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Introduction to process, techniques and components of physical assessment. PA is a complex process that requires effort and experience. Review PA

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Page 1: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA
Page 2: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Introduction to process, techniques and components of physical assessment.

PA is a complex process that requires effort and experience.

Review PA abbreviation table 4-1.

Page 3: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Head – to - Toe Assessment• Most comprehensive• Used to obtain baseline information to identify changes in patient status◦ organized - everything assessed from head progressing down to toes-

combines systems (head, assess neuro, MS of upper then later as proceed down assess MS of lower ext)

◦ used for complete PW- it minimizes position changes and requires less time

Body Systems Assessment◦ one system at a time◦ Cardiac: heart sounds, pulses, capillary refill, B/P◦ Respiratory: breath sounds, rate and depth, skin color◦ organized per body systems i.e. lung assessment, abdominal assess,

cardiovascular, neuro system◦ best used for focused physical assessment

May use either approach, just be organized.

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Page 4: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

From patient's right side Follow a sequences that minimizes

discomfort and position changes Respect patient privacy and minimize

embarrassment The scope of examination varies according

to illness and severity.

Page 5: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

The PA consists of detailed patient evaluation that consist of four fundamental techniques.

Inspection Palpation Percussion Auscultation

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Page 6: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Inspection - critical observation◦Take time to “observe” with eyes, ears, nose◦Use good lighting◦Look at color, shape, symmetry, position◦Odors from skin, breath, wound

Inspection is done alone and in combination with other assessment techniques

Page 7: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA
Page 8: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Palpation ◦Using hands to fell areas that cannot be seen◦light and deep touch◦Back of hand to assess skin temperature◦Fingers to assess texture, moisture, areas of

tenderness◦Assess size, shape, and consistency of lesions◦Organ size and location◦Rigidity or spasticity◦Crepitation & Vibration◦Position & Size◦Presence of lumps or masses◦Tenderness, or pain

Page 9: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Palpation Techniques

◦Light

◦Deep

◦Bimanual

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Page 10: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Percussion ◦ Sounds produced by striking body surface◦Produces 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

Page 11: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Direct – tapping the body directly with the distal end of a finger◦ sinus tenderness

Indirect- tapping a finger placed on the body, only the finger being struck touches the body◦ lung percussion

Blunt percussion-organ tenderness

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Page 12: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Percussion over normal lung tissue resonant, hollow note

Percussion over solid organ dull note Percussion over stomach tympanic note Percussion over large muscle flat note

Page 13: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Auscultation ◦ listening to sounds produced by the body Direct auscultation – sounds are audible

without stethoscope Indirect auscultation – uses stethoscope

◦Describe sound characteristics (frequency, pitch intensity, duration, quality) Flat diaphragm picks up high-pitched

respiratory sounds best Bell picks up low pitched sounds such as

heart murmurs

Page 14: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Instrument: stethoscope (to skin) Diaphragm –high

pitched soundsHeartLungsAbdomen

Bell – low pitched soundsBlood vessels

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Page 15: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Environment & Equipment

Technique General survey Head to toe or systems

approach Minimize exposure Areas to assess first –

unaffected areas, external before internal parts

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Page 16: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

See table 4-2 Stethoscope Ophthalmoscope

◦Consist of a head and handle◦The head contains viewing lenses and beam

selection controls◦The viewing lens control to focus the instrument

Otoscope◦Consist of head and handle

Page 17: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA
Page 18: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Skin is the largest organ in the body Skin is composed of

1. Epidermis- outermost portion of a relatively uniform, thin but tough, composed of thickness stratum germinativum and stratum corneum

◦ a. color derived from three sources Brown- pigment melanin Yellow-orange tones of pigment carotene Red-purple tone in underlying vascular bed

Page 19: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

2. Dermis- bulk of skin; the inner supportive layer

consisting mostly of connective tissue or collagen

is tough fibrous protein that enables skin to resist

tearing and allows skin to stretch with movement.

3. Subcutaneous layer- adipose tissue made up of

lobules of fat cells used for energy. It provides

insulation for temperature control and aids in

protection by its soft cushioning effect

Page 20: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

1. Previous history of skin diseases2. Skin Color- affected by genetic factors and

physiological factors. -Variations of skin color

Cyanosis- blue tinge Pallor- loss of rosy glow in skin, paleness Erythema- redness of the skin, increase in

climate temperature, inflammation, infection

Page 21: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

• Plethora- redness of skin caused by increase RBS

• Ecchymosis- large diffuse areas usually black and blue , results of injuries

• Petechiae- small pinpoint hemorrhages can denote some type of blood disorder

• Jaundice- yellow staining of skin usually caused by bile pigments

Page 22: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

3. Changes in mole size, shape, tenderness, bleeding check for abnormal characteristics of

pigmented lesions. Note any freckles and changes and any

birthmarks (report any changes in size, itching, burning, bleeding of moles)

