CPE Physical Assessment PDF

Preview

Summary

Download CPE Physical Assessment PDF

Description

Physical Assessment 1. 2. 3. 4.

Walk in and sanitize your hands while introducing yourself. Let patient know you are going to be their nurse today. Verify patients name, date of birth, and if any allergies? Inform patient it’s time for their assessment which involves putting your stethoscope on them and you will be asking then to do a few tasks for you, “is that okay?” 5. Put gloves on for assessment. (“how are you feeling today, any pain”) 6. Ask patient to see both hands and explain you are checking for capillary refill.

a. Nails: Healthy fingernails and toenails should generally be a pink color - with the healthy nail plate being pink, and the nail being white in color as it grows off the nail bed, shape of convex curve, smooth and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 3 seconds. 7. Ask patient to squeeze you two fingers (the index and middle finger crossing the index finger) this compare the hands for strength asymmetry. 8. Check radial pulse on each arm 9. Have patient touch each finger to the thumb. (A test for coordination of the movements of the upper extremities). 10. Have patient hold both arms straight in front of him, assess each arm, have patient make a muscle and check the brachial pulse that should be right under the bicep in each arm (The client’s skin should be uniform in color, unblemished and no presence of any foul odor. Patient has good skin turgor and skin’s temperature is within normal limit). 11. Have patient flex elbows and rotate shoulders in a backward motion. (elbow flexion test is an elbow examination procedure to test for cubital tunnel syndrome and checking ROM of the shoulders). 12. Smile and ask patient to smile (is used to check for one-sided facial weakness, a classic sign of stroke, or the Facial Nerve, also known as cranial nerve VII) 13. The face of the patient should appear smooth and has uniform consistency and with no presence of nodules or masses. 14. Access the head of the patient, hair should be thick, silky, evenly distributed and has a variable amount of body hair. (No signs of infection, infestation, head of the patient is rounded, normocephalic, symmetrical, no skull nodules or masses and depressions when palpated). 15. Assess the eyes, have patient look at your forehead while shining the pen light in one pupil (reflex) while watching the opposite pupil, making sure both move together 16. Have patient follow the tip of your pen light, starting with the patient’s nose being the center of focus and have the patient follow the pen light as you make an “X” and a “+” sign with the pen light and follow it as you touch the patients nose. 17. Have patient read the small letter, then the large letters on your badge. 18. Have patient cover one eye at a time and check peripheral vision on both eyes. a. OPTIC Cranial Nerve II (function: visual acuity) Checks EOM (extraocular muscle) Snellen chart, 20 feet back

b. OCCULOMOTOR Cranial Nerve III (function: Upward, downward, medial eye movement, lid elevation, pupil construction) EOM- Cardinal positions, Open eyes, PERRLA. c. TROCLEAR Cranial Nerve IV (function: EOM (down / in) Movements that reflect the inward and downward movement of eye. d. ABDUCENS Cranial Nerve VI (Function: lateral eye movement) Move object left/right. 19. Use pen light and check ear shell and the back of the ear (looking for critters or bruising or cerebrospinal fluid (CSF) and the inside of the ear, critters can come out of ear canal or live behind the ear. While assessing an ear, test their hearing before moving to the other ear. Have patient cover the ear on the opposite side, rub your gloved fingers together to see if the patient can hear it. a. VESTIBULECOCHLEAR/ACOUSTIC Cranial Nerve VIII (function: hearing and equilibrium) Whisper/voice test. Weber test (tuning fork on forehead), Rinne test, (tuning fork on mastoid process), Romberg test (for equilibrium). 20. Assess patients nose, looking for a deviated septum. 21. Have patient close eyes and identify what they are smelling. a. OLFACTORY Cranial Nerve l (function: smell) Done when loss of smell is reported, head trauma, change in mental statues. With eyes closed place simple odor under one nostril at a time while holding another nostril closed. Looking for asymmetry. 22. Have patient open their mouth and say “ahhh”, have them move their tongue around in mouth while you look at their teeth and gums. Have them stick their tongue out, move back and forth, and swallow. After swallowing have them reopen their mouth again and look inside mouth to make sure they were able to swallow, should be nice and clear, no spit. a. GLOSSOPHARYNGEAL, Cranial Nerve IX  Sensory-Taste...posterior 3rd of tongue...too hard to test.  Motor- gag reflex, touch pharynx with cotton applicator. 23. Have patient move their head back and forth as if they are saying “No”, then up and down like saying “yes”. (wanting to see patients full ROM in the neck). 24. Have your stethoscope ready, and have patient lie down (30 degrees HOB elevation), look for jugular venous distension (JVD), listen to the carotids for a carotid bruit (is the unusual sound that blood makes when it rushes past an obstruction in an artery when the sound is auscultated with the bell portion of a stethoscope) 25. Listen to the trachea and have the patient breath in and out. 26. Palpate each carotid, one at a time. 27. MUST be able to identify the suprasternal notch VERBALLY (U-shaped depression just above the sternum, in between the clavicles) 28. Costal Angle (there right and left costal margins form an angle where they meet at the xiphoid process) 29. Angle of Louis (Ribs are counted from this level to downwards. 2nd rib lies at Sternal angle of Louis).

