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Physical Assessment I Ch. 15

Physical Assessment Performed in a head to toe fashion.Based on the subjective data collected from a patient and objective data observed and assessed. The most essential task you can do for a patient. Know what is normal. Then you can identify what is abnormal.
Definition of Baseline A baseline is not the “normal” for the average person, it is the normal for the individual. A baseline is the vital findings you identified when you complete that first assessment. Purpose is to know "range".
Purpose of Exam May be complete for a baseline. Used to gather baseline data about the patient. You can’t identify changes if you don’t have a baseline. Supplement, confirm, or refute data obtained in the history
Purpose of Exam Including promoting self assessment and self-care i.e. hygiene, breast or testicular exams etc. Confirm and identify nursing diagnosis
Where to start Always start with communication. Ask the client about their health history which includes recent illness, injury, past surgeries, medications, allergies, inherited disorders, family history of illness, social history, and psychological history
Where to start The physical exam supplements, confirms or refutes the history. Nursing diagnosis comes after a thorough assessment. The information gathered provides a baseline database to compare the patient to over time
Other History to Consider Past medical and surgical history. Psychosocial history. Family history. Social history. Occupation. Nutritional history. Compliance
Cultural Sensitivity The care they provide their sick Food, Alternative therapies and Health beliefs, Sex of care giver, Clothing, Personal space
Physical Assessment: 8 things The 3rd Degree. Location. Onset. Duration. Quality. Severity. Relieving factors. Aggravating factors
Inspection Observing/looking
Palpation Light and deep feeling with hands. May palpate skin for moisture, texture, turgor, tenderness, thickness, organs, and nodes.
Palpation Save painful sight for last last. Assess from side to side comparing each side. You are feeling for texture, shape, size, consistency, and pulsation.
Percussion Tapping to note dull verses hollow and organ outlines. Can determine the location, size, and density of underlying structures. Always compare sides
Auscultation Listening with stethoscope. To listen to sounds made by the body organs to detect variations from normal. Wash your hands prior to client contact. Always compare sides.
Fingertips Most sensitive
Dorsal or back of hand Temperature changes
Palms Vibration
Grasp with fingertips Turgor, position, consistency
Environment Private, well equipped, good lighting, quite, warm and safe (check those siderails)
Equipment Gather all equipment prior to the exam, use gloves, when appropriate, good batteries, functioning equipment, warming equipment (i.e. speculum), bed at safe level
Client Comfortable, cell phones off, explain procedure, offer drape for privacy, and if the client needs to void before the physical be sure to collect the urine specimen as you may need it later.
Assessment of Age Groups Children are apprehensive and often may cry. Gather the history from the parent or guardian. Use a non-threatening approach. May require a brief play time with the child. Speak to the child using their first name. Speak to the parents more formally.
Assessment of Age Groups: Adolescents Treat adolescents in a mature manner. The adolescent has a right to privacy and may speak to you regarding their sexual behavior.
Assessment of Age Groups: Older Adults Assess ADL’s. Vision. Hearing. Support system. Ability to take meds. Financial constraints. Mini mental exam. Use of assistive devices. Mobility
Assessment of Age Groups: Older Adults Can the patient hear you? When positioning think about the patients comfort and arthritic problems Assess for depression Assess sexuality – men may be taking Viagra which is contraindicated with nitrates.
Assessment Begins when you first meet the patient. General appearance. Dress. Mobility. Behavior. Vital signs. Height and weight. Speech
Appearance and Behavior Includes: Race and gender. Age. Signs of distress. Body type. Posture Gait. Body movement. Home meds. History (patient and family). Hygiene and grooming. Dress. Body odor. Affect and mood. Speech
Vital Signs Generally done before the physical however, if the patient is apprehensive it may be wise to do vitals signs before and after the exam.
Height and Weight Ask the patient what their weight is normally. Assess the patients normal diet and if they were trying to lose weight. Assess body image – anorexia/bulimia. .
Height and Weight Weigh infants on a basket or platform scale. The infant should be undressed and preferable without a diaper. If weighing with a DRY diaper you must subtract the weight of the diaper from the infants weight
Integument/Skin Reveals changes in oxygenation, circulation, nutrition, local tissue damage, and hydration.
Risk for skin trauma related to immobility Neurologically impaired. Chronically ill. Orthopedic patients. Diminished mental status. Cardiac and oxygenation compromised. Inadequate nutrition
Integument: Assess Color. Moisture. Temperature. Texture. Turgor. Vascularity. Edema. Lesions
The Skin Observe for edema (pitting or non pitting), vascular markings (bruising, petechiae), lesions, redness, striae, odors, and heat or coolness.
Pallor Easiest seen in the face, buccal mucosa, conjunctivae, and nail beds. Pallor in dark skin persons may make their color seem like a yellow – brown or ashen grey. Lack of blood flow or lack of blood
Cyanosis Easiest seen in the lips, nail beds, palpebral conjunctivae, and palms. Lack of oxygen
Jaundice Yellow – orange discoloration. Best observed by looking at the sclera
Moisture Refers to wetness and oiliness. Observe for excess of oil, dryness, wetness, flaking (dandruff), crusting, dullness, and scaling (fishlike).
