Physical Assessment

Required Reading
Review

chapter 27 in Kozier and Erb - you are e pected to !now normal vital signs and how to assess them "oday#s lecture$ K%E p& '2( ) '*+, '**-'-2, and p& 2.( /review chapter 0.1$ components o2 a nursing health history Recommended videos$ 3"45 '222 through '227 ) 6ne 2or each ma7or system
6n reserve in A-4 lab

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9e

t wee!$ K%E pages '*+ - .2' 5hapter highlights ) read them, and answer review questions :tudy ;uide ) use it <emone % =ur!e ) use it to loo! up nursing diagnoses>nursing interventions>plan o2 care

Physical 3ealth Assessment

9ursing

history and physical e amination 9urses use physical assessment s!ills to$
?evelop /obtain baseline data1 and e pand the data base 2rom which subsequent phases o2 the nursing process can evolve "o identi2y and manage a variety o2 patient problems /actual and potential1 Evaluate the e22ectiveness o2 nursing care Enhance the nurse-patient relationship @a!e clinical 7udgments

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E

cept 2or those occasions when you see a patient speci2ically to conduct a nursing assessment, the assessment must be integrated into routine nursing care
E ample$ the bath is a per2ect time to incorporate assessment s!ills

:ee

=o 2*-0 2or the 3ead-to-"oe 2ramewor! that is used 2or assessment

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:ub7ective

data - :aid by the client

/:1
6b7ective

data - 6bserved by the nurse

/61
9ursing

Process

:6APAER

Preparing 2or the assessment

E

plain when, where and why the assessment will ta!e place 3elp the client prepare /empty bladder, change clothes1 Prepare the environment /lighting, temperature, equipment, drapes, privacy
:ee "able 2*-2 2or equipment used during assessment

Positioning
Positions

used during nursing assessment, medical e aminations, and during diagnostic procedures$
?orsal recumbent :upine :ims Prone <ithotomy ;enupectoral

:ee

"able 2*-2 2or client positions

Assessment "echniques
Anspection

- critical observation

"a!e time to BobserveC with eyes, ears, nose Dse good lighting <oo! at color, shape, symmetry, position 6dors 2rom s!in, breath, wound ?evelop and use nursing instincts
Anspection

is done alone and in combination with other assessment techniques

Assessment "echniques
Palpation

- light and deep touch

=ac! o2 hand to assess s!in temperature Eingers to assess te ture, moisture, areas o2 tenderness Assess size, shape, and consistency o2 lesions :ee =o 2*-F, p& '2- to describe characteristics o2 masses

Assessment "echniques
Percussion

- sounds produced by stri!ing body sur2ace

Produces di22erent notes depending on underlying mass /dull, resonant, 2lat, tympani1 Dsed to determine size and shape o2 underlying structures by establishing their borders and indicates i2 tissue is air-2illed, 2luid-2illed, or solid :ee table 2*-F, page '(+ 2or percussion notes

Assessment "echniques
Auscultation - listening to sounds produced by the ?irect auscultation ) sounds are audible without stethoscope

body

Andirect auscultation ) uses stethoscope

Know how to use stethoscope properly /practice1 Eine-tune your ears to pic! up subtle changes /practice1 ?escribe sound characteristics /2requency, pitch intensity, duration, quality1 /practice1
Elat diaphragm pic!s up high-pitched respiratory sounds best =ell pic!s up low pitched sounds such as heart murmurs Practice using =6"3 diaphragms

PRA5"A5E

5omplete 3istory and Physical

9ursing

history is subjective - includes things li!e biographic data, the chie2 complaint, source o2 the data, history o2 present illness, past medical history, immunization history, allergies, habits /tobacco, E"631, stressors, 2amily history including genogram, patterns o2 health care, and a review o2 the body#s systems :ee Eigure 0.-F, pp& 27+-270

3istory o2 Present Allness

3PA

is a chronological story o2 what has been happening

@ust get details o2 the problem, there2ore must be systematic 6<EGGAA" /one system ) there are others1$ onset, location, 2requency, quality, quantity, aggravating 2actors, alleviating 2actors, associated symptoms, treatments tried /include all treatments - R , 6"5, herbal, 2ol!1 <ots o2 systems ) 2ind one that wor!s, and use it

