Physical Assessment Validation PDF

Preview

Summary

Physical assessment validation script...

Description

Abdomen: (stand on right side)  4 quadrants are: Right Upper Quadrant, Left Upper Quadrant, Right Lower Quadrant and Left Lower Quadrant  9 Regions are: Right hypochondriac region, epigastric region, left hypochondriac region, right lumbar region, umbilical region, left lumbar region, right iliac region, hypogastric region, and left iliac region  I will inspect all 4 quadrants of the abdomen for: o Scars and striae noting size, appearance, and location o Dilated veins o Rashes, lesions, and masses using the ABCDE of skin assessment o Umbilicus noting contour, location, inflammation or hernia o Contour of Abdomen (flat, scaphoid, rounded, or protuberant) o Peristalsis and pulsations which are best seen squatting at eye level  Peristalsis is a wave motion and normal aortic pulsation is visible in epigastric area  I will now auscultate all 4 quadrants of the abdomen beginning in RLQ o Bowel sounds include: 1 min  Active- range from 5 to 30 per min  Hypoactive- less than 5 per min  Hyperactive- more than 30 per min  Borborygmus- stomach growling heard without a stethoscope  Absence of bowel sounds- must listen for at least 5 min before determining bowel sounds are absent  Causes include appendicitis and late bowel obstruction  Venous Hum which is a continuous medium pitched sound heard in the epigastric and umbilical area (bell)  May indicate hepatic cirrhosis  Friction Rubs- (heard in liver and spleen)  Abnormal, rough grating sound.  May indicate infection, inflammation, and malignancy  I will percuss all 4 quadrants of the abdomen (12) o Tympany is air-filled areas; Dullness is solid areas o Ask if pain is present prior to beginning and auscultate that area last. o Liver span: percuss along the right MCL  Should average 6 to 12 cm in adult.  Liver width is greater in men and tall individuals. o Spleen:  Percussion should sound tympanic  Trauma or infection could produce a dull sound o Stomach:  Sound is tympanic over the gastric air bubble.  I will now palpate all 4 quadrants of the abdomen o I will ask my patient if there is any pain and if yes, I will palpate that area last o Begin with light palpation then proceed to deep palpation o Using light palpation, I will assess for:

 superficial pain  organs and masses  muscular resistance  abdominal tenderness o Using deep palpation, I will assess for:  deep masses noting size, location, mobility, contour, consistency, and tenderness  aorta (prominent pulsation with lateral expansion suggests an aortic aneurysm)  reflexes (upper abdominal reflexes and lower abdominal reflexes; umbilicus should deviate toward the stimulus for both)  Absence of reflex could indicate a pyramidal tract lesion

Musculoskeletal  Inspect Size and symmetry for o Bilateral symmetry  Color and texture of skin and nail beds o normal nail bed- should be firm with a 160-degree angle between fingernail and nail base o capillary refill- upper and lower extremities o I will observe for clubbing using the Shamroth Technique.  Ask patient to place both index fingers together  Normally, space should be diamond shaped  No space when clubbing occurs o assess for arterial insufficiency using 3 P’s  Pain, pallor, pulselessness  Pigmentation, rashes, scars, and ulcers o Ulcers may or may not be present on the lower extremities with arterial insufficiency  I will inspect Venous pattern (have client stand up for lower extremities) o Venous pattern should be flat and barely visible o Prominence and edema may suggest venous obstruction  Impaired circulation o May be judged by skin color, temperature, peripheral pulse, blanching nail beds, and peripheral edema  Edema o Edema is abnormal interstitial fluid o Describe pitting edema scale (1+ slightly deep, 4+ extremely deep) o Mild edema may be present in the lower extremities with arterial insufficiency  Hair distribution o Hair loss over the feet and toes is associated with arterial insufficiency Palpate  Lymph nodes o Epitrochlear lymph node drains the hand and lower arm  Located by having the person flex the elbow to 90 degrees while you palpate between the triceps and biceps muscle o superficial inguinal  located horizontally and vertically to the inguinal area  Tenderness in region of femoral vein  Edema  Calf for deep phlebitis o Homan’s sign is an indication of deep phlebitis o Have patient dorsiflex the foot- note any pain or soreness in calf would be positive  Assess complete range of motion

