N U R S I N G 8 6 9

Physical Assessment

Purpose

N U R S I N G 8 6 9 •Gather baseline data •Supplement, confirm, or refute data in nursing hx •Confirm and identify nursing diagnosis •Make clinical judgments about changing status •Evaluate the physiological outcomes of care

Data

N U R S I N G 8 6 9 •Subjective •Objective

Subjective Data

N U R S I N G 8 6 9 •What client or family tells you • Symptoms • “I’m in pain” • “I feel anxious” • “There is a stabbing pain in my chest”

Objective Data

N U R S I N G •Information gained through the nurses’ senses •Signs or observations 8 6 •B/P 120/70 9 •Lung sounds clear in all lobes bilaterally •Pt grimaces with pain and guards abdomen •Abdomen soft, tender, nondistended

Health History

N U R S I N G 8 6 9 •Provides baseline subjective information •Family history •Life patterns •Sociocultural history •Spiritual health •Mental reactions •Emotional reactions

Skills

N U R S I N G •Inspection 8 6 9 •Palpation •Percussion •Auscultation •Olfaction

Inspection

N U R S I N G •Process of observation 8 6 9 •Good lighting •Position and expose body parts for optimal viewing •Inspect for size, shape, color, symmetry, & position

Palpation

N U R S I N G •Patient should be relaxed and positioned comfortably 8 6 9 •Tender areas palpated last •Warm hands, gentle touch, short fingernails •Apply pressure slowly, gently, and deliberately •Light palpation precedes deep palpation •Assess softness/rigidity, masses, temperature, size •Vital arteries NOT palpated in manner that obstructs flow

Percussion

8 6 9 N U R S I N G •Tapping to evaluate size, borders, and consistency of body organs and discover fluid in body cavities •Helps verify abnormalities reported from x-ray •Character of sound depends on density of underlying tissue •Abnormal sounds suggest mass, air, or fluid in organ or body cavity •Direct method •Indirect method

Ausculation

N U R S I N G •Sounds produced by body •Quiet environment 8 6 •Good stethoscope 9 •Stethoscope placed next to skin •Diaphragm used for high-pitched sounds •Bell used for low pitched sounds

Listen….

N U R S I 1. Frequency/pitch: # vibrations per second N G 8 6 9 2. Loudness: soft, medium, loud 3. Quality: types: gurgling, blowing 4. Duration: short, medium, long

Olfaction

N U R S I N G 8 6 9 •Be familiar with nature and source of body odors •Foul odors can help detect infections

Sytematic Approach

N U R S I N G 8 6 9 •Head-to-toe assessment •Major body systems assessment

Head-to-toe

N U R S I •Begins at head and progresses down to the toes N G 8 6 9 •Most comprehensive •Used to obtain baseline information to identify changes in patient status

Major body systems

N U R S I •Focuses on one system at a time N G 8 6 9 •Cardiac: heart sounds, pulses, capillary refill, B/P •Respiratory: breath sounds, rate and depth, skin color

N U R S I N G 8 6 9

Stethoscope

Head-to-toe

N U R S I •Neuro status N G •Mucous membranes and skin 8 6 9 •Cardiac assessment •Respiratory assessment •Abdominal assessment •Upper and lower extremities •Accessories such as IV line, catheters, & dressings

General Appearance

N U R S I N G 8 6 9 •Assess during initial contact with client •Look for signs of distress •Body type •Posture •Hygiene •Dress •Mood •Speech •Signs of abuse

Consciousness Level

N U R S I N G 8 6 9 •Assessed by talking with client •How difficult is it to get the client to respond?

•Alert and oriented x 3 •Oriented to person, place, and time

Pupillary Response

N U R S I N G 8 6 9 •Shine light through pupil onto retina •Cranial nerve III stimulated •Observe for pupillary constriction •Observe for accomodation •Pupils: black, round, regular, equal in size, 3-7 mm

Pupils

N U R S I N G 8 6 9 •Cloudy pupil: cataracts •Dilated pupil: glaucoma, trauma, neurologic disorder •Constricted pupil: drug use •Pinpoint pupil: opioid intoxication

PERRLA

N U R S I N G 8 6 9 Pupils equal, round, reactive to light, accommodation

Mucous Membranes

N U R S I N G 8 6 9 •Inside lower lip •Inside cheek •Nares •Conjunctiva •Look at : color, hydration, texture, lesions •Normal : red, smooth, moist, without lesions

