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Physical AssessmentChapter 13

Sonia Green

Physical Assessment

• One method of gathering health data

• First step in the nursing process

• Performed on every patient to gather

objective data

Purposes

• Purposes

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Techniques

• Techniques

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Inspection

• Inspection (purposeful observation)

– -

– -

– -

– -

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Percussion

• Percussion (striking or tapping a part of the body)

– Least used nursing assessment

– Fingertips are used to produce vibratory sounds

– Discomfort should not be felt if it is done correctly

– Pain may indicate disease process of tissue injury

Palpation

• Palpation (lightly touching the body or

applying pressure)

– Light Palpation

– Deep Palpation

Light Palpation

• Light Palpation

– Use fingertips

– Back of hand

– Palm of the hand

– Used on surface of skin

– Used to feel surface of the skin

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Deep Palpation

• Deep Palpation

Performed by depressing tissue approx 1”

using forefingers of one or both

Auscultation

• Auscultation (listening to body sounds)

Requires stethoscope

Requires repeated practice

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Equipment

• Equipment

Gloves

Examination gown

Cloth or paper drapes

Scale

Stethoscope

Sphygmomanometer

Thermometer

Pen light/ Flashlight

Tongue blade

Assessment form and pen

Environment

• Environment

Provide privacy

Warm

Padded/adjustable table/bed

Sufficient Room

Adequate lighting

Facilities for hand washing

Clean counter or surface

Lined receptacle for soiled articles

Physical Assessment

• PERFORMING A PHYSICAL ASSESSMENT

Gathering General Data

Draping and Positioning

Systematic Approach

Examining the Client

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Gathering General Data

• Gathering General Data

Physical appearance

Level of consciousness

Body size

Posture

Gait

Mood & emotional tone

Use of ambulatory aids

Data Collection Approach

• Head-to-toe approach

• Body Systems Approach

Physical Assessment

• Data Collection

– Body Systems

Divided into six general area

Head & Neck

Chest

Extremities

Abdomen

Genitalia

Anus

Rectum

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Physical Assessment

• Head & Neck

– Assess mental status

– Assess symmetry of craniofacial structures (eyes,

ears, nose, mouth) function

– Skin

– Oral & Nasal mucous membranes

– Hair & Scalp

Mental Status Assessment

• Mental Status Assessment

– Cognitive Level

– Attention

– Concentration

– Memory

– Abstract Thinking

Assessment Equipment

• Eyes

Appearance

Color

Size

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Visual Acuity

• Visual Acuity

– Contacts

– Glasses

– False Eye

Snellen Eye Chart

• Snellen Eye Chart

– _

– _

– _

– _

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Pupil Size

• Pupil Size

– Estimated in millimeters in normal light conditions

– Normal round and equal in size

– Consensual response

– Accommodation

– Documentation

Extraocular Movements

• Extraocular Movements

– Instruct pt to focus on & track the nurse’s finger

– Object should be moved six different positions

– Eyes should have coordinated movement

– See Figure 13-10 ; page 235

Visual Field Examinations

• Visual Field Examination (assessment of

peripheral vision and continuity in the visual

field).

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Ears

• Ears

– External ears examined

– Inspect & Palpate

– Otoscope

• Used to examine the tympanic membrane

• Used to examine the eardrum

Voice Test

• Voice Test

– Stand 2 ft behind & to the side of the pt

– Instruct the pt two cover the ear on the opposite side

– Whisper a color, number, or name into the uncovered ear

– Instruct the pt to repeat the whispered word

– Continue with the same pattern increasing the volume

– Repeat the test in the opposite ear

Weber Test

• Weber Test

– Performed by striking tuning fork on nurse’s palm

– Place vibrating stem in the center of head

– Ask the pt is sound is hear equally

See Figure 13-13 page 237

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Rinne Test

• Rinne Test

– Performed with tuning fork

– First strike the tuning fork

– Place stem behind the ear (mastoid area)

– Instruct pt to report when sounds stops

– Move vibrating tuning fork near the ear canal

Audiometry

• Audiometry (measurement of hearing acuity

at various sound frequencies)

