Physical Assessment PDF

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Physical Assessment Purposes of Physical Exam      

Establish the nurse–patient relationship Gather data about the patient’s general health status Confirm, clarify information from history Identify patient strengths Identify actual and potential health problems Establish a base for the nursing process o Confirm and identify nursing diagnoses o Evaluate outcomes

Types of Health Assessments    

Comprehensive o Conducted upon admission to healthcare facility Ongoing partial o Conducted at regular intervals (every shift, every 2 hours, etc.) Focused o Conducted to assess a specific problem Emergency o Conducted to determine life-threatening or unstable conditions

Two Components of a Nursing Assessment    

Health history—focus on interviewing skills Physical assessment—head-to-toe sequence, system sequence Systematic and organized Starts the minute the health care provider walks in the door

Considerations When Performing Health Assessment    

Lifespan considerations Cultural considerations and sensitivity Patient preparation Environmental preparations

Factors to Assess During a Health History        

Biographical data Reason for seeking health care History of present illness Past health history Family history Functional health Psychosocial and lifestyle factors Review of systems

Preparing the Patient for Physical Assessment      

Consider the physiologic and psychological needs of the patient. Explain the process to the patient. Explain that physical assessments will not be painful (decrease patient fear and anxiety). Explain each procedure in detail as it is conducted. Ask the patient to change into a gown and empty bladder. Answer patient questions directly and honestly.

Preparing the Environment for Physical Assessment      

Privacy Lighting Quiet environment Warm Prepare examination table Collect necessary equipment

Equipment             

Thermometer Sphygmomanometer Scale Flashlight or penlight Stethoscope Metric tape measure and ruler Eye chart (Snellen’s chart) Tuning fork Ophthalmoscope Otoscope Nasal speculum Vaginal speculum Percussion hammer

Positions        

Sitting—used to take vital signs, allows visualization of upper body Standing—assessment of posture, gait, and balance Supine—allows relaxation of abdominal muscles Dorsal recumbent—used for patients having difficulty maintaining supine position Sim’s—assessment of rectum or vagina Prone—assessment of hip joint and posterior thorax Lithotomy—assessment of female rectum and vagina; used for brief period only Knee–chest—assessment of the rectal area; used for brief period only

Techniques

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Inspection: assessing size, color, shape, position, and symmetry Palpation: assessing temperature, turgor, texture, moisture, vibrations, and shape Percussion: assessing location, shape, size, and density of tissues Auscultation: assessing the four characteristics of sound, that is, pitch, loudness, quality, and duration

Characteristics of Masses Determined by Palpation       

Shape Size Consistency Surface Mobility Tenderness Pulsatile

Palpation   

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Light (gentle) o Depress less than 1 cm (1/2 inch) Moderate o Depress 1 to 2 cm (0.5 to 0.75 inch) Deep o Risk of internal injury o Only by experienced APs Patient should be relaxed Palpate tender or sensitive areas last

Abdominal Quadrants and Underlying Organs

Percussion   

Tapping to produce vibration Sounds depends on the density of the underlying tissue Sometimes difficult to differentiate the sounds o Tympanic o Dull o Resonance o Flat

Auscultation 

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Listening to the sounds of the body o Diaphragm – high pitched sounds o Bell – low pitched sounds Characteristics of sound heard on Auscultation o Pitch—ranging from high to low o Loudness—ranging from soft to loud o Quality—for example, gurgling or swishing Duration—short, medium, or long

Smell    

Detects presence of possible infection Detects possible alcohol & substance abuse Detects possible hyperglycemia Detects hygiene issues

General Appearance        

Gender Skin color Age Any distress Body type Posture Gait and Movement Hygiene and grooming

General Assessments 

Objective data

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Height Weight Vital signs  BP, T, P, R  obtain O2 sat  Pain (subjective)

Assessing the Integument   

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Health history Physical Assessment Skin Assessment o Inspection  Skin color (Cyanosis, Pallor, Jaundice)  Skin vascularity and lesions (Ecchymosis, Petechiae); Table 25-3 &4 (primary and secondary lesions) o Palpation  Temperature  Texture  Moisture  Turgor (fullness or elasticity of skin) Nails o Inspect – Shape, angle, texture, color

Hair and Scalp o Inspect – color, texture and distribution of hair o Inspect scalp for color, dryness, scaliness, lumps lesions, lice, dandruff o Palpate lumps or masses if noted

Assessing the Head and Neck   

Health history Physical assessment Eyes o Inspect  External structures – color, edema, symmetry, lesions, discharge  Internal structures - ophthalmoscope  Extraocular movements  Visual acuity  Peripheral vision  PERRLA and convergence o Palpate  Pain over lacrimal glands

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Ears o

Inspect  External ear –size, symmetry, shape, lesions  Ear canal – wax plugs, redness, edema, drainage, foreign bodies  Tympanic membrane – redness, swelling, perforation (normal – intact, translucent, shiny and gray) o Palpate  External ear – pain, edema, lesions  Mastoid process – tenderness o Assess for vertigo, tinnitus o Assess hearing and sound conduction  Weber test  Rinne test Nose and Sinuses o Inspect  Color of mucous membrane, lesions, growths or polyps, drainage, bleeding, swelling, nasal septum intactness and deviation o Palpate  Frontal and maxillary sinuses for pain and edema Mouth and Pharynx o Inspect o Lips, gums, teeth, tongue, hard and soft palate o Mucous membrane for color, swelling and lesions o Symmetry of tonsils, red and swollen tonsils o Bleeding gums o Dentures, missing teeth, cavities o Tongue coatings, fissures, redness and swelling of tongue, lesions or ulcers, movement o Assess Gag reflex Neck o

