral throughout. Anterior clear to auscultation. Respirations effortless/regular. RR: 12/min.

  21. Basic Cardiovascular Assessment • Inspection • Palpation • Auscultation

  22. Cardiovascular Inspection • Identify Cardiac landmarks • Note skin color • Observe precordium • PMI at 5th ICS

  23. Cardiovascular Palpation • Palpate precordium in 5 locations: • Apex (Mitral valve) • Left lateral sternal border • Epigastric area • Base Left • Base Right • Feel for pulsations, lifts, heaves, thrills

  24. Cardiovascular Auscultation • Aunt Polly Takes Meds • Aortic Valve – 2nd ICS right sternal border • Pulmonic Valve – 2nd ICS left sternal border • Tricuspid Valve – 4th ICS left sternal border • Mitral Valve – 5th ICS mid-clavicular line

  25. Normal Heart Sounds • S1 (1st sound – LUB) – tricuspid and mitral valves close; Systole begins. (1 Lion Trapped and Mad) • S2 (2nd sound – DUB) – aortic and pulmonic valves close; Diastole begins. (2 Dogs Awake and Playing)

  26. Abnormal Heart Sounds • Murmurs – Harsh blowing sounds caused by disruption of blood flow. • May be systolic (between S1 & S2) or diastolic (between S2 and S1) • May indicate stiff valve, valve doesn’t fully close, septal defect

  27. Abnormal Heart Sounds • Extra Sounds: • S3 – immediately after S2; rhythm: Ken TUCKy • S4 – heard immediately before S1; rhythm: FLOrida

  28. Cardiovascular Documentation Example • Apical pulse 76/min and regular, BP 120/70. S1 S2 without murmurs. No noted lifts, heaves or thrills.

  29. Vascular Assessment • Inspection • Palpation

  30. Vascular Inspection • Skin color, appearance, edema • Mucous membranes pink • Look for abnormal pulsations

  31. Vascular Palpation • Skin temperature and texture • Capillary Refill • Pulses – strength, quality • Central vessels – Carotid arteries • Peripheral pulses – location, quality

  32. Vascular Documentation • Pulses (name all that you have palpated) intact and 2+. No thrills noted. Skin intact, no varicosities, no pedal edema. Capillary refill in fingers <3 seconds.

  33. Abdominal Assessment • Inspection • Auscultation • Percussion • Palpation

  34. Abdominal Inspection • Color • Contour – symmetrical side to side in size and shape • Observe for distention or ascites • Observe for lesions, scars, striae • Inspect for abdominal wall movement • Umbilicus - inverted, protruding; displaced or center of abdomen

  35. Abdominal Auscultation • Listen with diaphragm in all 4 quads • Begin with RLQ->RUQ ->LUQ->RLQ in zig-zag motion

  36. Abdominal Auscultation • Normal bowel sounds – high pitched irregular gurgles or clicks occurring 5-30 times/minute in adult • Abnormal bowel sounds • Absent – none heard after 5 minutes • Hypoactive – soft, infrequent; 1/min • Hyperactive – loud rushing sounds every 2-3 sec

  37. Abdominal Palpation • Light palpation • Place palmar surface on the abdomen and extend fingers. Lightly press with your fingers • Assess for tenderness and guarding in all 4 quads

  38. Abdominal Documentation Example • Abdomen soft, rounded, no masses or pulsations. Surgical scar R inguinal area. + bowel sounds (5-30/min). No tenderness noted with light palpation.

  39. Basic Neurological Assessment • Mental status • Appearance – hygiene, grooming, posture, body language, facial expressions • Communication – rate of speech, ability to pronounce words, tone, volume, choice of words; ability to respond to questions • Memory – long term and short term

  40. Level of Consciousness (LOC) • Includes arousal and orientation • Arousal based on type of stimuli required to produce a response. Verbal – Tactile – Painful stimuli • Glasgow Coma Scale – grade eye, motor and verbal responses (pg 314-315 Vol 2) • LOC descriptions: • Lethargic • Stuporous • Comatose

  41. Orientation • Awareness of time, place, person, situation • Time: year, date, time of day • Place: awareness of surroundings (i.e. in hospital) • Person – both self-identity and recognition of familiar persons • Situation – reason for assessment

  42. Sensory Function • Looking for areas of altered sensation • Assessment includes: light touch, light pain, temp, vibration, stereognosis, graphesthesia, point location

  43. Cerebellar & Motor Function • Neuro aspect of motor function related to activity of cerebellum. Responsible for coordination, smoothness of movement & balance • Assess gait, balance, coordination

  44. Pupillary Response • Testing Cranial nerve III (oculomotor) • PERRLA – Pupils Equal Round Reactive to Light and Accommodation • Tests should be done in dimly lit room

  45. Neurological Documentation Example • Alert and oriented to person, place, time, situation. Thought coherent. Mood: Pleasant. PERRLA. Hand grips strong and equal bilaterally. Point-to-point movements intact. Gait stable. Point location intact.

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