Assessment Physical Assessment Part 1 Helen Harkreader, RN, PhD

AssessmentAssessment

Physical Assessment Physical Assessment

Part 1Part 1

Helen Harkreader, RN, PhDHelen Harkreader, RN, PhD

Nursing AssessmentNursing Assessment

gathering information about the gathering information about the health status of a person health status of a person

identify concerns and needs that can identify concerns and needs that can be treated or managed by nursing be treated or managed by nursing care.care.

look, listen, touch, look, listen, touch, to make an informed decision about to make an informed decision about

care.care.

Types of AssessmentTypes of Assessment

InitialInitial FocusedFocused OngoingOngoing Shift AssessmentShift Assessment EmergencyEmergency

Health HistoryHealth History

Reason for admission/chief complaintReason for admission/chief complaint Demographic informationDemographic information History of present illnessHistory of present illness Family historyFamily history Other historyOther history

Medical: diabetes, heart disease, renal Medical: diabetes, heart disease, renal diseasedisease

Surgical historySurgical history

Health HistoryHealth History

It’s important to remember:It’s important to remember: Nursing care is more concerned Nursing care is more concerned

with with helping the personhelping the person manage or manage or

function with a health problem function with a health problem Not with Not with

diagnosing and treating illnesses.diagnosing and treating illnesses.

Physical ExamPhysical Exam

Usually follows historyUsually follows history Head to toe approachHead to toe approach Includes (as needed): inspection, Includes (as needed): inspection,

palpation, auscultation, and palpation, auscultation, and percussionpercussion

General SurveyGeneral Survey

How do they look overall?How do they look overall? What can you discern just by looking What can you discern just by looking

at and talking with them?at and talking with them? Are they Are they orientedoriented?? What is their mood?What is their mood? How about nutritional status?How about nutritional status? Vital signs?Vital signs?


As you introduce your self and As you introduce your self and establish trust with the patient your establish trust with the patient your are beginning the general surveyare beginning the general survey


Level of consciousnessLevel of consciousness OrientationOrientation ConfusionConfusion MemoryMemory Mood, affectMood, affect Signs of distress: dyspnea, anxietySigns of distress: dyspnea, anxiety

Planes of the BodyPlanes of the Body

Sagittal (through midline)-divides Sagittal (through midline)-divides right and left; medial and lateralright and left; medial and lateral

Frontal plane- divides anterior and Frontal plane- divides anterior and posteriorposterior

Transverse – divides top to bottom Transverse – divides top to bottom through pelvis; superior and inferiorthrough pelvis; superior and inferior

Proximal and distalProximal and distal

InspectionInspection

Visual examination - lookingVisual examination - looking Color, shape, size, symmetry, Color, shape, size, symmetry,

position and movementposition and movement Good lighting is very important Good lighting is very important

PalpationPalpation

Assessment through touchAssessment through touch Temperature, moisture, texture, Temperature, moisture, texture,

tenderness, masses, and edematenderness, masses, and edema May be light or deep, one hand or May be light or deep, one hand or

twotwo Make sure your hands are clean and Make sure your hands are clean and

fingernails short!fingernails short!

PercussionPercussion

Short, sharp strikes to the body Short, sharp strikes to the body surface to produce palpable surface to produce palpable vibrations and soundsvibrations and sounds

Maybe direct (one hand) or indirect Maybe direct (one hand) or indirect (two hands)(two hands)

Can detect size, shape, density and Can detect size, shape, density and location of structureslocation of structures

AuscultationAuscultation

Listening to the sounds in the body Listening to the sounds in the body (usually with a stethoscope)(usually with a stethoscope)

Used to listen to lung sounds, heart Used to listen to lung sounds, heart sounds and abdominal soundssounds and abdominal sounds

Keep your stethoscope clean!Keep your stethoscope clean!

HEENTHEENT

Head, Eyes, Ears, Nose, ThroatHead, Eyes, Ears, Nose, Throat Look at distribution of hair. Are there Look at distribution of hair. Are there

any lumps on the head? any lumps on the head? Discolorations?Discolorations?

Is head normal size? Upright? Are the Is head normal size? Upright? Are the facial structures symmetrical in facial structures symmetrical in shape?shape?

