Physical Examination (ER)

INTRODUCTION An accurate physical assessment requires an organized and systematic approach using the techniques of inspection, palpation, percussion, and auscultation. It also requires a trusting relationship and rapport between the nurse and the patient to decrease the stress the patient may have from being physically exposed and vulnerable. The patient will be much more relaxed and cooperative if you explain what will be done and the reason for doing it. While the findings of a nursing assessment do sometimes contribute to the identification of a medical diagnosis, the unique focus of a nursing assessment is on the patient's responses to actual or potential problems. Instruments And Equipment : y Instruments And Equipment Stethoscope Sphygmomanometer Thermometer Torch Wooden tongue depressors Measuring tape

Examining a Patient: General Principles & Etiquettes: y Examining a Patient: General Principles & Etiquettes Meet, greet, introduce Sign Post Consent Explain to patient Be polite: say please & thank you Patient Comfort Thank the patient and cover at the end Most patients view physical exam with apprehension & anxiety - feeling vulnerable & exposed

Examining a Patient: Examination environment: y Examining a Patient: Examination environment Hand Washing Proper light Privacy & Confidentiality Use curtains & shades Presence of a chaperon when examining female patients Correct position of Doctor & Patient Ideally examiner should be on right side of patient Proper Exposure Ensure your hands are warm

Examining a Patient: Examining Patient Basic Steps: y y y y Inspection Palpation Percussion Auscultation

FACTS ABOUT PHYSICAL ASSESSMENT a. Physical assessment is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination. A physical assessment should be adjusted to the patient, based on his needs. It can be a complete physical assessment, an assessment of a body system, or an assessment of a body part. b. The physical assessment is the first step in the nursing process. It provides the foundation for the nursing care plan in which your observations play an integral part in the assessment, intervention, and evaluation phases. c. The chances of overlooking important data are greatly reduced because the physical assessment is performed in an organized, systematic manner, instead of a random manner. PURPOSES OF A PHYSICAL ASSESSMENT a. A comprehensive patient assessment yields both subjective and objective findings. Subjective findings are obtained from the health history and body systems review. Objective findings are collected from the physical examination. (1) Subjective data are apparent only to the person affected and can be described or verified only by that person. Pain, itching, and worrying are examples of subjective data. (2) Objective data are detectable by an observer or can be tested by using an accepted standard. A blood pressure reading, discoloration of the skin, and seeing the patient in the act of crying are examples of objective data. (3) Objective data are sometimes called signs, and subjective data are sometimes called symptoms. (4) Data means more than signs or symptoms; it also includes demographics, or patient information that is not related to a disease process. b. The purposes for a physical assessment are: (1) To obtain baseline physical and mental data on the patient. (2) To supplement, confirm, or question data obtained in the nursing history.

(3) To obtain data that will help the nurse establish nursing diagnoses and plan patient care. (4) To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems.

CONSIDERATIONS IN PREPARING A PATIENT FOR A PHYSICAL ASSESSMENT a. Establish a Positive Nurse/Patient Rapport. This relationship will decrease the stress the patient may have in anticipation of what is about to be done to him. b. Explain the Purpose for the Physical Assessment. The purpose of the nursing assessment is to gather information about the patient's health so that you can plan individualized care for that patient. All other steps in the nursing process depend on the collection of relevant, descriptive data. The data must be factual, not interpretive. c. Obtain an Informed, Verbal Consent for the Assessment. The chief source of data is usually the patient unless the patient is too ill, too young, or too confused to communicate clearly. Patients often appreciate detailed concern for their problems and may even enjoy the attention they receive. d. Ensure Confidentiality of All Data. If possible, choose a private place where others cannot overhear or see the patient. Explain what information is needed and how it will be used. It is also important to convey where the data will be recorded and who will see it. In some situations, you should explain to the patient his rights to privileged communication with health care providers. e. Provide Privacy From Unnecessary Exposure. Assure as much privacy as possible by using drapes appropriately and closing doors. f. Communicate Special Instructions to the Patient. As you proceed with the examination, inform the patient of what you intend to do and how he can help, especially when you anticipate possible embarrassment or discomfort.