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Dse

whatever system wor!s 2or you, but use a system /6<EGGAA", PGR:", pain intensity scales, etc1
Pain, quality>quantity, radiation, setting, timing Rate pain 2rom 0 to 0+ Dse age appropriate tools /2aces1

5ulturally

appropriate care

E am 6rder and ?ocumentation

?ate

and identi2ying data - name, age, se , race, place o2 birth /i2 pertinent1, marital status, occupation, religion :ource and reliability o2 history 5hie2 complaint H reason 2or visit /succinct1 3PA - the long version o2 the 55 /6<EGGAA"1 P@3 - general health, childhood illness, adult illnesses, psychiatric illnesses, in7uries, hospitalizations, surgery, immunizations, habits, allergies /9K?A1

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5A;E

questions$

0& 3ave you ever thought you should Cut down 2& 3ave you ever been Annoyed by criticism o2 your drin!ingI (& 3ave you ever 2elt Guilty about drin!ingI F& ?o you ever have an Eye-opener in the morningI

JE: to any o2 the above questions - need to investigate 2urther to see i2 there is a drin!ing problem

6rder % ?ocumentation
E3

- age and health o2 parents and siblings or cause o2 death /genogram1K 3"9, ?@, 54?, 5a, 3A, arthritis, addictions R6: /sub7ective head-to-toe review1
;eneral - recent wt& change, 2atigue, 2ever :!in - rashes, lesions, changes, dryness, itching, color change, hair loss, change in hair or nails Eyes - change in vision, 2loaters, glasses, 3A, pain

6rder % ?ocumentation
R6:

Ears - pain, loss o2 hearing, vertigo, ringing, discharge, in2ections 9ose and sinuses - 2requent colds, congestion, 3A, nosebleed @outh and throat - condition o2 teeth and gums, last dental visit, hoarseness, 2requent sore throats 9ec! - lumps, sti22ness, goiter =reasts - lumps, pain, discharge, =:E

6rder % ?ocumentation
R6:

Respiratory - cough, sputum, wheezing, asthma, 56P?, last PP?, last 5LR, smo!ing history /can do here, or with BhabitsC1 5ardiac - heart trouble, chest pain, :6=, murmur, h>o rheumatic 2ever, past EK;, E3 o2 heart disease M'+ yrs o2 age ;A - problems swallowing, heartburn, vomiting, bowel habits, pain, 7aundice Drinary - 2requency, incontinence, pain, burning, hesitancy, nocturia, polyuria

6rder % ?ocumentation
R6:

;enitalia - lesions, discharge, se ual orientation, se ual 2unction, menstrual history, contraception, pregnancy history, ":E Peripheral vascular - intermittent claudication, varicose veins, blood clots @: - muscle or 7oint pain, redness, sti22ness, warmth, swelling, 2amily history 9euro - 2ainting, blac!outs, seizures, wea!ness

6rder % ?ocumentation
R6:

Endocrine - sweats, s!in change, heat or cold intolerance, e cessive thirst /polydipsia1, e cessive urination /polyuria1, weight change, menstrual changes Psychiatric - mental illness, thoughts o2 harming sel2 or others
All

o2 R6: is subjectiveK PE is objective

5omplete 3%P - 6b7ective

3istory

is subjective; Physical assessment is objective

6b7ective portion o2 e am begins with the general surveyK Each body system reviewed in te t has nursing history at the beginning o2 the procedure 2or the ob7ective e am An actual practice, you get most o2 the history be2ore ever touching the client, but there are usually additional history questions to as! during the e am

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6rder

o2 e am - head to toe in systematic order 6rder o2 techniques - APPA /Anspection, Palpation, Percussion, Auscultation1 =e systematic, but be 2le ible based on patient#s needs
Nhen might you change order o2 e amI
An

practice, you o2ten will do B2ocusedC PE e amine only the pertinent parts PRA6RA"AOE /A=5#s, @aslow1

;eneral :urvey
;eneral

appearance, gait, nutrition status /96" to be con2used with nutrition history1, state o2 dress, body build, obvious disability, speech patterns, a22ect /mood1, hygiene, body odor, posture, race, gender, height, weight, vital signs 3eight up to age 2 is recumbent
Add head circum2erence i2 child is less than 2 years old