HEENTHEENT

Basically a Cranial nerve assessmentBasically a Cranial nerve assessment You You do notdo not need to check each need to check each

cranial nerve at this point, but be cranial nerve at this point, but be aware of what they are and how to aware of what they are and how to assess them.assess them.

HEENTHEENT

Does the mouth droop? Does the mouth droop? Talk to the patient. Do all the facial muscles Talk to the patient. Do all the facial muscles

move together? move together? Can the person see and hear well?Can the person see and hear well? Pupils equal, round and reactive to light and Pupils equal, round and reactive to light and

accommodation.accommodation. What does this mean?What does this mean? Check the eye muscle function. Have the patient Check the eye muscle function. Have the patient

follow your finger to all eight positions.follow your finger to all eight positions. Inspect the ear and assess hearing by talking to Inspect the ear and assess hearing by talking to

the patientthe patient

Cranial NervesCranial Nerves

examine sensation and movement of examine sensation and movement of the face: the facial nerve--CN VII and the face: the facial nerve--CN VII and the trigeminal nerve--CN Vthe trigeminal nerve--CN V

List the function of each cranial List the function of each cranial nerve. Which ones are used for nerve. Which ones are used for swallowing?swallowing?

Other HEENTOther HEENT

Check the nose for abnormalitiesCheck the nose for abnormalities If warranted, palpate the sinuses for tendernessIf warranted, palpate the sinuses for tenderness Look at mouth and neck. Take a look at the Look at mouth and neck. Take a look at the

tongue. Are there white patches? Red patches?tongue. Are there white patches? Red patches? Check range of motion for the neck (gently!).Check range of motion for the neck (gently!). Look at the neck for jugular vein distention. Look at the neck for jugular vein distention.

This could indicate a heart problem.This could indicate a heart problem.


Where are these structures?Where are these structures? Lymph nodesLymph nodes Jugular veinsJugular veins Carotid arteriesCarotid arteries TracheaTrachea Trapezius and sternocleidomastoidTrapezius and sternocleidomastoid


To assess the lymph nodes, place To assess the lymph nodes, place both hands on the neck at the same both hands on the neck at the same time and palpate using the time and palpate using the pads of pads of your fingersyour fingers..

Normal: not palpable or smooth, firm, Normal: not palpable or smooth, firm, less than 1 cm, mobile, and less than 1 cm, mobile, and nontendernontender

Head and NeckHead and Neck

size, symmetry, position and size, symmetry, position and movement of head movement of head

temporomandibular joint temporomandibular joint

SkinSkin

InspectionInspection Intact, free of lesionsIntact, free of lesions Pink toned or underlying healthy glowPink toned or underlying healthy glow

PalpationPalpation Warm, cold, moist, dryWarm, cold, moist, dry Lesion: Hard, firm, feels like fluidLesion: Hard, firm, feels like fluid Movable, fixed, attached to underlying Movable, fixed, attached to underlying

structuresstructures

Skin ColorSkin Color

cyanosis (central, peripheral, cyanosis (central, peripheral, circumoral), circumoral),

jaundice, jaundice, pink tone, glowing, ashenpink tone, glowing, ashen pallor, pallor, erythemaerythema

SkinSkin

TurgorTurgor MoistureMoisture TemperatureTemperature

Skin DisruptionsSkin Disruptions

macules, papules, nodulesmacules, papules, nodules vesicles, bullavesicles, bulla scales, plaque, patches (vitiligo)scales, plaque, patches (vitiligo) petechiae, necrosis, keloid petechiae, necrosis, keloid linear, annularlinear, annular

Describing LesionsDescribing Lesions

Size, color, type (primary, Size, color, type (primary, secondary), location, distributionsecondary), location, distribution local vs. generalizedlocal vs. generalized Annular, linearAnnular, linear Abrasion, lacerationAbrasion, laceration

HairHair

DistributionDistribution TextureTexture Cleanliness, groomingCleanliness, grooming Scalp for lesionsScalp for lesions InfestationsInfestations

NailsNails

Capillary refillCapillary refill Abnormal shapeAbnormal shape ClubbingClubbing

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Assessment Physical Assessment Part 1 Helen Harkreader, RN, PhD