BASIC NURSING Chapter 21 Physical Assessment pg.485 – Flashcards
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Health assessment
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This is a comprehensive assessment of the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community.
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Nursing assessments
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This term focus on the client's functional abilities and physical responses to illness and other stressors. In contrast, medical assessments focus on disease and pathology.
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Medical assessments
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This focus on disease and pathology.
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Physical examination, or physical assessment
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This is the techniques used to gather objective data about the body, develop nursing diagnosis, & plan care, manage client problems/monitor status of problems, evaluate nursing care.
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A physical examination is performed for any of several reasons:
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■ To obtain baseline data about physical status and functional abilities to serve as a comparison as the patient's health status changes. ■ To identify nursing diagnoses, collaborative problems, and wellness diagnoses, to form the basis for the plan of care. ■ To monitor the status of a previously identified problem. ■ To screen for health problems. Regular checkups can help to identify health problems at early stages.
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Comprehensive physical assessment includes:
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a health history interview and a complete head-to-toe examination of every body system.
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A focused physical assessment
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This pertains to a particular topic, body part, or functional ability rather than overall health status, and it adds to the database created by the comprehensive assessment.
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A system-specific assessment
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This is a focused assessment limited to one body system (e.g., the lungs, the peripheral circulation).
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Ongoing assessment
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This is performed as needed, after the initial database is completed, and, ideally, at every interaction with the patient.
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Name some system-specific assessments?
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Assessing bowel sounds when a client has abdominal pain ■ Listening to breath sounds, counting respirations, and obtaining pulse oximetry readings to assess a patient's respiratory status
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How Do I Prepare to Perform a Physical Examination?
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- A head-to-toe approach starts at the head and neck and progresses down the body, examining the feet last. - A body systems approach examines each system in a predetermined order (e.g., musculoskeletal, cardiovascular, neurological).
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To do an assessment nurse should:
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Have a theoretical knowledge of A&P, examination equipment and techniques, therapeutic communication, and documentation. Self-knowledge is also important.
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Besides having a knowledge what else is essential when we are preforming the assessment?
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Prepare the environment; privacy , bed linens for comfort, disposable papers over the examination bed, noises to minimum, temperature, light, instruments, equipment, and prepare the client. Make sure they know what is happening, and make them comfortable.
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What strategies can you use to make the client more comfortable during an abdominal assessment?
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Have the client empty his bladder prior to his abdominal exam. Use a supine position with flexed knees, which relaxes his abdominal muscles. If the client has a painful area, examine that area last to minimize his discomfort. Use light palpation to assess for tenderness and guarding before proceeding to deep palpation.
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How Do I Position the Client for a Physical Examination?
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The client will need to assume a variety of positions during a comprehensive physical examination. To begin the examination, seat the client on the side of the bed or examination table. Face the client, and establish eye contact. This helps to build rapport and put the client at ease. If unable to sit, accommodate.
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Which skills do we use for the physical assessment?
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These include inspection, palpation, percussion, auscultation, and sometimes olfaction.
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A. Inspection B. Palpation C. Percussion D. Auscultation E. Olfaction
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A. This is the use of sight to gather data. B. This is the use of touch to gather data. C. This is tapping your fingers on the skin using short strokes. D. This is the use of hearing to gather data. E. This is the use of the sense of smell to gather data.
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How Do I Modify Assessment for Different Age Groups? A. Infants: B. Toddlers C. Preschoolers
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A. This group is usually held by parents, if not than position them on a padded examination table and if there are siderails, raise them to prevent falls. Do not leave the their side or turn your back. B. They can be challenging to examine. They are interested in exploring the environment, but they also like to stay close by a parent, often in the parent's lap C. They are developing initiative and, as a result, usually cooperate with an examination. Allow them to sit in a parent's lap if she wishes.
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How Do I Modify Assessment for Different Age Groups? Cont'd D. School-Age Children E. Adolescents F. Young and Middle Adults G. Older Adults
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D. They have a rapidly expanding vocabulary and usually seek approval of parents, teachers, and healthcare providers. E.They are self-conscious and introspective and may wish to be examined without parents or siblings present, at least during the more personal aspects of the exam. F. Most of them are able to cooperate during a physical examination and do not require a modified approach G. They are adjusting to changes in physical abilities and health. As part of a comprehensive exam, assess the client's support system and ability to perform activities of daily living.
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The acronym SPICES will help you to remember common problems of older adults that require nursing intervention. What does it mean?