Antegumentary :ystem
Antegument includes s!in, hair, and nails
Anspect$

s!in color and uni2ormity o2 color, moisture, hair pattern, rashes, lesions, pallor, edema Palpate$ temperature, turgor, lesions, edema /see pp& '(., '(7, '(- on s!in lesionsK :ee bo p& '(* on describing edema1 Percussion and auscultation$ rarely used on s!in "erminology$ pallor, cyanosis, edema, ecchymosis, macule, papule, cyanosis, 7aundice, types o2 edema, vitiligo, hirsutism, alopecia, etc&

Antegumentary :ystem
3air

- te ture, distribution, scalp, critters 9ails - inspect and palpate

Nhy palpateI 5yanosis - is it true or d>t coldI =lanch test /a!a capillary re2ill or 5E"1$ delayed return o2 color indicates poor arterial circulation 5lubbing - loss o2 normal angle between nail and nail bed d>t chronic o ygen deprivation /picture p& 'F21
:!in

) !now terminology, draw diagrams, ta!e pictures

3EE9"
3ead Eyes

- inspection and palpation - inspection and palpation

:ize, shape, symmetry Anspect and palpate lids, lashes, inspect eye position and symmetry and position, symmetry and size o2 pupils 4isual acuity with :nellen chart
2+>2+ - 2irst number /numerator1 is distance 2rom chart :econd number is distance at which a normal eye could have read that line /6D, 6?, 6:1 Always record i2 tested cc /with correction1

Eyes

4isual acuity /:nellen 2or distance, Rosenbaum 2or near vision1 4isual 2ields - assess peripheral vision E6@s - chec!s . ocular movementsK tests 59 (, F, and . Pupil response to light and accommodationK Eig& 2*-22, p& '(+ and =o 2*--, p& '(0 /PERR<A1
Pupils constrict o light, and also to accommodate 2or near vision /dilate 2or dimness and distance1

?irect and consensual pupil response 5orneal light re2le - chec!s eye alignment Eundoscopic e am - ophthalmoscope "erminology - myopia, presbyopia, ptosis, etc

Ears
Anspection

and palpation

Anspect size, shape, position, discharge, lesions Palpate 2or tenderness, any lesions
Review

anatomy o2 ear and inner ear ;ross hearing acuity$ normal voice, whisper test, Neber and Rinne /=o 2*-0', p& '(*1 Anternal ear /behind tympanic membrane1 ) otoscope can loo! through "@ /Eigure 2*-2* and 2*-2-, p& '(71

9ose and :inuses

Anspection,

palpation, percussion Anspect color o2 mucosa, presence o2 discharge

"here is a nasal speculum ) most people don#t li!e it Assess 2or patency
Palpate

2or tenderness Percuss 2or tenderness over 2rontal and ma illary sinuses /Procedure 2*-*1

@outh and "hroat

Anspection,

palpation, auscultation Anspect and palpate lips, tongue, oral cavity, tonsils, pharyn /color, moisture1, teeth, breath, presence o2 e udate, erythema, lesions, palate
Read di22erences in oral e am 2or elderly clients Enlarged tonsils are graded
;rade 0 ) wnl ;rade 2 ) tonsils b>w pillars and uvula ;rade ( ) tonsils touching uvula ;rade F ) tonsils touching each other /!issing tonsils1

5ampbell-3o22man ;rant
6ral

health is strongly lin!ed to overall health

Read through materials in pac!et :tudents will do complete oral assessment during clinic visit, and then will have to do an oral assessment on each patient they are assigned to ta!e care o2 Eorm

"hroat and 9ec!

Anspect

and palpate nec! 2or trachea /should be at midline1, thyroid, lymph nodes /2igure 2*-F2 and F(, p& '.71 Auscultate carotids 2or bruits /bell1
A2 bruit is heard, palpate 2or carotid thrill Palpate one side at a time
Per2orm

R6@ on nec! /active and passive1

"hora and <ungs

5hanges

in respiratory status can happen very slowly, or very quic!ly, so respiratory status is assessed care2ully, and 2requently :ee 2igure 2*-F7, p& '70 and 2igure 2*-F* and F-, p& '72 2or chest landmar!s - need to !now angle o2 <ouis, how to count ribs, how to describe locations, what is under the sur2ace
<andmar!s are things 2elt or seen used to document location o2 something