Peripheral Pulses

N U R S I N G 8 6 9 •Apply firm pressure with pads of index and middle finger on pulse site without occluding pulse •Measure strength of pulse and equality •Assess carotid, radial, and pedal •Also assess brachial, posterior tibial, and dorsalis pedis

PERIPHERAL PULSES

PERIPHERAL PULSES

Grading

N U R S I N G 8 6 9 •0 – Absent, not palpable •1+- Diminished, barely palpable •2+- Easily palpable, normal pulse •3+ - Full pulse, increased •4+ - Strong, bounding, cannot be obliterated

Capillary refill

N U R S I N G N 8 6 9 •Should test fingers and toes •Press down on nail to compress capillaries •Color goes white, then release •Color should return briskly; < 3 seconds •Document “sluggish” if > 3 seconds

Heart

N U R S I N G 8 6 9 •Review: heart is in the center of the chest, behind and to left of the sternum •Base is at top, apex is the bottom tip •Apex touches anterior chest wall at 5 th medial to left midclavicular line intercostal space •Heart pumps blood through 4 chambers •Events on left side occurs just before those on right •Valves open and close, pressures within rise and fall and chambers contract as blood flows though each chamber

HEART

Cardiac Cycle

N U R S I N G 8 6 9 •Systole: ventricles contract and eject blood from left ventricle into aorta and from right ventricle into pulmonary system •Diastole: ventricles relax and atria contract to move blood into ventricles and fill coronary arteries

Heart Sounds

N U R S I N G 8 6 9 S1: Lub: mitral valve closure S2: Dub: Aortic valve closure APE to Man: Aortic, pulmonic, Erb’s Point, Tricuspid, Mitral

HEART

Lung Sounds

8 6 9 N U R S I N G N U R •Apex and bases opposite from heart: apex at top, bases at bottom •Right lung has 3 lobes, left has two •Angle of Louis where 2 •2 nd intercostal space is below 2 on right nd rib articulates with sternum nd rib and is starting point •Use diaphragm of stethoscope •Inspiration and expiration = one breath •Listen to both in each area •Go from apex to bases comparing side to side

LUNGS

Respiratory Rate

N U R S I N G 8 6 9 •Measure respiratory rate without client’s awareness •After checking radial pulse, keep hand at pulse site and begin counting respirations •Observe depth of respirations •Documentation for normal: lungs sounds clear and equal in all lobes bilaterally

Skin

8 6 9 N U R S I N G •Color •Turgor •Assess for breakdown

Abdomen

N U R S I N G 8 6 9 •Sounds, masses, tenderness •Divide into four quadrants: RUQ, RLQ, LUQ, LLQ •Inspect then auscultate •Bowel sounds: absent, hypoactive, hyperactive •Listen continuously for 5 minutes to determine absence •Palpate and/or percuss after listening •Abdomen should be soft, non-tender, non-distended

ABDOMEN

ABDOMEN

Lower Extremities

N U R S I N G 8 6 9 •Pedal pulses •Foot strength bilaterally •Homan’s Sign •Capillary refill •Edema •Pain

EDEMA

Vital Signs

N U R S I N G 8 6 9 •Temperature •Pulse •Respirations •Blood Pressure

Temperature Sites

N U R S I N G 8 6 9 •Oral •Rectal (one degree higher than oral) •Axillary (one degree lower than oral) •Tympanic •Esophageal •Pulmonary artery •Urinary bladder

Factors

N U R S I N G 8 6 9 •Age •Exercise •Hormone level •Circadian rhythm •Stress •Environment •Temperature alteration

Blood Pressure

N U R S I N G 8 6 9 •Lateral force on walls of artery by pulsing blood under pressure from heart •Maximum pressure with ejection is systolic •Minimum pressure with ventricular relaxation is diastolic •Measured in mm Hg •Normal Adult: 110-140/60-90

Factors affecting B/P

N U R S I N G 8 6 9 •Age – B/P increases with age •Stress •Race – increased in African-Americans •Medications •Diurnal Variation •Gender

Orthostatic Hypotension

N U R S I N G 8 6 9 •Decrease in blood pressure when changing from lateral to upright position •Can be caused by dehydration, anemia, prolonged bedrest, vasodilation from B/P medications •Record B/P and pulse with client lying, sitting, and standing. Obtain readings 1-3 minutes after position change.