Nursing: Physical Assessment – Flashcards
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Objectives
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-Identify the purpose of obtaining a patient's health history -Identify the 10 components of a complete health history -Describe the purpose and procedure for each technique used in the physical exam (PE) -Describe appropriate patient prep for a complete assessment -State an appropriate sequencing to conduct a physical exam -Describe "normal" or expected findings for each of the systems/areas assessed. -Identify the types and sources of patient data. -Differentiate between subjective/objective data and primary/secondary data. -Determine the skills required for data collection and validation
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Purpose of physical exam
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-Obtain baseline data about patient's functional abilities -Supplement, confirm, or refute data obtained in nursing history -Obtain data that will help establish nursing diagnoses and care plan -Evaluate physiological outcomes of health care and the progress of a patient's health problem. -Make clinical judgments about patient's health status -Identify areas for health promotion and disease prevention
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Types of data
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Subjective and Objective
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Subjective data
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- Referred to as symptoms - Only patient can tell you - Ex: itching, pain, and feelings - "I feel short of breath" or "I'm in a lot of pain."
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Objective data
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- Referred to as signs -Detectable by observer or can be measured/tested against an accepted standard. - EX: rashes, altered vital signs, visible drainage, swelling - EX: Lab results, diagnostic imaging, other studies - EX: Lung sounds clear bilaterally, diminished in right lower lobe.
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Sources of data
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Primary and Secondary
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Primary data
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- Patient is this source of data (BEST source) - Except when: too old, too young, too confused, too ill.
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Secondary data
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- All sources other than the client are considered this source of data - All data should be validated by lab results, if possible.
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Physical assessment components
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-General appearance -Vital Signs -Head/neck -Chest/back -Abdomen -Genitals/anus -Upper/lower extremities
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Preparation for assessment
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-preparing patient -preparing environment -positioning -draping -instrumentation (stethoscope, BP cuff, etc.)
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Preparing the patient
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-Type of prep for exam -Explanation of the physical exam -Confidentiality -Patient should empty bladder -Recognize that people of the same age differ
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Preparing the environment
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-Type of prep for exam -Time should be convenient for both patient and nurse (Ex: Do bath after breakfast) -Well light and equipment organized for efficient use -Warm enough to be comfortable -Provide privacy
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Positioning
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-Type of prep for exam -Several positions are required during exam -Consider patient's ability to assume a position -Some may be embarrassing and uncomfortable and should not be maintained for long periods -Minimize amount of position changes
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Draping
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-Type of prep for exam -Arranged so area to be assessed is exposed and other body areas are covered -This also provides privacy and warmth.
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Instrumentation
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-Type of prep for exam -All equipment should be clean
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Techniques
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-Inspection -Palpation -Percussion -Auscultation
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Inspection
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-Visual examination -To assess moisture, color, symmetry -Also includes otoscope to look into ears, smell, and hearing
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Palpation
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-Touch (light and deep) -Used to determine texture (hair), temperature (skin), vibration, position, size, consistency and mobility of organs, pain, distention (bladder), pulsation and presence of pain (abdomen)
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Percussion
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-the act of striking the body surface to illicit sounds that can be heard or vibrations that can be felt -Indirect and direct
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Percussion sounds
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1) Flatness 2) Dullness 3) Resonance 4) Hyperresonance 5) Tympany
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Flatness
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- Extremely dull sound produced by very dense tissue (muscle or bone) -Soft intensity, high pitch, short duration
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Dullness
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- Thudlike sound produced by dense tissue (liver, spleen, heart) - Medium intensity, medium pitch, moderate duration
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Resonance
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- Hollow sound (Lungs filled with air/ normal lung) - Loud intensity, low pitch, long duration
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Hyperresonance
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- Booming (emphysematous lung) - Not heard in normal body - Very loud intensity, very low pitch, very long duration
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Tympany
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- Musical or drumlike sound (stomach filled with air/gas) - Loud intensity, high pitch, moderate duration - Reflects the least dense tissue (greatest amount of air)
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Indirect percussion
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-To hear or feel vibrations of fluid, solids, air, and/or masses - Physician does this usually
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Direct percussion
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-To hear or feel vibrations in the sinuses. - Physician does this usually
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Auscultation
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-Process of listening to sounds produced within the body. - Direct and indirect
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Direct auscultation
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- listen with the ear
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Indirect auscultation
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- listen with stethoscope
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Pitch
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Frequency of the vibrations (number of vibrations/sec)
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Intensity
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- Amplitude - Refers to loudness or softness of sound
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Duration
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Length of sound (long or short)
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Quality
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- Subjective description of sound - Ex: Whistling, gurgling, snapping
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Auscultation techniques
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-Pitch: listening for vibration - high or low -Intensity of sound - loud or soft -Duration of sound - long or short -Quality of sound - subjective
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Senses used for physical assessment
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- Vision, smell, hearing, touch
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Vital signs
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-Should always be a part of any type of assessment - know normals - Temperature, pulse, respirations, BP, height/weight, pain?
