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Physical AssessmentDENNIS NABOR MUÑOZ,RN
Physical Health AssessmentNursing history and physical examinationNurses use physical assessment skills to:
Develop (obtain baseline data) and expand the data base from which subsequent phases of the nursing process can evolve
To identify and manage a variety of patient problems (actual and potential)
Evaluate the effectiveness of nursing careEnhance the nurse-patient relationshipMake clinical judgments
Except for those occasions when you see a patient specifically to conduct a nursing assessment, the assessment must be integrated into routine nursing careExample: the bath is a perfect time to
incorporate assessment skillsSee Box 28-1 for the Head-to-Toe
framework that is used for assessment
Subjective data - Said by the client(S)
Objective data - Observed by the nurse(O)
Nursing ProcessSOAPIER
Preparing for the assessmentExplain when, where and why the assessment
will take placeHelp the client prepare (empty bladder,
change clothes)Prepare the environment (lighting,
temperature, equipment, drapes, privacySee Table 28-2 for equipment used during
assessment
PositioningPositions used during nursing assessment,
medical examinations, and during diagnostic procedures:Dorsal recumbentSupineSimsProneLithotomyGenupectoral
See Table 28-2 for client positions
Assessment TechniquesInspection - critical observation
Take time to “observe” with eyes, ears, noseUse good lightingLook at color, shape, symmetry, positionOdors from skin, breath, woundDevelop and use nursing instincts
Inspection is done alone and in combination with other assessment techniques
Assessment TechniquesPalpation - light and deep touch
Back of hand to assess skin temperatureFingers to assess texture, moisture, areas of
tendernessAssess size, shape, and consistency of lesionsSee Box 28-4, p. 529 to describe
characteristics of masses
Assessment TechniquesPercussion - sounds produced by striking
body surfaceProduces different notes depending on
underlying mass (dull, resonant, flat, tympani)Used to determine size and shape of
underlying structures by establishing their borders and indicates if tissue is air-filled, fluid-filled, or solid
See table 28-4, page 530 for percussion notes
Assessment TechniquesAuscultation - listening to sounds
produced by the body Direct auscultation – sounds are audible without
stethoscope Indirect auscultation – uses stethoscope
Know how to use stethoscope properly (practice)
Fine-tune your ears to pick up subtle changes (practice)
Describe sound characteristics (frequency, pitch intensity, duration, quality) (practice) Flat diaphragm picks up high-pitched respiratory
sounds best Bell picks up low pitched sounds such as heart
murmurs Practice using BOTH diaphragms
PRACTICE
Complete History and PhysicalNursing history is subjective - includes
things like biographic data, the chief complaint, source of the data, history of present illness, past medical history, immunization history, allergies, habits (tobacco, ETOH), stressors, family history including genogram, patterns of health care, and a review of the body’s systems
See Figure 16-4, pp. 270-271
History of Present IllnessHPI is a chronological story of what has
been happeningMust get details of the problem, therefore must
be systematicOLFQQAAT (one system – there are others):
onset, location, frequency, quality, quantity, aggravating factors, alleviating factors, associated symptoms, treatments tried (include all treatments - Rx, OTC, herbal, folk)
Lots of systems – find one that works, and use it
Use whatever system works for you, but use a system (OLFQQAAT, PQRST, pain intensity scales, etc)Pain, quality/quantity, radiation, setting, timingRate pain from 1 to 10Use age appropriate tools (faces)
Culturally appropriate care
Exam Order and DocumentationDate and identifying data - name, age, sex,
race, place of birth (if pertinent), marital status, occupation, religion
Source and reliability of historyChief complaint = reason for visit (succinct)HPI - the long version of the CC
(OLFQQAAT)PMH - general health, childhood illness,
adult illnesses, psychiatric illnesses, injuries, hospitalizations, surgery, immunizations, habits, allergies (NKDA)
CAGE questions:1. Have you ever thought you should Cut
down2. Have you ever been Annoyed by criticism
of your drinking?3. Have you ever felt Guilty about drinking?4. Do you ever have an Eye-opener in the