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Sleep disorders; Problems with eating or feeding; Incontinence; Confusion; Evidence of falls; Skin breakdown
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The general survey
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This is your overall impression of the client. It begins at first contact and continues throughout the exam. Look at : Physical appearance Age Gender Level of consciousness Skin color Facial features Body structure Nutrition Symmetry Posture Position Body build, contour Body type Mobility Gait Range of motion Behavior Facial expression Mood and affect Speech Dress Personal hygiene
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Appearance and behavior
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We are looking for this when we observe the client's general characteristics. Look for indications of their mood and mental status—for instance, does he make eye contact with you? Notice any signs of distress, either physical or emotional. Observe the condition of your client's face, and note the quality of the visible skin; for example, excessive wrinkling of the skin from sun exposure, tobacco use, or illness may make the client appear older than his stated age. Be sure to consider cultural background, because this may influence your findings and interpretation.
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Body type and posture
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This is observed with your client's body size, build, and gait. As you introduce yourself and greet him, assess his muscle strength, mobility, and skin temperature and texture.
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Speech
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We are observing this by watching: ■ Inappropriate or illogical responses may be associated with psychiatric disorders. ■ Difficulty speaking or changes in voice quality may indicate a neurological problem. ■ Rapid may be a sign of anxiety, hyperactivity, or use of stimulants. ■ Hoarseness could indicate inflammation in the throat from infection, overuse, a foreign body, or perhaps a tumor or other obstructive material. ■ Slow may be due to depression, sedation from medications, or neurological disorders. ■ Vocabulary and sentence structure provide information about the client's educational level and comfort with the language. ■ A foreign accent with hesitancy and/or sparse verbalization may signal a language barrier and a need for an interpreter.
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Dress, grooming and hygiene
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We observe for this by watching client's ability to dress and perform personal hygiene is affected by physical and emotional well-being.
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Mental state
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This includes level of consciousness and capacity to interact: ■ Bizarre responses may signal a psychiatric problem. ■ Lethargy may be due to medications; depression; or a neurological, thyroid, liver, kidney, or cardiovascular disorder. ■ Confusion and irritability may indicate hypoxia or medication side effects. ■ Inability to provide a health history or to recall information may indicate a neurological disorder.
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Vital Signs
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We should assess this as a part of the general survey and with subsequent assessments. Analyze for trends.
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Height and weight
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This data provide valuable information about your client's growth and development, nutritional status, overall general health, and risk for various diseases such as diabetes and heart disease. Also for dosage of medication.
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BMI
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It evaluates the relationship between height and weight.
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Integumentary system
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IT consists of the skin, hair, and nails. In a comprehensive exam, you assess this system briefly in the general survey, and then in greater detail as you move to examine other areas of the body.
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Skin
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To perform this assessment, observe color, lesions, and other characteristics. Also notice unusual odors. An unpleasant body odor may be a sign of poor hygiene, the presence of a wound, or underlying disease. Assess for color, temperature, moisture and edema.
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The warning signs of malignant lesions are as follows:
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A—for asymmetry B—for border irregularity C—for color variation D—for diameter greater than 0.5 cm E—for elevation above the skin surface
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Hair
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When assessing it, use inspection and palpation to obtain data about color, texture, distribution, and condition of the scalp. It should be clean and free of debris
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Nails
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This when they are healthy, they are level, firm, and similar to the color of the skin. It s smooth and uniform in texture. Examine them on both hands and feet. Examine the color, texture and shape.
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Head
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You will use all the assessment techniques—inspection, palpation, percussion, and auscultation—in the HEENT exam.
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HEENT stands for
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Head, Eyes, Ears, Nose, and Throat.
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Head
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Taking individual variation into account, on inspection the skull should be rounded and the face symmetrical in appearance and movement. Inspect its size; if it seems unusual, measure it.
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Skull
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It should be smooth and symmetrical to palpation. Contour abnormalities, bulging, or tenderness result from trauma, congenital anomalies, or surgery.
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TMJ (temporomandibular joint) syndrome
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Irregular jaw movement or cracking of the jaw what?
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Eye
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When examining this part, examine: Eyelids, Sclera and Conjunctiva,Lens and Cornea, Pupils, Vision activity, Visual Field and the Internal Structure
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Eye movement and function involve the following cranial nerves:
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CN III (oculomotor) CN IV (trochlear) CN VI (abducens) CN II (optic) works together with CN III to control the pupillary reaction to light
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PERRLA:
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Pupils Equal, Round, Reactive to Light and Accommodation.
