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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.