morning?YES to any of the above questions -
need to investigate further to see if there is a drinking problem
Order & DocumentationFH - age and health of parents and
siblings or cause of death (genogram); HTN, DM, CVD, Ca, HA, arthritis, addictions
ROS (subjective head-to-toe review) General - recent wt. change, fatigue, feverSkin - rashes, lesions, changes, dryness,
itching, color change, hair loss, change in hair or nails
Eyes - change in vision, floaters, glasses, HA, pain
Order & DocumentationROS
Ears - pain, loss of hearing, vertigo, ringing, discharge, infections
Nose and sinuses - frequent colds, congestion, HA, nosebleed
Mouth and throat - condition of teeth and gums, last dental visit, hoarseness, frequent sore throats
Neck - lumps, stiffness, goiterBreasts - lumps, pain, discharge, BSE
Order & DocumentationROS
Respiratory - cough, sputum, wheezing, asthma, COPD, last PPD, last CXR, smoking history (can do here, or with “habits”)
Cardiac - heart trouble, chest pain, SOB, murmur, h/o rheumatic fever, past EKG, FH of heart disease <50 yrs of age
GI - problems swallowing, heartburn, vomiting, bowel habits, pain, jaundice
Urinary - frequency, incontinence, pain, burning, hesitancy, nocturia, polyuria
Order & DocumentationROS
Genitalia - lesions, discharge, sexual orientation, sexual function, menstrual history, contraception, pregnancy history, TSE
Peripheral vascular - intermittent claudication, varicose veins, blood clots
MS - muscle or joint pain, redness, stiffness, warmth, swelling, family history
Neuro - fainting, blackouts, seizures, weakness
Order & DocumentationROS
Endocrine - sweats, skin change, heat or cold intolerance, excessive thirst (polydipsia), excessive urination (polyuria), weight change, menstrual changes
Psychiatric - mental illness, thoughts of harming self or others
All of ROS is subjective; PE is objective
Complete H&P - ObjectiveHistory is subjective; Physical
assessment is objectiveObjective portion of exam begins with the
general survey; Each body system reviewed in text has nursing history at the beginning of the procedure for the objective exam
In actual practice, you get most of the history before ever touching the client, but there are usually additional history questions to ask during the exam
Order of exam - head to toe in systematic order
Order of techniques - IPPA (Inspection, Palpation, Percussion, Auscultation)
Be systematic, but be flexible based on patient’s needsWhen might you change order of exam?
In practice, you often will do “focused” PE - examine only the pertinent parts
PRIORITIZE (ABC’s, Maslow)
General SurveyGeneral appearance, gait, nutrition status
(NOT to be confused with nutrition history), state of dress, body build, obvious disability, speech patterns, affect (mood), hygiene, body odor, posture, race, gender, height, weight, vital signs
Height up to age 2 is recumbentAdd head circumference if child is less than 2
years old
Integumentary SystemIntegument includes skin, hair, and nailsInspect: skin color and uniformity of color,
moisture, hair pattern, rashes, lesions, pallor, edema
Palpate: temperature, turgor, lesions, edema (see pp. 536, 537, 539 on skin lesions; See box p. 538 on describing edema)
Percussion and auscultation: rarely used on skinTerminology: pallor, cyanosis, edema,
ecchymosis, macule, papule, cyanosis, jaundice, types of edema, vitiligo, hirsutism, alopecia, etc.
Integumentary SystemHair - texture, distribution, scalp, crittersNails - inspect and palpate
Why palpate?Cyanosis - is it true or d/t cold?Blanch test (aka capillary refill or CFT):
delayed return of color indicates poor arterial circulation
Clubbing - loss of normal angle between nail and nail bed d/t chronic oxygen deprivation (picture p. 542)
Skin – know terminology, draw diagrams, take pictures
HEENTHead - inspection and palpation
Size, shape, symmetryEyes - inspection and palpation
Inspect and palpate lids, lashes, inspect eye position and symmetry and position, symmetry and size of pupils
Visual acuity with Snellen chart 20/20 - first number (numerator) is distance from
chart Second number is distance at which a normal eye
could have read that line (OU, OD, OS) Always record if tested cc (with correction)
EyesVisual acuity (Snellen for distance, Rosenbaum for near vision)
Visual fields - assess peripheral visionEOMs - checks 6 ocular movements; tests CN 3,
4, and 6Pupil response to light and accommodation; Fig.