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Pain
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- considered 5th vital sign - subjective - Ask about location, description, duration, and level on scale of 1-10.
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Neurologic system
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-Orientation -Level of consciousness -Commands -Stimulus -Speech (slurred) -Pupils -Motor fxn -Extremities -Reflexes (scale 0-4)
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Introduction
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1) Wash hands and put on PPE 2) Introduce self 3) Ask patient's name as well as "What year/season is it?" "Do you know where you are?" "Do you know why you are here?"
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General appearance
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- Level of consciousness (awake, sedated, unconscious) - Respiratory status (Even, secretions) - Skin color (pale, jaundiced) - Nutritional status (underweight/overweight) - Facial expression - Speech (slurred?) - Response to introduction (understanding/ hearing)
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Measurement
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- Vital signs (temp, P, R, BP) - Pain (Location, description, duration, level) - Pulse oximetry
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Head
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- Pupils (PERRLA) - Nose and mouth - Scalp and ears - Neck veins - Lymph nodes
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Auscultation assessment
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1) Auscultate anterior/posterior respirations 2) Auscultate apical pulse (rate/rhythm) 3) Auscultate heart sounds (4 areas) 4) Auscultate bowel sounds
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Abdomen
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- Inspect contour and color (flat, distention) - Palpate - Assess drains, tubing, dressings (if any) - Ask about last bowel movement
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Genitourinary
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- Assess urine output (Amount/color) - Voiding or catheter? - Wash hands
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Skin
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- Palpate skin temperature (hot/cool/diaphoretic) - Assess skin turgor (1-3 second return) - Capillary refill (< than 3 seconds) - Assess wounds/IV site (if needed) - Areas of redness/breakdown? - Standardized tools of risk (Braden scale)
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Musculoskeletal
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- Put new gloves on - Assess symmetry of movement (ROM) - Assess strength - Pulses (radial and pedal-bilateral) - Homan's sign - Assess peripheral edema - Use of assistive devices (cane, walker, crutches)
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Closure
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- safety checks (side rails up, lower bed) - Documentation
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Eye assessment
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- PERRLA - Pupil, Equal, Round, Reactive, Light, Accommodation
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Mouth assessment
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Look at: - Hard/soft palate - Teeth - Tongue - Tonsils - Uvula
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Respiratory sounds
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Types: 1) Crackles 2) Wheezes 3) Stridor
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Crackles
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- Respiratory sound - Sounds like rolling hair in ear - Unrelieved by coughing, bronchitis, CHF
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Wheezes
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- Respiratory sound - high pitched, expiratory sound, usually will not clear with coughing, asthma, bronchitis
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Stridor
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- Respiratory sound - Narrowing of upper airway, inspiratory, harsh, high pitched sounds that can be heard without stethoscope
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Clubbing of fingers
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- Result of lung problems - Indicative of COPD and other respiratory issues
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Angle of Louis
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- Starting point for locating the ribs anteriorly (front) - the junction between the body of the sternum (breastbone) and the manubrium (handle-like superior part of sternum that joins with the clavicles) - AKA Manubriosternal junction
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Deformities of chest
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- Pigeon chest - Funnel chest - Barrel chest
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Pigeon chest
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- permanent deformity - may be due to rickets (abnormal bone formation due to lack of dietary calcium) - Narrow transverse diameter, increased anteroposterior diameter, protruding sternum
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Funnel chest
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- Congenital defect - Opposite of pigeon chest - Sternum depressed, narrow anteroposterior diameter
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Barrel chest
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- Ratio of anteroposterior to transverse diameter is 1 to 1 - Seen in people with: thoracic kyphosis - excessive convex curvature of thoracic spine emphysema - chronic pulmonary condition in which the air sacs (alveoli) are dilated.
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S1 heart sounds
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- closure of mitral and tricuspid valve - "lub"
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S2 heart sounds
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- Closure of semilunar (aortic) and pulmonic valves - "dub"