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Assess

size and shape o2 thora

<oo! 2or de2ormities /Eig& 2*-'2, p& '7F1 =arrel chest 2rom asthma or 56P?
Presence

o2 supernumery nipples Eor e22iciency, you usually assess posterior chest 2irst Antercostal spaces /A5:1 are names according the rib they lie beneath
Fth rib lies superior to Fth A5: Posterior, you have to count spinous processes to name ribs and A5:s

=REAK

<ungs
Anspect,

Palpate, Percuss /normal note is resonance1, Auscultate /normal is clear and equal bilaterally1
Auscultate using diagram in Eigure 2*-'' and 2*-'-, p& '77-'7*

Assess

and document respiratory rate, rhythm, and e22ort

Respiratory "erminology
Eupnea "achypnea =radypnea Apnea 3yperventilation 3ypoventilation ?yspnea

Respiratory Narning :igns

An

ious e pression :uprasternal % intercostal retractions 9asal 2laring 5ircumoral cyanosis 3ypere panded chest
A<NAJ: RE@E@=ER J6DR A=5s

=reath :ounds
Auscultate

using diaphragm, use a systematic approach, compare each side to the other, document when and where sounds are heard 9ormal breath sounds$ bronchovesicular, bronchial, and vesicular
Abnormal breath sounds are called adventitious sounds

=reath :ounds
:tridor

- may be heard without stethoscope, shrill harsh sound on inspiration d>t laryngeal obstruction Nheeze - may be heard with or without stethoscope /document which1, high-pitched squea!y musical soundK usually not changed by coughingK ?ocument i2 heard on inspiration, e piration, or bothK @ay clear with cough
9oise is caused by air moving through narrowed or partially obstructed airway 3eard in asthma or E=A

=reath :ounds
5rac!les

- heard only with stethoscope /2ormerly called rales1$ 2ine, medium, coarse short crac!ling sounds /thin! hair1K @ay clear with cough
@ost commonly heard in basesK easier to hear on inspiration /but occurs in both inspiration and e piration1

;urgles

- heard only with stethoscope /2ormerly called rhonchi1$ <ow pitched, coarse wheezy or whistling sound - usually more pronounced during e piration when air moves through thic! secretions or narrowed airways ) sounds li!e a moan or snoreK best heard on e piration /but occur both in and out1

 Eriction

rub ) ;rating, crea!ing, or rubbing sound heard on both inspiration and e pirationK not relieved by coughingK due to pleural in2lammation ?ocument breath sounds as clear, decreased or absent, compare right to le2t, and describe type and location o2 any adventitious sounds
5"A= or ==: cl P H NOT =: clear /=: could be bowel sounds & & &1

 An2ants

) respiratory rate is much 2aster, breath sounds seem louder and harsher
=abies belly breathe, so watch abdomen 2or counting respirations rather than watching chest /up to about age . years1

Elderly

) 6steoporosis and postural changes can decrease respiratory e22ort and 2unctionK cilia decrease in number and 2unction, so mucous is not cleared as easily, putting elderly at increased ris! 2or respiratory in2ections

4ideo

=reasts and A illae

Anspection

and palpation

Anstruct 2emale clients to per2orm =:E q month @en have some glandular tissue beneath nippleK women have glandular tissue throughout breast and into a illa
<argest portion o2 glandular tissue in women in in upper outer quadrant :ee bo page 2*-27, p& '** on breast health guidelines

Anspect 2or symmetry, contour /shape1, loo! 2or any areas o2 hyperpigmentation, retraction or dimpling, edema Palpate breasts, areolae, nipples and a illary lymph nodes in both men and women
=e sure to include tail o2 :pence

 9ewborns ) may have breast swelling and>or mil!y discharge 2rom nipples 2or up to 2 wee!s "anner :taging is a se ual maturity ratingK 2emale breast development is one o2 the things rated /' stages1 ;ynecomastia ) enlargement o2 breast tissue in malesK o2ten occurs during puberty, and o2ten a22ects only one breast, or a22ects one more so size is not symmetric Pregnant women ) breasts enlarge as glandular tissue responds to pregnancy hormones to prepare 2or breast2eeding Elderly ) glandular tissue is replaced by 2atty tissue, and elasticity o2 connective tissue is lost a2ter menopause, both contribute to breasts becoming pendulous or 2laccid