Physical Assessment

Acute Care Nursing Program 2005

Outline Assessment Process Respiratory Assessment Cardiac Assessment Neurological Assessment Abdominal Assessment Neurovascular Assessment

Assessment Process Inspection Palpation Percussion Auscultation

Gather information – base line Record trends

Respiratory Assessment Inspection Palpation Percussion Auscultation

Respiratory Assessment Inspection

General appearance, colour

Scaring Symmetry Shape Position of trachea Work of breathing

Rate Rhythm Cough – productive?

Respiratory Assessment Palpation

Chest excursion Tactile and vocal fremitus

Respiratory Assessment Percussion

Normal – resonant, hollow sound Solid - dull Percussion is done in the intercostal

spaces Percussion is done both on the posterior

chest and lateral chest

Respiratory Assessment Auscultation

Systematic approach Note adventitious (extra)

Crackles Wheeze Friction rub

Respiratory Assessment

Cardiac Assessment Inspection Palpation (Percussion) Auscultation

Cardiac Assessment Inspection

JVP Oedema Colour

Cardiac Assessment Palpation

Pulse Oedema Capillary refill Blood pressure

Cardiac Assessment Auscultation

Normal S1 S2

Abnormal S2 split S3 S4

Cardiac Assessment

Neurological Assessment Glasgow Coma Scale Cranial Nerves

Glasgow Coma Scale Assess neurological status Assessment of best response

Eyes Verbal Motor

Glasgow Coma ScaleScor

eBest Eye Best Verbal Best Motor

6 ----------- ----------- Obeys

5 ---------- Orientated Localises pain

4 Spontaneous Confused Withdraws

3 To speech Inappropriate Flexion

2 To Pain Incomprehensible Extension

1 None None None

Cranial Nerves 12 cranial nerves 3rd – 12th within brainstem

(Midbrain, Pons, Medulla)

Cranial NerveFunction: Sensory Smell

Assessment: Recognition of

odor

IOlfactory

Cranial NerveFunction: Sensory Information from

the retina

Assessment: Visual acuity

IIOptic

Cranial NerveFunction: Motor Four of the six

extra-ocular muscles

Assessment: Response to light Moves eye Elevates upper

eyelid

IIIOculomotor

Cranial NerveFunction: Motor Controls the

oblique eye muscle

Assessment: Moves eye right,

left, up and down

IVTrochlear

Cranial NerveFunction: Mixed Three sensory

Corneal Reflex One motor

Assessment: Normal facial

sensation Blinks Clenches teeth

VTrigeminal

Cranial NerveFunction: Motor Lateral rectus

muscle of eye

Assessment: Moves eye

laterally

VIAbducens

Cranial NerveFunction: Mixed Sensory

Tongue Motor

Eyelids

Assessment: Elevates

eyebrows Puffs checks Recognizes

tastes

VIIFacial

Cranial NerveFunction: Sensory Hearing

Assessment: Whisper in each

ear

VIIIVestibulocochlear

Cranial NerveFunction: Mixed Sensory

Taste buds Motor

Gag reflex

Assessment: Taste testing Test gag

IXGlossopharyngeal

Cranial NerveFunction: Mixed Motor branches

to the pharyngeal and laryngeal muscles

Viscera of the thorax and abdomen

Assessment: Same as IX

XVagus

Cranial NerveFunction: Motor Innervates the

sternocleidomastoid and trapezius muscles

Assessment: Shrugs shoulders

XIAccessory

Cranial NerveFunction: Motor Tongue muscles

Assessment: Sticks out tongue

XIIHypoglossal

Abdominal Assessment Inspection Auscultation Percussion Palpation

Abdominal Assessment Inspection

Asymmetry Engorged veins Intestinal movements Lesions Scars Swelling

Abdominal Assessment Auscultation

Systematic Bowel sounds

Abdominal Assessment Percussion

All four quadrants Tympanic- air filled structures Dull – solid structures

Bowel Liver Bladder

Abdominal Assessment Palpation

Light and Deep Tenderness, guarding, rigidity

Define organs Kehr’s sign McBurney’s point Murphy’s sign

Neurovascular Assessment Colour Temperature Capillary Refill Peripheral Pulses Swelling Movement Sensation

References A Practical guide to clinical assessment

http://medicine.ucsd.edu/clinicalmed/ Smith SF, Duell DJ & Martin BC, 2005,

Clinical Nursing Skills, Prentice Hall, New Jersey.