30. Auscultate aortic, pulmonic, tricuspid, and mitral area using correct anatomical landmarks. a. Aortic – 2nd intercostal, right side of sternum b. Pulmonic – 2nd intercostal, left side of sternum c. ERB point – 3rd intercoastal, left side of sternum d. Tricuspid – 4th intercostal, left side of sternum e. Mitral (bicuspid) – 5th intercostal, mid-clavicular 31. Auscultate apical heart rate using anatomic landmark. a. Landmark – 5th intercostal, mid-clavicular

32. While listening to the apical pulse, have patient put their right hand on their chest, find their radial pulse and correlate the lub-dub (Apex) that you are hearing to the radial pulse you are feeling. (if they correlate in practice, we are done, if irregular do it for 1 minute). (“All People Enjoy Time Magazine”) if female and able get patient to hold up their left breast while listening to the Apex, or if not able, you will need to use the back of your hand to push breast up. 33. Inspect thorax for size, symmetry, shape, AP diameter and color. 34. Instruct patient to breathe deeply through the mouth during auscultation of lungs. Move stethoscope systematically side to side from top to bottom over posterior and anterior surface to auscultate all lobes, tracheal, bronchial, bronchovesicular and vesicular breath sounds.

35. While patient is still supine move down to the GI. Inspect abdomen for masses, lesions, size, contour, and symmetry. 36. Auscultate all 4 quadrants for presence of bowel sounds. Start in the LRQ where the ilium is. (small intestine meets up with the large intestine, always chyme going through there, should always hear gurgling). Listen until you hear a gurgle.

 Listen for 1 full minute if hypoactive sounds.  Listen up to 5 minutes if no bowel sounds. 37. Inquire if there is any abdominal tenderness before palpating. Light palpation of all quadrants and inguinal area for tenderness, distention, muscle resistance. 38. Inquire date, amount, color and consistency of last bowel movement. 39. Palpate bladder for distension and tenderness, ask about frequency, urgency, straining and other changes or abnormalities. Collect urine specimen for color, amount, clarity, odor, particulate matter. 40. Move to the foot of the bed, have patient roll up pants and remove socks to check for symmetry. (looking to see if everything is coming down evenly, like one leg not shorter than the other, everything is in line). 41. Take thumbs and start below the knees, gently pressing on both outer sides of each tibia, checking for edema. 42. Check for the dorsalis pedis pulse, have patient spread legs a little outward to assess the posterior tibial pulse (be sure to know where the posterior tibial is located, inside foot not outside, fat way to fail CPE!!!).

43. Check for sensation and function in feet. Ask patient if they can feel you touch on the bottom of the feet, wiggle their toes, look between the toes, and check for cap refill on the fat pad of each toe, some people will have their nails painted or fungal toes. 44. Have patient or you raise each foot one at a time and check heels for any skin breakdown. 45. Have patient bend knees. Once bent have patient ease one leg sideward at a time, this is checking hips. At a 45-degree angle palpitate the popliteal pulse. Have patient lay their legs flat again. (awesome way to see back of legs) 46. Ask about femoral pulse??? 47. Assess motor response of lower extremities. Have patient perform an action against your gently resistance with hands on outer part of the lower legs pushing in, then hands inside lower legs pushing out. (checked for adductor, abductor and hips). 48. Deferring the genital area for CPE, but in the hospital setting you would assess this area. 49. Have patient put socks back on and sit on the side of the bed with feet dangling. (change gloves since you have been touching the feet while patient is getting ready.) 50. Assess the back of the head and back of the patient, auscultation of lungs, move stethoscope systematically side to side from top to bottom over posterior and anterior. 51. Have patient stand up and bend over (dangling, not quite touching feet) checking the patient’s spine or any deformities. 52. Have patient walk a few feet and back to check patience gait.

53. The last part is the sensation test. Have patient raise up their pants and sleeves and show them the cotton ball (soft) and the cotton swab (hard) and demonstrate what you are going to do. Have patient close their eyes and as you touch each extremity ask if it was soft are hard and where, left or right leg, check or arm? 3 areas per each section.

....