-Done by audiologist

-Exact pitch & volume deficits are

measured

-Hearing is measured in decibels

Nose

• Nose

-Inspect the nose & the nasal passages

-Septum should be midline

-Nasal passage equal in size

-Assess smelling acuity

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Mouth & Oral Membranes

• Mouth & Oral Membranes

– Mouth, tongue, teeth

– Inspect

-tongue should be midline (normal)

-note unusual breath odors

-note normal color of mucous membrane

-assess pt’s smile

Skin Assessment

• Facial Skin

– Smooth

– Uniform

Review TABLE 13-3 Page 238

Review TABLE 13-4 page 239

Skin Assessment

• Alteration in skin integrity

– Wound

– Ulcer

– Abrasion

– Laceration

– Fissure

– Scar

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Hair

• Hair

– Scalp hair

– Eyebrows

– Eyelashes

-color

-texture

-distribution

Scalp

• Scalp

– Assess by separating the hair

• Inspect the skin

• Palpate for any unusual contour

Skin Assessment

Turgor (resiliency of the skin)

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Neck

• Neck

– Support the head in midline position

– Assess

Trachea

ROM

-Palpate

Carotid arteries

Physical Assessment

• Chest & Spine

– Assess

• Shape of Chest

• How it moves during breathing

• Note curved appearance of spine

• Skin turgor, breast, heart sounds & lung sounds

Chest Shape

• Chest Shape & Movement

– Alters with abnormalities

– Expands equally with normal breathing

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Spine

• Spine

– Normal

• Shoulders equal height

• Midline

Spine

• Spine

– Common Deviations

• -

• -

• -

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Physical Assessment

• Breast

– Examination

• Teaching

Figure 13-19 page 242

Breast Examination

Heart Sounds

• Heart Sounds

– Normal Heart Sounds

– Abnormal Heart Sounds

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Heart Sounds

• Normal Heart Sounds

– S1 & S2

– S1 is the lub

– S2 is the dub

Heart Sounds

• Abnormal Heart Sounds

– S3 & S4

– S3 normal for children

– S3 abnormal for adults

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Lung Sounds

• Lung Sounds

– Normal Lung Sounds

• Tracheal sounds

• Bronchial sounds

• Bronchovesicular sounds

• Vesicular sounds

Lung Sounds

• Lung Sounds

– Abnormal Lung Sounds

• -

• -

• -

• -

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Extremities

• Extremities

– Assess

• Alignment

• Mobility

• Strength

• Compare size

• Skin temperature

• Nails

Extremities

• Extremities

– Assess

• Capillary refill time

• Palpate local peripheral pulses

• Check for edema

Fingernails and Toenails

• Assess

– -

– -

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Capillary Refill Time

• Observe the color in the nail bed.

• Depress the nail bed, displacing capillary

blood.

• Release the pressure

• Note how many seconds it takes for color to

come back.

Edema

• Evidenced by:

– Weight gain

– Tight rings

– Patterns in skin

Edema

• Determining presence of edema

– Press thumb or finger into the tissue

– If indentation remains (pitting edema)

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Skin Sensation

–Assess

»Light touch

»Warmth

»Cold

»Sharp

»Dull

»Vibration

Abdomen

• Assessment

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Bowels Sounds

• Assessed

– Admission

– Every shift

– Sounds

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Abdominal Girth

• Measured if abdomen enlarged

• Measured daily

– Use a tape measure

– Measure around largest diameter

– Measure from same location

– Ensure by marking on the skin

Genitalia

• Don Gloves

• Inspection

Anus & Rectum

• Assessment

– Gloves

– Position pt on side

– Knees bent

– Separate buttocks

– Observe external orifice

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REVIEW SKILLS

• Skill 13-1 page 250-251

Questions

WEBSITES

• www.medicine.osu.edu/exam

• www.thepoint.lww.com

• www.wilkes.med.ucla.edu/intro.html

• www.blaufuss.org

• www.sci.sdsu.edu/multimedia/heartsounds