PHYSICAL EXAMINATION y For patients who have been 'categorized' as trauma patients, this examination should be performed in a "secure environment" (usually the back of an ambulance, enroute to a Trauma Center,) with the patient "trauma naked." y Keep in mind that immobilization of the Cervical Spine MUST be maintained throughout this process, for patients of suspected trauma. y Also keep in mind that where an "aspect" of the patient has left and right 'components,' that only one side is checked at a time. The reason for this is, that if the patient reacts to any painful stimuli, and right and left aspects were being checked at the same time, the EMT-B would be unable to identify if the source of the reaction was from the right or left side. y Start at the top of the head. Palpate the scalp and superior aspect of the skull. You are looking for cuts, lumps, depressions, 'soft' spots, and unstable segments of skull (or as we explain to our students: "wet stuff, hard stuff, soft stuff, or squishy stuff.") Inspect the posterior aspect of the scalp and skull, to the extent that C-spine immobilization will allow, for the same "stuff." Inspect the lateral aspects of the skull. Inspect the ears, looking for blood, or cerebral spinal fluid. Inspect the anterior aspect of the head, including the forehead and general appearance of the face. Inspect the eyes, looking for discoloration, irregular or unequal pupils. Using a light source, check for "pupil response." Check the nose for irregular shape or discharge of any blood or fluid. Check the mouth, opening it to check for abnormal odor. Check the maxillae, and mandible for instability. y Check the neck. Re-palpate the carotid pulse. Record the findings. Inspect the neck for Jugular Vein Distention (JVD,) Tracheal Deviation, and the presence of Stoma. y Check the chest. Inspect the surface for blood, holes, bruises and unstable segments. Palpate the anterior aspect of the chest checking each rib (careful to check only one side at a time,) and following each rib around to the posterior aspect as far as C-Spine immobilization will allow. Check for symmetrical rise and fall of the chest with each respiration, by placing the heels of your hands on the lower border of the rib cage (your fingers extended toward the patient's neck,) while waiting for the next respiratory cycle. Both of your hands should rise and fall with the chest, symmetrically. Auscultate the lungs for breath sounds and record the findings.

Check the abdomen. Inspect for blood, holes, evisceration. Palpate for lumps or rigidity, checking one quadrant of the abdomen at a time. Use your finger tips to "look" as deep into the abdomen as possible. Use you finger tips to "look" for that lump (it may be as small as a golf ball, or as large as a soccer ball.)

Check the pelvis. First one side then the other. Palpate each hip checking for instability. Inspect each half of the pelvis, looking for blood, holes and bruising. Check the pelvis as a unit (for stability) by placing the heal of each hand on the hips, wrapping the fingers around the hip toward the buttocks, "grabbing" the superior iliac crest, and applying gently increasing, but firm pressure downward, then VERY GENTLY, without risking movement of the patient, attempt to 'rock' the pelvis by attempting to elevate the superior aspect of the pelvis, while attempting to depress the inferior aspect.

Check the lumbar spine. Slide a gloved hand under the patient, into the arch formed by the lower back (the "small of the back") to the extend possible without moving the patient. Withdraw the gloved hand and inspect the glove for 'new' blood. (If signs of bleeding are encountered during this part of the assessment, perform the "posterior" check at this point, as explained below.)

Check the perineum. Inspect the genitalia for signs of injury. (During testing it is suggested that this process be verbalized only, DUH!)

Check the extremities. Upper and lower, one at a time. (In any order.) Circumferentially 'wrap' your hands around the proximal aspect of the limb and palpate toward the distal aspect. Look for blood as you do so. Palpate for lumps, and obvious inconsistencies in bone structure. At the distal structure (hand or foot) palpate for structural inconsistencies and palpate each of the phalanges for the same inconsistencies. Ask the patient to squeeze your hand (for hand assessment,) or push against your hand (for foot assessment.) Check pulses at the distal structure (Radial pulse for the hand, Posterior Tibial or Dorsalis Pedis for the foot.) Scrape your thumbnail along the palm of the hand, or the pad of the foot, to see if the patient is reacting to sensory input.

Check the posterior. This is, under 'normal' circumstances the final part of the detailed physical exam. An over-simplified preview of the process suggests that you will log-roll the patient and inspect the posterior aspect of the patient's body, inspecting and palpating for all of the same "wet stuff, hard stuff, soft stuff, or squishy stuff." However, in order to maintain a professional image, and prepare for the next 'step' in the process, while moving the patient as little as possible, we need to prepare to "apply" a long spine-board to this patient, in conjunction with checking the posterior aspect of the body.

Be certain that sufficient help is available to safely log-roll the patient, while C-spine immobilization is maintained. Have other members of the team retrieve and place a long spineboard adjacent to the patient on the side of the patient opposite to the "rolling/inspecting" team. Through the coordinated effort of the "rolling team" (as learned in "Lifting and Moving,") roll the patient until the posterior surface can be properly assessed. Once assessed, place the backboard and roll the patient (again, in a coordinated manner) back onto the backboard. Secure the patient to the backboard and prepare for movement to a near-by ambulance.

Check vital sign trend. Re-assess the vital signs. This will be the first of several sets, that will establish the 'trend.'

During this entire process it is important to address life threatening conditions that are encountered. At this point it is appropriate to deal with any 'secondary' injuries or conditions that were revealed by the assessment process. In the course of dealing with 'life threats' it is not only possible, but very likely that your decision to transport this patient occurs very early on in the assessment of this patient. Consequently, the major part of the detailed assessment of the patient MAY occur in the back of the ambulance while enroute to the Trauma Center. At whatever point you decide that this patient needs to be moved to the ambulance, employ the help of other members of the team, execute a proper log roll, render the patient's posterior aspect visible (by cutting the clothing 'up the back,' so that an appropriate inspection and palpation of the back can be performed, apply the backboard, and leave the 'balance' of the patient's clothing to act as a drape until the patient is 'secure' in the back of the ambulance. Remove the balance of the clothing, once in the ambulance and continue with the detailed examination.

PHYSICAL EXAMINATION (ER)

Submitted by: JM Floyd R. Medenilla BSN-IV Section A

Submitted to: Maam Annabelle Santos

July 11, 2011