o Observe for pain, limitation, spastic movement, deformity o May indicate a problem with a joint, muscle group, nerve supply Neurological  Hi my name is Kate and I will be your nurse today.  I will start by assessing the Reflexes o Deep tendon reflex- elicited by tapping a tendon o Superficial or cutaneous- obtained by stimulating the skin o Pathological- present in disease o Reflex Scale- 0 to 4+ zero being no response, 2+ being normal, and 4+ being hyperactive o I will assess the types of deep tendon reflexes bilaterally:  Biceps- normal response is flexion of the elbow  Triceps- normal response is extension of the elbow  Supinator/brachioradialis- normal response is flexion of elbow and supination of forearm  Knee- normal response is extension of the leg  Ankle- normal response is plantar flexion  Babinski/plantar response- normal response is toes flex or remain still  Abnormal response is fanning of toes which may indicate pyramidal tract lesion  This response is considered normal before age 1  Assess Motor Coordination o Gait normal, heel to toe (tandem walking)  Abnormal can place client at risk for injury, indicate intoxication or a neuromuscular disorder o Muscle strength (upper and lower; describe using muscle strength scale)  Scale is 0 to 5, 0 being no movement and 5 being normal movement against gravity and resistance o Romberg- loss of balance would be a positive Romberg which could indicate cerebellar ataxia or vestibular dysfunction  Assess Sensory (Upper and Lower extremities) eyes closed o Primary Sensory Function  Pain and light touch (describes temperature test)  If superficial touch and pain is not intact assess primary sensation to temperature using one cold and one hot test tube  Vibration  Client should tell when and where vibration is felt  Position  Client should be able to tell you when finger is moving and in which direction  Test fingers and toes o Discriminative Sensation  Stereognosis  Tactile agnosia is the inability to recognize objects by touch, may indicate a parietal lobe lesion  Graphesthesia (number identification)

 Client should be able to identify the numbers you are drawing Point localization  Use dull object to touch patient. They should be able to tell you where you are touching Assess Meningeal signs: o Brudzinski's sign- note stiffness or pain  Involuntary flexion of the hips and knees would indicate a positive sign for meningeal irritation o Kernig's sign- note pain in lower back and resistance to straightening the leg at the knee o If a client has a negative Brudzinski’s sign and a positive Kernig’s sign, you may want to consider disc disease as a possible problem 



Cranial Nerves: 1. Olfactory a. Sensory b. Test for identification of odors. Absence of a sense of smell may result from excessive smoking, sinus condition or cocaine use 2. Optic a. Sensory b. Snellen eye chart is used to test a person’s visual acuity hold chart 12 inches i. Numerator is always 20 which is the distance in feet the person is standing ii. Denominator is the distance at which a person with normal vision can read the chart 3. Oculomotor a. Motor b. EOM (Assess CN III, IV, and VI together) i. Look for nystagmus (abnormal rhythmic oscillations of the eyes) in 6 cardinal fields of gaze (hold 6-12 inches from eyes) ii. Perform corneal light reflex- light should be reflected in the same place in both eyes 1. Strabismus is due to muscle weakness iii. Perform cover/uncover test 1. Observe any movement in eye as it attempts to refocus c. PERRLA (pupils equal, round, react to light, and accommodation) i. Assess pupil size, shape 1. Normal size is 3-5 mm for adult ii. Response to light (direct and consensual) 1. Normally, the eye in light constricts and the other constricts simultaneously 2. Increased intracranial pressure can affect pupil’s reaction to light iii. Perform test for Accommodation- move object toward nose 1. Eyes adaptation to near vision 4. Trochlear a. Motor b. EOM (Assess CN III, IV, and VI together) i. Look for nystagmus (abnormal rhythmic oscillations of the eyes) in 6 cardinal fields of gaze (hold 6-12 inches from eyes) ii. Perform corneal light reflex- light should be reflected in the same place in both eyes

1. Strabismus is due to muscle weakness iii. Perform cover/uncover test iv. Observe any movement in eye as it attempts to refocus 5. Trigeminal- innervated the nasal and oral mucosa, facial skin, and corneal reflex a. Sensory and motor b. Sensation of the skin of face- have the person tell you whether it is sharp or dull and compare each side of the face c. Assess Corneal reflex- touch the cornea with cotton, normally the person should blink d. Lateral jaw movement- move jaw side to side and note any tenderness or immobility e. Palpate temporal and masseter muscles- have person clench teeth while you palpate the muscles. i. Note strength of muscle contraction 6. Abducens a. Motor b. EOM (Assess CN III, IV, and VI together) i. Look for nystagmus (abnormal rhythmic oscillations of the eyes) in 6 cardinal fields of gaze (hold 6-12 inches from eyes) ii. Perform corneal light reflex- light should be reflected in the same place in both eyes 1. Strabismus is due to muscle weakness iii. Perform cover/uncover test 1. Observe any movement in eye as it attempts to refocus 7. Facial a. Sensory and motor b. Taste on the anterior 2/3 of tongue. Person should be able to identify the taste c. Movement of forehead and mouth- ask person to smile, frown, close both eyes, wrinkle forehead, puff out cheeks, and raise eyebrows. Observe for asymmetry and weakness 8. Acoustic a. Sensory b. Whisper test- if the individual hears the words well, hearing can be reported as normal 9. Glossopharyngeal a. Sensory and motor b. Taste on the posterior 1/3 of tongue- person should be able to identify different tastes c. Ask person to say ahh and watch the uvula and soft palate. They should rise and fall symmetrically i. Also assessed with cranial nerve 10 10. Vagus a. Sensory and motor b. Ask person to say ahh and watch the uvula and soft palate. They should rise and fall symmetrically i. Also assessed with cranial nerve 9