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Eye assessments have the following major components:
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Inspection of the external eye and lids Snellen exam for distance vision Near vision assessment with newsprint Color vision check Visual field examination Internal eye exam with an ophthalmoscope
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Ears and hearing
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These structures are involved in both hearing and equilibrium. The external collects and conveys sound waves to the middle . It protects the middle from environmental factors such as humidity and temperature and prevents entry of foreign matter. The middle contains the tympanic membrane and cavity, the eustachian tube, and the ossicles(the small bones of the middle : the malleus, incus, and stapes). The middle conducts sound waves to the inner. The inner is responsible for hearing and equilibrium. To assess hearing, you will need a quiet room and a tuning fork.
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What are the different tests in hearing?
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The Weber and Rinne Tests - Hearing involves transmission of sound vibrations and generation of nerve impulses along CN VIII. The Weber test assesses both aspects. When you place a vibrating tuning fork on the center of the client's head, he should be able to sense the vibration equally in both ears. Record a positive Weber test if the vibration is louder in one ear. The Romberg Test - Along with the cerebellum and midbrain, vestibular cells in the ear are responsible for maintaining equilibrium. To assess equilibrium, perform the Romberg test. The client should be able to stand with feet together and eyes closed, and maintain balance with minimal swaying. Swaying and moving (positive Romberg) may indicate a vestibular or cerebellar disorder
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Your client has a negative Weber test. What further testing is required?
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No further testing is required. This is a normal result.
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Nose
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Sinuses and this are part of the respiratory system and are the organs of smell. Vaporized molecules sniffed into the upper cavities trigger receptors that generate impulses along the olfactory nerve (CN I) that travel to olfactory centers in the temporal lobes. The sense of smell diminishes in older adults because of a gradual decrease in and atrophy of the olfactory nerve fibers
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The Mouth and Oropharynx
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The structures of the mouth include the lips, tongue, teeth, gingiva (gums), uvula, hard and soft palate, and salivary glands and ducts. On external inspection, the mouth and lips should be symmetrical and without lesions, swelling, or drooping. The lips, buccal mucosa (mucous membrane of the cheeks), and gums should be smooth, moist, and pink in color The teeth should be fixed to the gum and without obvious debris or darkening that may indicate caries. Tooth decay and periodontal (gum) disease are common. Poor oral hygiene is a major contributing factor for both. When inspecting the mouth, carefully examine all aspects of the tongue: dorsal, ventral, and lateral. The tongue should be moist, symmetrical, slightly rough, smooth, pink, and freely movable. The hard palate, soft palate, and oropharynx should be pink, moist, and intact. If the tonsils are present, they should be symmetrical, small in size, and free of exudate in a healthy person. The uvula is midline and should rise on phonation (vocalization).
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Neck
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It has components of the musculoskeletal, neurological, vascular, respiratory, endocrine, and lymphatic systems. The sternocleidomastoid and trapezius muscles form the landmarks of it, known as the anterior and posterior triangles. The symmetrical muscles center and coordinate movement of the head. Asymmetrical head position may result from damage to the muscles, swelling, or masses. Painful or erratic movement may be due to a benign condition, such as muscle spasm, or to significant problems, including meningitis, neurological injuries, or chronic arthritis. The trachea, thyroid gland, anterior cervical nodes, and carotid arteries are positioned in the anterior triangle; the posterior cervical nodes are in the posterior triangle. You will palpate the tracheal rings and the cricoid and thyroid cartilage in the midline of the anterior
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Thyroid
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Normally this is a smooth, firm, and nontender part of our body. It is often nonpalpable. However, its abnormalities are common. An enlarged ____ may be associated with either hypo____ism or hyper_____ism. Its tenderness usually results from inflammation. Its masses may be malignant but are usually benign.
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Lymph nodes
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The cervical ____ ____ occur in three chains .The anterior chain is in the anterior triangle, the posterior chain in the posterior triangle. There is a deep cervical chain under the sternocleidomastoid muscle. These are generally not palpable, although occasionally it can be felt, especially in young children. Normal ones are small, mobile, soft, and nontender. You should describe enlarged ones (greater than 1 cm in diameter) according to their location, size, shape, consistency, mobility, and tenderness. Enlarged or tender ones may be caused by infection, malignancy, and other diseases.
