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CHAPTER 4Physical Assessment

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OBJECTIVE DATA DEFINED OBJECTIVE DATA DEFINED

Objective data as Objective data as OBSERVED by OBSERVED by the examiner the examiner

Can be seen, heard, & measured Can be seen, heard, & measured –– Examples: rashes, altered vital signs, Examples: rashes, altered vital signs,

visible drainage or SWELLING/EDEMA visible drainage or SWELLING/EDEMA –– Lab results, diagnostic imaging, and Lab results, diagnostic imaging, and

other studiesother studies

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WHAT DO YOU OBSERVE? WHAT DO YOU OBSERVE?

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OBJECTIVE VERSES OBJECTIVE VERSES SUBJECTIVE SUBJECTIVE

–– Subjective data is what the Subjective data is what the patient patient says it issays it is

–– Examples: Examples: painpain, nausea, vertigo, and , nausea, vertigo, and anxietyanxiety

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Signs and SymptomsSigns and Symptoms

DiseaseDiseaseIt is any disturbance of a It is any disturbance of a structure or function of the body.structure or function of the body.It is recognized by a set of signs It is recognized by a set of signs and symptoms.and symptoms.

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Signs and SymptomsSigns and SymptomsRisk Factors for Development of Risk Factors for Development of

DiseaseDisease–– A risk factor is any situation, lifestyle, A risk factor is any situation, lifestyle,

habit, environmental condition, genetic habit, environmental condition, genetic predisposition, physiologic condition, predisposition, physiologic condition, and other that increases the and other that increases the vulnerability of an individual or a group vulnerability of an individual or a group to illness or accident.to illness or accident.

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Signs and SymptomsSigns and Symptoms

Terms Used to Describe DiseaseTerms Used to Describe Disease–– ChronicChronic

––6 months and longer, often for a 6 months and longer, often for a personperson’’s lifetime s lifetime

–– AcuteAcuteBegins abruptly, severe signs and Begins abruptly, severe signs and symptoms and then often subsides symptoms and then often subsides after a period of treatmentafter a period of treatment

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AssessmentAssessment

Process of making an Process of making an evaluationevaluation or or appraisalappraisal of the patientof the patient’’s conditions condition

Collection of subjective (pt. feels) Collection of subjective (pt. feels) and objective data (what the and objective data (what the caregiver observes)caregiver observes)

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AssessmentAssessment

Medical AssessmentMedical Assessment–– Functions That May Be Expected of the Functions That May Be Expected of the

PT PT –– Preparing the exam roomPreparing the exam roomAssisting with equipmentAssisting with equipmentPreparing the patientPreparing the patientCollecting specimensCollecting specimens

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Initiating the Initiating the NurseNurse--Patient Patient Relationship Relationship (remember it helps (remember it helps reduce potential liability)reduce potential liability)

Introduce yourself and state name, Introduce yourself and state name, position, and purpose of the position, and purpose of the interview.interview.Convey competence and Convey competence and professionalism.professionalism.Convey empathy Convey empathy

AssessmentAssessment

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Guess what ? Time to put you in Guess what ? Time to put you in the driver seat.the driver seat.

Break into twoBreak into two’’ss Grab your mind Grab your mind Shy ones are going to have an anxiety Shy ones are going to have an anxiety

attack!attack! Practice makes perfect Practice makes perfect Perform a nursing introduction to your Perform a nursing introduction to your

partner partner

We will discuss the process after the We will discuss the process after the exerciseexercise

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AssessmentAssessment

Nursing Health HistoryNursing Health History–– Reasons for Seeking Health CareReasons for Seeking Health CareChief complaintChief complaint

––Document information in patientDocument information in patient’’s s own words.own words.

––““I have been having a lot of I have been having a lot of breathing problems for last two breathing problems for last two weeksweeks””

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SOAP:SOAP:

SSubjective dataubjective dataOObjective data, bjective data, AAssessment, ssessment, PPlan. lan.

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AssessmentAssessment

–– Psychosocial and Cultural HistoryPsychosocial and Cultural HistoryData about primary language, cultural Data about primary language, cultural groups, educational background, groups, educational background, attention span, and developmental attention span, and developmental stagestageCoping skills and family supportCoping skills and family supportIdentify major beliefs, values, and Identify major beliefs, values, and behaviors when treating thembehaviors when treating them

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AssessmentAssessment

Nursing Physical AssessmentNursing Physical Assessment–– Performing the Nursing Physical Performing the Nursing Physical

AssessmentAssessmentItems needed:Items needed:

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Figure 4Figure 4--11

Equipment used during a physical examination.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

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AssessmentAssessment

–– HeadHead--toto--Toe AssessmentToe AssessmentNeurologicNeurologic

––Level of consciousnessLevel of consciousness––Level of Level of orientationorientation––Hand gripsHand grips

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Figure 4Figure 4--33

Assess skin turgor by grasping fold of skin on back of patient’s hand, sternum, forearm, or abdomen.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

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AssessmentAssessment

–– HeadHead--toto--Toe Assessment (continued)Toe Assessment (continued)Head and neckHead and neck

––Note facial expression.Note facial expression.––Note symmetry of features.Note symmetry of features.

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Figure 4Figure 4--99

Palpation of arterial pulses.

(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)

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TIME FOR YOUR PHYSICAL TIME FOR YOUR PHYSICAL

““My name is weeMy name is wee--wee and I will be wee and I will be doing your head to toe assessment doing your head to toe assessment todaytoday””