Moisture contributing causes including: Time of year, smoking, thyroid conditions, humidity, exposure to sun, stress, dehydration, excessive perspiration, and inadequate nutrition.
Skin Temperature Depends on amount of blood circulating to the surface. May have an increase temperature with infection, trauma, or deep vein thromboses. Reduction of temperature may lead you to think of lack of blood flow to the area
Melanoma An aggressive form of skin cancer left untreated will lead to death.
Normal nail Approximately 160-degree angle between nail plate and nail.
Clubbing Change in angle between nail and nail base (eventually larger than 180 degrees); nail bed softening, with nail flattening; often, enlargement of fingertips. Causes: Chronic lack of oxygen; heart or pulmonary disease
Beau's lines Transverse depressions in nails indicating temporary disturbance of nail growth (nail grows out over several months). Causes: Systemic illness such as severe infection, nail injury
Koilonychia (spoon nail) Concave curves. Causes: Iron deficiency anemia, syphilis, use of strong detergents
Splinter hemorrhages Red or brown linear streaks in nail bed. Causes: Minor trauma, subacute bacterial endocarditis, trichinosis
Paronychia Inflammation of skin at base of nail. Causes: Local infection, trauma
Health History for Neurological Exam Headaches. Seizures. Tremors. Dizziness. Vertigo. Numbness or tingling of body parts. Visual disturbances/changes. Weakness, pain. Changes in speech
Medications/drugs that influence neurological assessment Analgesics. Alcohol. Sedatives. Hypnotics. Antipsychotics. Antidepressants. Nervous system stimulants. Recreational drugs. Ask for recent changes in: Increase irritability. Mood swings. Memory loss. Change in energy level
Neurological Exam Behavior. Appearance. Language. Intellectual functioning. Patient orientation. Time, person, place. Mini mental status exam (MMSE)
Level of consciousness Glasgow coma scale. Pupillary reaction. Mental and Emotional Status. Mental Status. Questionnaire tool. Mini mental status exam. Any change or alteration in mental or emotional status reflects cerebral cortex disturbance
Cerebral functioning Allows a person to understand written and spoken
Aphasia Ineffective communication
Sensory (receptive) Cannot understand written or verbal speech
Motor (expressive) Patient understands all that is said or spoken but cannot write or speak appropriately
Immediate recall 5-8 numbers forward or 4-6 backwards (typically will see serial 7’s backward from 100).
Recent Provide three unrelated objects and 5 minutes later as to repeat. Or ask what was for breakfast and verify with person at breakfast.
Remote Recall mothers maiden name, birthday, or another special date in history. Intellectual functioning
Knowledge Knowledge of illness or reason for hospitalization.
Sensory function CNS conducts sensation of pain, temperature, position, vibration, crude touch, and fine touch. Test – Have client close eyes and state where stimulus strikes, sharp versus dull, at arms, trunk, and legs. Done symmetrically, random
Cranial nerves OOOTTAFAGVSH. On Old Olympus towering tops a Finn and German viewed some hops. Cranial Nerves !
Deep tendon reflexes Done by stretching muscle mildly and striking tendon with hammer
Cutaneous reflexes Stimulating skin superficially.
Cutaneous reflexes: Grades 0 no response. 1+ low normal with slight muscle contraction. 2+ normal with visible muscle twitch and movement of the muscle or arm. 3+ brisker than normal; may not indicate disease. 4+ hyperactive and very brisk; often with spinal cord disorders
Eye Health History Eye pain. Photophobia. Burning. Itching. Excess tearing. Crusting. Film or curtain vision. Halos. Diplopia. Floaters. Dark spots. Flashing lights. Visual Acuity. Ability to see small detail. Testing of central vision. Snellen chart.
Ectropion Eye Lid margins that turn out
Entropion Eye Lid margins that turn in
Lacrimal apparatus Upper outer wall of anterior part of orbital. Responsible for tear production. Typically not felt unless becomes obstructed. Assess for redness or edema
Conjunctivitis Highly contagious, crusty drainage on the eyelid margins
Arcus senilis Thin white ring around the iris
Cornea Transparent, colorless, shiny, smooth
Pupils Size, shape, equality, accommodation, reaction to light.
Cloudy pupils Cataracts
Pinpoint Opiod intoxication (Heroin, fentanyl, meperidine)
Auricles Color, size, shape, symmetry, lesions, moles, cysts, nodules, tender, pain with palpation?
Three types of hearing loss Conductive. Sensorineural mixed. Hearing Loss
Conductive An interruption of sounds from outer ear to inner ear r/t sounds not transmitted through outer and middle ear structures
Sensorineural Inner ear, auditory nerve damage, or hearing center in brain damaged Sounds is lost beyond the bony ossicles
Whisper test One ear occluded and whisper
Nose and Sinuses Allergies. Drug use. Occupational exposure. Nasal obstruction. Deviated septum. Infections. Polyps. Headaches. Post nasal drip
Created by: maggardba