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Breasts
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These consist of glandular, adipose, and connective tissue; smooth muscle; and nerves. Their size and shape vary among women, and commonly one is slightly larger than the other and their functions are sexual stimulation and milk production for nourishing offspring. Breast tissue and lymph drainage for the breast extend up into the axilla. The majority of breast tumors are found in the tail of Spence, in the axilla. A breast exam therefore always includes an exam of the axillae.
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Chest and Lungs
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The ____, or thorax, is the bony cage that protects the heart, lungs, and great vessels. The ribs, sternum, and vertebrae form the chest. Be systematic in your assessment: Always assess the areas of the ____ and ____ in the same order. Before beginning the thoracic exam, review the following important landmarks that will help you visualize the underlying structures and perform an accurate assessment: 1. Identify positions vertically on the anterior chest in relation to the ribs. 2. On the posterior chest, identify positions vertically in relation to the vertebra. 3. Use a series of imaginary vertical lines to further aid in identifying locations. 4. Use imaginary lines on the lateral and posterior chest as well
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List and describe the location of the horizontal and vertical landmarks of the anterior chest.
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To locate sounds vertically, use the intercostals spaces (ICS). The 1st rib is tucked up next to the clavicle. The 1st ICS is between the 1st and 2nd rib. The space between the 2nd and 3rd ribs is the 2nd ICS, and so forth. The left midclavicular line begins at the midpoint of the patient's left clavicle and extends vertically down the length of the chest. The right midclavicular line begins at the midpoint of the right clavicle, and so on. The midsternal line is a vertical line running through the center of the sternum. The anterior axillary lines begin (on the right and on the left) at the anterior axillary folds. They are used to locate sounds both on the anterior and lateral chest.
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List and describe the location of the horizontal and vertical landmarks of the posterior chest.
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To locate sounds vertically, use the vertebrae. The prominent vertebra at the base of the neck is the seventh cervical vertebra (C7). The next one down is T1 (first thoracic). Counting down to about T9 should be adequate. The vertebral line extends vertically down the spine. The right and left scapular lines are vertical lines through the inferior angle of the scapula.
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List and describe the location of the vertical landmarks of the lateral chest.
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The anterior axillary lines begin (on the right and on the left) at the anterior axillary folds. They are used to locate sounds both on the anterior and lateral chest. The posterior axillary lines are vertical lines through the posterior axillary fold. The midaxillary line is a vertical line from the middle of the axilla.
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Chest Shape and Size
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The normal adult chest is symmetrical and rises and falls with respirations. The chest diameter expands up to 3 in. (7.6 cm) with deep inspiration. Spinal alterations, such as kyphosis(excessive curvature of the thoracic spine) and scoliosis (lateral curvature of the spine) alter the shape of the thoracic cage. Osteoporosis, a common disorder associated with aging, is associated with increased porosity of the vertebrae.
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Breath Sounds
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Listen to breath sounds in a quiet room by auscultating one full respiratory cycle at each site. Directly apply the stethoscope to the client's skin. Compare breath sounds bilaterally. Three types of breath sounds are heard: 1. Bronchial breath sounds are loud, high-pitched, tubular sounds; expiration is of longer duration than inspiration. 2. Bronchovesicular breath sounds are medium pitched with an equal inspiratory and expiratory phase. 3. Vesicular breath sounds are soft, low-pitched, breezy sounds with a lengthy inspiratory phase and a short expiratory phase
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Abnormal Breath Sounds:
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■ Diminished breath sounds are heard with poor inspiratory effort, in the very muscular or obese, or with restricted airflow. ■ Misplaced breath sounds (e.g., bronchial breath sounds heard over the lung fields) indicate constriction of flow. ■ Adventitious breath sounds, such as wheezes, rhonchi, and rales, are sounds heard over normal breath sounds. If an abnormal sound is heard, have the client cough and listen again. ■Bronchophony, whispered pectoriloquy, and egophony are other three abnormal sounds. These are abnormal voice sounds that result from consolidation of lung tissue.
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Abnormal sounds include:
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Crackles, rhonchi, wheezes, pleural friction rub
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Cardiovascular system
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This system consists of the heart and the blood vessels. The heart is a muscle that pumps blood throughout the body. In a healthy adult, it is about the size of a clenched fist. The blood vessels, which make up the vascular system, have two main networks: the pulmonary circulation and the systemic circulation
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Pulmonary circulation: Systemic circulation:
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Oxygen-depleted blood circulates from the heart into the lungs, where it is oxygenated, then back to the heart. When blood enters from the heart, it enters in this system.