28-22, p. 530 and Box 28-9, p. 531 (PERRLA)Pupils constrict o light, and also to accommodate for
near vision (dilate for dimness and distance)Direct and consensual pupil responseCorneal light reflex - checks eye alignmentFundoscopic exam - ophthalmoscopeTerminology - myopia, presbyopia, ptosis, etc
EarsInspection and palpation
Inspect size, shape, position, discharge, lesionsPalpate for tenderness, any lesions
Review anatomy of ear and inner earGross hearing acuity: normal voice,
whisper test, Weber and Rinne (Box 28-15, p. 538)
Internal ear (behind tympanic membrane) – otoscope can look through TM (Figure 28-28 and 28-29, p. 537)
Nose and SinusesInspection, palpation, percussionInspect color of mucosa, presence of
dischargeThere is a nasal speculum – most people don’t
like itAssess for patency
Palpate for tendernessPercuss for tenderness over frontal and
maxillary sinuses (Procedure 28-8)
Mouth and ThroatInspection, palpation, auscultationInspect and palpate lips, tongue, oral
cavity, tonsils, pharynx (color, moisture), teeth, breath, presence of exudate, erythema, lesions, palateRead differences in oral exam for elderly
clientsEnlarged tonsils are graded
Grade 1 – wnl Grade 2 – tonsils b/w pillars and uvula Grade 3 – tonsils touching uvula Grade 4 – tonsils touching each other (kissing tonsils)
Campbell-Hoffman GrantOral health is strongly linked to overall
healthRead through materials in packetStudents will do complete oral assessment
during clinic visit, and then will have to do an oral assessment on each patient they are assigned to take care of
Form
Throat and NeckInspect and palpate neck for trachea (should
be at midline), thyroid, lymph nodes (figure 28-42 and 43, p. 567)
Auscultate carotids for bruits (bell)If bruit is heard, palpate for carotid thrillPalpate one side at a time
Perform ROM on neck (active and passive)
Thorax and LungsChanges in respiratory status can happen
very slowly, or very quickly, so respiratory status is assessed carefully, and frequently
See figure 28-47, p. 571 and figure 28-48 and 49, p. 572 for chest landmarks - need to know angle of Louis, how to count ribs, how to describe locations, what is under the surfaceLandmarks are things felt or seen used to
document location of something
Assess size and shape of thoraxLook for deformities (Fig. 28-52, p. 574)Barrel chest from asthma or COPD
Presence of supernumery nipplesFor efficiency, you usually assess posterior
chest firstIntercostal spaces (ICS) are names
according the rib they lie beneath4th rib lies superior to 4th ICSPosterior, you have to count spinous processes
to name ribs and ICSs
BREAK
LungsInspect, Palpate, Percuss (normal note is
resonance), Auscultate (normal is clear and equal bilaterally)Auscultate using diagram in Figure 28-55 and
28-59, p. 577-578Assess and document respiratory rate,
rhythm, and effort
Respiratory TerminologyEupneaTachypneaBradypneaApneaHyperventilationHypoventilationDyspnea
Respiratory Warning SignsAnxious expressionSuprasternal & intercostal retractionsNasal flaringCircumoral cyanosisHyperexpanded chest
ALWAYS REMEMBER YOUR ABCs
Breath SoundsAuscultate using diaphragm, use a
systematic approach, compare each side to the other, document when and where sounds are heard
Normal breath sounds: bronchovesicular, bronchial, and vesicularAbnormal breath sounds are called
adventitious sounds
Breath SoundsStridor - may be heard without stethoscope, shrill harsh sound on inspiration d/t laryngeal obstruction
Wheeze - may be heard with or without stethoscope (document which), high-pitched squeaky musical sound; usually not changed by coughing; Document if heard on inspiration, expiration, or both; May clear with coughNoise is caused by air moving through narrowed
or partially obstructed airwayHeard in asthma or FBA
Breath SoundsCrackles - heard only with stethoscope (formerly called rales): fine, medium, coarse short crackling sounds (think hair); May clear with coughMost commonly heard in bases; easier to hear on
inspiration (but occurs in both inspiration and expiration)
Gurgles - heard only with stethoscope (formerly called rhonchi): Low pitched, coarse wheezy or whistling sound - usually more pronounced during expiration when air moves through thick secretions or narrowed airways – sounds like a moan or snore; best heard on expiration (but occur both in and out)
Friction rub – Grating, creaking, or rubbing sound heard on both inspiration and expiration; not relieved by coughing; due to pleural inflammation
Document breath sounds as clear, decreased or absent, compare right to left, and describe type and location of any adventitious soundsCTAB or BBS cl + =NOT BS clear (BS could be bowel sounds . . .)
Infants – respiratory rate is much faster, breath sounds seem louder and harsherBabies belly breathe, so watch abdomen for
counting respirations rather than watching chest (up to about age 6 years)
Elderly – Osteoporosis and postural changes can decrease respiratory effort and function; cilia decrease in number and function, so mucous is not cleared as easily, putting elderly at increased risk for respiratory infections
Video
Breasts and AxillaeInspection and palpation
Instruct female clients to perform BSE q monthMen have some glandular tissue beneath nipple;
women have glandular tissue throughout breast and into axilla Largest portion of glandular tissue in women in in upper
outer quadrant See box page 28-27, p. 588 on breast health guidelines
Inspect for symmetry, contour (shape), look for any areas of hyperpigmentation, retraction or dimpling, edema
Palpate breasts, areolae, nipples and axillary lymph nodes in both men and women Be sure to include tail of Spence
Newborns – may have breast swelling and/or milky discharge from nipples for up to 2 weeks
Tanner Staging is a sexual maturity rating; female breast development is one of the things rated (5 stages)
Gynecomastia – enlargement of breast tissue in males; often occurs during puberty, and often affects only one breast, or affects one more so size is not symmetric
Pregnant women – breasts enlarge as glandular tissue responds to pregnancy hormones to prepare for breastfeeding
Elderly – glandular tissue is replaced by fatty tissue, and elasticity of connective tissue is lost after menopause, both contribute to breasts becoming pendulous or flaccid