Page 23: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

ABCDE• Asymmetry of pigmented lesion -one that

is not regularly round or oval• Border irregularity -notching,

scalloping, ragged edges or poorly defined margins

• Color variation -areas of brown, tan, black, blue, red, white or combination

• Diameter greater than 6mm• Elevation and enlargement

Page 24: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

4. Texture- palpate note any marks or scaring

skin should be smooth and firm

5. Temperature- symmetrically feel each part of

the body, compare upper area with lower areas

check for hypothermia and hyperthermia Normal finding: warm Changes: cool, cold, hot

Page 25: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

6. Turgor-amount of elasticity in skin, grasp index finger pull it taut and quickly release- elastic skin immediately assumes in normal position, poor turgor suspended or tented; turgor shows hydration and nutrition

7. Moisture or dryness- check face, hands, axilla, skin folds; shows diaphoresis or dehydration

8. Are there any rashes or lesions; note color, elevation, pattern or shapes, size, location and distribution on body, any exudates

Page 26: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

9. Is there any itching (purities)10. What medication are you taking11. Note mobility12. Note any edema- accumulation of fluid in the

intercellular spaces; to check for edema, imprint your thumbs firmly against the ankle malleolus or the tibia. If pressure leaves a dent in the skin “pitting” present1+= mild pitting, slight indentation, no

perceptible swelling of the leg 2=+ moderate pitting, indentation subsides

rapidly

Page 27: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

3+= Deep pitting, indentation remains for a short time; leg looks swollen 4+=Very Deep pitting, indentation lasts a long time, leg is very swollen.

13.thickening uniform over body except thick over palms and soles of feet

Page 28: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA
Page 29: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA
Page 30: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Depress pretibial area & medial malleolus for 5 seconds

Grade pitting edema1+ to 4+

Page 31: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

1. Hair- ◦ inspect for color (comes from melanin) graying may

begin at 3rd decade; ◦ Texture maybe fine or thick; straight, curly, or kinky;◦ Quality maybe shinny or dull;◦ Distribution- coarse or elastic

2. Scalp- inspect for ticks or lice3. Nails- Shape and Contour- curved or flat,

edges smooth, rounded, clean; - Consistency- smooth, regular, nor brittle or

splitting, thickness, firm - Color- translucent, pink nails base

- inspect nail beds for clubbing

Page 32: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Capillary return or refill: normal = less than 3 seconds◦ used to evaluate the ability of the circulatory system to

restore blood to the capillary system (perfusion).◦ Capillary refill is evaluated at the nail bed in a finger.

(a)Place your thumb on the patient’s fingernail and gently compress.

(b)Pressure forces blood from the capillaries. (c)Release the pressure and observe the fingernail. (d) As the capillaries refill, the nail bed returns to its normal deep

pink color. (e)Capillary refill should be both prompt and pink. (f) Color in the nail bed should be restored within 2 seconds,

about the time it takes to say "capillary refill."

Page 33: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA
Page 34: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Monitoring Skin Condition Check color Temperature Abnormalities Excessive dryness, moisture, itching, flaking General texture of skin Skin turgor Edema Cleanliness Odor Discoloration (ecchymosis, petechiae, purpura,

erythema, altered pigmentation)

Page 35: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Go to this website for a tutorial on skin assessment

http://www.logicalimages.com:80/morphology/morphology3_content.html

Page 36: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA
Page 37: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

We think a normal temperature is 98.6 degrees Fahrenheit (37 degrees Centigrade) - based on the average of a few measurements taken 100 years ago. Actually, normal temperature in healthy adults ranges from 97 to 99.9 degrees Fahrenheit.

Page 38: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

How to take an oral temperature : Place thermometer under tongue; use probe cover Wait 3 minutes if mercury thermometer, 10 seconds if

electronic Wait 10 minutes after eating or drinking hot or cold liquids How to take a rectal temperature : Use lubrication and probe cover Rectal temperature is   0.4-0.5 degrees C (0.7 to 0.8

degrees F) higher than oral Use of axillary temperature : Axillary temperature correlates poorly with rectal

temperature It may be OK to do axillary reading in neonates if can't do

rectal thermometer

Page 39: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Why bother to check blood pressure? For each 20 mm rise in systolic blood pressure or 10

mm rise in diastolic blood pressure over 115/75: ◦Risk of stroke increases ◦Risk of heart disease doubles ◦Risk of renal failure increases

Systolic and diastolic blood pressure : Systolic blood pressure is the highest pressure in the

arteries, just after the heart beats Diastolic blood pressure is the lowest pressure in the

arteries, just before the heart beats Blood pressure is measured indirectly by blood

pressure cuff (sphygmomanometer)

Page 40: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Inflating cuff increases pressure until it cuts off arterial circulation to the arm

Deflating cuff, decrease pressure by 2 to 3 mm of mercury per second until blood first enters the artery, creating turbulence; this causes a sound with each heartbeat