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Coronary circulation
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This circulates blood through the heart itself, is a part of the systemic circulation.
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Heart
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This organ is positioned at an angle on the left side of the chest in the 3rd, 4th, and 5th intercostal spaces (ICS). To facilitate auscultation of specific sounds, perform the cardiac assessment with the client in three positions: sitting, supine, and left lateral recumbent.
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Assessing heart:
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Compare assessment of heart functions with vascular findings. Assess PMI. Use inspection and auscultation. Locate anatomical landmarks. Identify S1 and S2.
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Apical Pulse (AP)
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Know & verbalize the anatomical landmarks to find the Point of Maximal Impulse (PMI) Locate suprasternal notch Angle of Louis (approx. 2 inch below sternal notch) Slide to Left = Level of 2nd rib - Intercostal space just below rib - Stay along the sternal border - Count down to 5th intercostal space - Move laterally to midclavicular line= PMI or apical pulse
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Vascular System
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Assess blood pressure. Assess integrity of the peripheral vascular system. Use inspection, palpation, and auscultation.
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Why do we never palpate both carotid arteries at the same time?
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Because bilateral pressure may impair cerebral blood flow. Palpate very lightly and avoid massaging the carotid artery, because pressure on the carotids will cause the pulse rate to drop, and can even lead to cardiac arrest. As a general rule, avoid palpating the carotids except during cardiopulmonary resuscitation or when it is necessary to assess them for a specific reason (such as in a comprehensive physical exam, or when an underlying pathology makes it necessary to establish that circulation to the head is adequate).
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Peripheral Pulses
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- Femoral Located along the crease midway between the pubic bone and the anterior iliac crest. From umbilicus, angle toward thigh. May need to press firmly with your 2nd, 3rd & 4th fingertips if pt. is obese. - Dorsalis Pedis(Pedal pulse) and Posterior Tibial are two peripheral in our feet
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Abdomen
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Complex assessment because of organs located in the abdominal cavity. It can review underlying locations Inspection Auscultation Palpation- light palpation Inquire about elimination habits
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Female Genitalia and Reproductive Tract
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Includes assessment of external organs only. Lesions, rashes, skin condition, discharge, hair distribution. Understand cultural sensitivity. Identify changes across the lifespan. Our assessment uses inspection.
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Male Genitalia
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Use inspection to observe for any abnormalities. Assess external genitalia, skin condition, rash, lesions, discharge. Hair distribution. Ask about TSE.
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Rectum and Anus
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Advanced practice nurses perform internal exam Perform after genital assessment during peri-care is ideal. Provide privacy. Our assessment use inspection to observe for abnormalities- lesions, hemorroids.
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Musculoskeletal System
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Inspection: Gait, postural abnormalities, overall status Palpation: Joints, skin, Range of motion Muscle tone and strength
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Neurological System
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Observe mental and emotional status Intellectual function A & O X 3 Sensory function- observe for normal feeling sensation Motor function- purposeful movement Cranial nerve function- advanced practice Reflexes-advanced practice
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What approach to assessment should you take if your client has no neurological problems but you are performing a comprehensive exam?
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Perform a focused exam that looks at each of the areas in the neurological exam.
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Your client is hospitalized for a documented cerebrovascular accident?
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Perform a comprehensive exam, and compare your findings with findings from previous exams.
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Your client has been admitted with an acute head injury and the extent of neurological injury is unknown?
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Perform a comprehensive exam, and compare your findings with findings from previous exams. Use well-defined screening tools whenever possible so that serial assessments can be made.
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What assessment techniques are used when examining the male genitourinary system?
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Inspection and palpation are the techniques used when examining the male genitourinary system.
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What is the most common hernia occurring in men?
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A hernia is a protrusion of the intestine (or other organ) through the wall that contains it. In men, this is most likely to be a protrusion of the intestine (a) through the abdominal wall (direct hernia), or (b) into the inguinal canal and possibly into the scrotum (indirect), or (c) through the abdominal musculature at the umbilicus for infants.
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What are the responsibilities of the nurse during an internal exam of the female genitourinary system?
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During an internal exam of the female genitourinary system, the nurse has the following responsibilities: Gathering equipment Preparing the patient Assisting the client and examiner during the procedure Assisting the client after the procedure Documenting the findings
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A rapid physical assessment (RPA)
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This assessment can play a key role in identifying health issues that will require a more thorough physical assessment, or for determining the need for diagnostic and laboratory tests.