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Inspect  Symmetry  Neck vein distension  ROM Palpate  Thyroid gland – symmetry, enlargement, lumps, bulging  Lymph nodes – if palpable assess the location, size, consistency, mobility and tenderness  Carotid pulses – one at a time

Assessing the Thorax and Lungs  

Health history Physical assessment

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Inspect  Color, shape or contour, breathing patterns, muscle development Normal: color consistent with face, symmetric, transverse diameter greater then anterioposterior diameter, 12 to 20 respirations Abnormal: Barrel chest (chronic lung disease), unequal chest expansion, use of accessory muscles for breathing, abnormal respirations

Palpate o Tenderness, chest expansion, lesions or masses, temperature Auscultate o Movement of air through tracheobronchial tree o Normal breath sounds (Listen for duration, pitch and intensity) o Adventitious sounds

Chest Auscultation  

Listen posteriorly at the lower margin o Lower lobes Anteriorly o Upper lobes

Normal Breath Sounds   

Bronchial (high pitch) Bronchovesicular Vesicular (low pitch)

Adventitious Breath Sounds       

Result from air moving through moisture, mucus, or narrowed airways If heard, listen for loudness, pitch, duration, location on chest wall, variations with breathing, any change after a cough or deep breath. Wheeze Rhonchi (sounds with secretions, ie. Brochial, trachial) Crackles (fine or coarse) Stridor (high pitch wheezing sound) Friction rub

Assessing the Cardiovascular and Peripheral Vascular System  

Health history Physical assessment o Inspect  Precordium – visible pulsations  Epigastric region – pulsation of abdominal aorta

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Extremities – color, temperature, lesions, venous patterns, and edema  Abnormal: Edema, varicosities, rashes, ulcers, pale and cool skin, discolorations, thickened toenails

Palpate  Carotid artery  Peripheral pulses  Capillary refill – on finger nails and toe nails  Normal: < 3 secs Auscultate  Aortic, pulmonic, Erb’s point, tricuspid and mitral area (normal: S1 & S2)  Extra heart sounds  S3 – normal in children and young adults, abnormal in middle and older adults  S4 – normal in older adult, abnormal in children and adults  Heart murmurs

Tissue perfusion   

Blanching with capillary refilling Clubbing Edema o Pitting edema o Edema scales

Peripheral Vascular Abnormalities 

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Venous o Color – normal or red, brown pigmentation o Temp – normal o Pulse – normal o Edema - present Arterial o Color – pale, dusky o Temp – cool o Pulse – diminished or absent o Edema – mild or none o Skin – thin, hair minimal, thick nails

Neurovascular Assessment   

Pain Pallor Peripheral pulses

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Paresthesia Paralysis Pressure

Assessing Breast and Axillae  

Health history Physical assessment o Inspect  Size, shape, symmetry, color, texture, skin lesions  Abnormal: Asymmetry, skin depressions, dimpling, discharge from nipple (except pregnancy), inversion o Palpate  All four quadrants and axilla  Nipple and areola  If mass detected, palpate for size, shape, consistency, location, tenderness,  Abnormal: Discharge, lumps, lesions, palpable lymph nodes

Assessing the Abdomen  

Health history Physical assessment o Inspect  Color, symmetry, contour, umbilicus, peristalsis, pulsations and visible masses  Abnormal: Asymmetry, mass, distension, visible peristalsis, visible pulsations, swelling (Ascites) o Auscultate (Should be done before palpation)  Bowel sounds in all 4 quadrants- RLQ-RUQ-LUQ-LLQ  Listen for 2 minutes or longer in each quadrant before charting as absent  Auscultate (using bell) for bruits over abdominal aorta, femoral arteries and iliac arteries  Abnormal: Bruits, increased or decreased bowel sounds or absent bowel sounds o Palpate  Mass, enlargement of organs, tenderness, pulsations

Assessing the Musculoskeletal  

Health history Physical assessment o Inspect and palpate muscles for tone and strength o Palpate the bones – pain, enlargement, symmetry o Inspect and palpate joints  Inspect ROM  Palpate for pain, swelling, nodules, crepitation o Inspect the spinal curves  Kyphosis  Lordosis

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Scoliosis

Assessing the Neurologic System  

Health history Physical assessment o Assess the level of awareness – Time/Place/Person  Time: What is today’s date? What day of the week is it? What season of the year is this? What was the last holiday?  Place: Where are you now? What is the name of this city? What state are we in?  Person: What is your name? How old are you? Who came to visit you this morning? o Assess the level of consciousness o Assess cranial nerve function o Assess motor and sensory function  Balance and gait  Coordination  Response to pain, touch, shapes and vibration o Neurovascular assessment

Assessing the Rectum and Anus  

Health history Physical assessment o Inspect  Anal region – lesions, ulcers, fissures, redness, external hemorrhoids, bleeding

Assessing Female Genitalia  

Health history Physical assessment o Inspect and palpate  External genitalia-color, size of labia majora and vaginal opening, lesions, discharge, swelling  Palpate labia for masses  Inspect internal genitalia

Assessing Male Genitalia  

Health history Physical assessment o Inspect and palpate  External genitalia – size, shape, contour, appearance of the skin, redness, edema, discharge, location of urinary meatus, symmetry of scrotum  Palpate testes – size, shape and consistency  Inspect and palpate inguinal region – should be free of bulges...