Sounds continue with each heartbeat until pressure lowers to the lowest pressure in the artery; then turbulence stops, so the sound stops

Systolic blood pressure is the cuff pressure at the first sounds; diastolic is the cuff pressure just before the sounds stop

Page 41: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Phase 1: sharp thuds, start at systolic blood pressure Phase 2: blowing sound; may disappear entirely (the

auscultatory gap ) Phase 3: crisp thud, a bit quieter than phase 1 Phase 4: sounds become muffled Phase   5: end of sounds -- ends at diastolic blood

pressure

Page 42: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA
Page 43: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Make sure the cuff is the right size - its width should be at least 40% of the arm's circumference. The cuff will overestimate blood pressure if too small and underestimate if too large.

Place the cuff snugly on patient's proximal arm, on skin ( not cloth), centered over the brachial artery (most cuffs have markings)

Support the patient's arm at heart level, using your arm or a desk

Your patient should sit in the chair for 5 minutes before BP is measured, and should have no caffeine or nicotine for 30 minutes before (JAMA 273, p.1211-1218, 1995)

Page 44: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

With fingers palpating radial or brachial artery, inflate cuff rapidly until you can't feel the pulse, then 20 mm higher

Release cuff at 2 to 3 mm Hg per second until you again feel the pulse; this is the palpable systolic pressure

Wait 30 seconds before measuring blood pressure Measuring palpable pressure first avoids risk of seriously

underestimating blood pressure because of the auscultatory gap (mistaking Korotkoff phase 3 for phase 1). Many doctors skip this step for time reasons and instead pump cuff to 200 mm Hg at the next step)

Page 45: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Phase 2 of the Korotkoff sounds can be inaudible - especially in older patients with systolic hypertension, who are at especially high risk of stroke. Inflating the cuff until you don't hear sounds can give you a reading of 140/86 when the patient's actual blood pressure is 220/86. Most physicians are pressed for time, so they instead inflate the cuff to 200 mm, which is beyond the auscultatory gap in most patients. But palpable systolic blood pressure is, according to research, more reliable.

Page 46: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Place bell of stethoscope (diaphragm is acceptable) over brachial artery

Rapidly pump the cuff to 20 to 30 mm Hg above palpable systolic pressure

Release pressure in the cuff by 2 to 3 mm Hg per second and listen for Korotkoff sounds, including systolic (first) and diastolic (last)

Record as systolic/diastolic. Check in both arms the first time you check a patient's blood pressure. It may differ by 10 mm Hg or more.

If the sounds continues to zero, record diastolic blood pressure as the point when sounds become muffled (phase 4) over zero: e.g. 130/70/0, or just as 130/70.

Page 47: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Rate

–Number of beats in 30 seconds x 2 Strength

–Bounding, strong, or weak (thready) Regularity

–Regular or irregular

Page 48: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

You need three readings on two occasions to diagnose hypertension, unless blood pressure is very high

Normal blood pressure in children is: ◦ 102/55 at 1 year, 112/69 at 5 years, 119/78 at 10 years

Blood pressures in adults (JNC VII: JAMA 289:2560-72, 2003): ◦ Normal: <120/<80 ◦ Prehypertensive: 120-139/80-89 ◦ Stage 1 hypertension: 140-159/90-99 ◦ Stage 2 hypertension: >160/>100

Page 49: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Carotid: in neck, medial to and below angle of jaw

Radial: ventral wrist proximal to base of thumb Brachial: antecubital fossa, medial to biceps

tendon Femoral: in groin, just medial to quadriceps Popliteal: middle of popliteal fossa; knee flexed

30 degrees Posterior tibial (PT): posterior to medial

malleolus, in ankle Dorsalis pedis (DP): dorsal foot, lateral to

extensor hallucis longus

Page 50: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Peripheral vascular disease : absent or diminished DP and PT pulses - carries risk of ulcers, infection, amputation and other vascular disease.

Obtaining arterial blood for blood gas measurement Finding femoral vein for emergency access (IV line)

Page 51: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

Adult: 60 to 100 Newborn: 120-170 1 year: 80-160 3 years: 80-120 6 years: 75-115 10 years: 70-110

Page 52: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

How to measure: observe rise and fall of chest In infants, count for 60 seconds; in adults, 15 or 30

seconds Normal respiration:      Adults: 12 to 20      Children:

newborn 30-80 1 year 20-40 3 years 20-30 6 years 16-22

Page 53: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

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Rate– Number of breaths in

30 seconds x 2 Quality

– Character of breathing Rhythm

– Regular or irregular

Effort– Normal or labored

Noisy respiration– Normal, stridor,

wheezing, snoring, gurgling

Depth– Shallow or deep

Page 54: Introduction to process, techniques and components of physical assessment.  PA is a complex process that requires effort and experience.  Review PA

http://medinfo.ufl.edu/other/opeta/vital/VS_main.html