c. Gag reflex- take tongue blade and touch the back of the throat. Gag reflex should be elicited. i. A lesion is suspected when there is an absent gag reflex 11. Spinal Accessory a. Motor b. Assess the trapezius by having person shrug shoulders upward against the resistance of your hands c. To assess the sternocleidomastoid muscle, ask the person to turn head from side to side as you try to assist the movements with your hand i. Note strength and contraction of the muscle groups 12. Hypoglossal a. Motor b. Tongue movement- have person move the tongue from side to side and touch the roof of the mouth. Observe for symmetry of movement. Should be smooth without any tremors.

Head and Neck Head and Face:  Have you noticed any problems with your hair or scalp? Inspection  Hair o Quality- course or fine; sudden changes may indicate body dysfunction  Dryness and coarseness may indicate hypothyroidism  Silkiness and fineness may indicate hypothyroidism o Quantity and distribution- terms include patchy, alopecia which is partial or complete loss of hair, and hirsutism which is excessive hair growth  Scalp (scaling, seborrhea, moles, and lumps)  Face (size, shape, symmetry, tics) o Palpebral fissures (spaces between the eyelids) and Naso-labial folds (creases extending from the angle of the nose to the corner of the mouth) o Exophthalmos is an abnormal protrusion of the eyes o Ptosis is the drooping of an eyelid caused by damage to cranial nerve III o Inspect Conjunctiva and Sclera of the eyes  Inflammation of the conjunctiva is conjunctivitis (pinkeye) Palpation:  Skull (size, shape, tenderness, symmetry, depressions/lesions) o Order of palpation (rotary motion: frontal, occipital, temporal, parietal)  Normocephalic skull should be round and symmetrical  Paranasal Sinuses (frontal and maxillary) for: o Tenderness, swelling, thickening, or secretions Ears: Inspect and Palpate:  Auricle/Pinna for size, configuration, location, and angle of attachment to head  Inspect the external ear canal for color, intactness, cerumen, discharge, redness, swelling o Normal ear canal should be clean, dry, free of lesions and minimal cerumen  Mastoid Process (nodules, tenderness) Perform Otoscopic Exam:

  



On adult and older child pull ear up, in children under 3 pull pinna down Inspect the inner ear canal for redness, swelling, lesions, foreign bodies, discharge Inspect the tympanic membrane o Normal should be shiny, pearly gray/light pink o Abnormal is Otitis media, blue, bulging, sunken membrane indicating dehydration Cone of Light o right ear- five o’clock o left ear- seven o’clock

Nose: Inspect:  External nose for deviations in shape, size, color  Nasal septum for symmetry, deviations o Nasal septum should separate nares in a straight line  Patency of nares- have person occlude one nostril and breathe through the other  Mucosa (using pen light) o Normal should be moist, pink and free of swelling o Rhinitis is inflammation and epistaxis is bleeding from nose Throat and Mouth: Inspect: (use a light when examining the mouth)  Lips (symmetry, color, edema, surface abnormalities, herpes simplex-cold sores)  Buccal mucosa for color, pigmentation, ulcers, white patches, nodules o Should be pink, smooth, moist and free of lesions  Gums and Teeth o Should be pink and free of lesions, inflammation, and bleeding o Should be 32 teeth (white, clean, straight, no decay)  Tongue and floor of mouth note symmetry, movement and color o Tongue should be pink, moist, and free of lesions o Floor of mouth is a common site for oral cancer  Roof of mouth o Should be white or pale pink and firm o Hard palate is where jaundice can be readily detected  Oropharynx (normal versus smoker) and Tonsils o Pharynx should be pink; yellowish red with nodules in smokers o Note any enlargement of the tonsils o Uvula should be located in the midline Neck: place individual in upright positions. You should stand in front of individual Inspect neck for:  Symmetry, masses, thyroid, abnormal pulsations, ROM (dropping chin to chest and then rolling head in a full circle, tracheal deviation Palpate  Lymph nodes (bilaterally) o Correct sequence (preauricular, postauricular, occipital, submental, submandibular,





tonsilar, deep cervical chain, supraclavicular) o If a node is palpable note the location, shape, size, mobility, consistency, tenderness, and delimitation o Tender nodes suggest infection while hard nodes suggest malignancy Thyroid (goiter, bruit, do not palpate) o Have person swallow a sip of water and palpate the thyroid as the person swallows o An enlarged thyroid gland is called a goiter o DO NOT PALPATE IF THYROID IS VISIBLY ENLARGED Trachea o Assess for deviation which may indicate mass, aneurysm, or pneumothorax...