Dr. Karima Elshamy. Faculty of Nursing Mansoura University. Egypt
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1 Physical Assessment
2 Dr. Karima Elshamy Faculty of Nursing Mansoura University Egypt
3 Physical Health Assessment Nursing history and physical examination Nurses use physical assessment skills to: Develop (obtain baseline data) and expand the data base from which subsequent phases of the nursing process can evolve To identify and manage a variety of patient problems (actual and potential) Evaluate the effectiveness of nursing care Enhance the nurse-patient relationship Make clinical judgments
4 Except for those occasions when you see a patient specifically to conduct a nursing assessment, the assessment must be integrated into routine nursing care Example: the bath is a perfect time to incorporate assessment skills framework that is used for assessment
5 Subjective data - Said by the client (S) Objective data - Observed by the nurse (O) Nursing Process SOAPIER
6 Preparing for the assessment Explain when, where and why the assessment will take place Help the client prepare (empty bladder, change clothes) Prepare the environment (lighting, temperature, equipment, drapes, privacy See Table for equipment used during assessment
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8 Positioning Positions used during nursing assessment, medical examinations, and during diagnostic procedures: Dorsal recumbent Supine Sims Prone Lithotomy Genupectoral See Table for client positions
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10 Assessment Techniques 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 Develop and use nursing instincts Inspection is done alone and in combination with other assessment techniques
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12 Assessment Techniques Palpation - 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 See Box 28-4, p. 529 to describe characteristics of masses
13 Assessment Techniques 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, filled, or solid See table 28-4, page 530 for percussion notes
14 Assessment Techniques Auscultation - listening to sounds produced by the body Direct auscultation sounds are audible without stethoscope Indirect auscultation uses stethoscope Know how to use stethoscope properly (practice) Fine-tune your ears to pick up subtle changes (practice) Describe sound characteristics (frequency, pitch intensity, duration, quality) (practice) Flat diaphragm picks up high-pitched respiratory sounds best Bell picks up low pitched sounds such as heart murmurs Practice using BOTH diaphragms PRACTICE
15 Complete History and Physical Nursing history is subjective - includes things like biographic data, the chief complaint, source of the data, history of present illness, past medical history, immunization history, allergies, habits, stressors, family history including genogram, patterns of health care, and a review of the body s s systems
16 History of Present Illness HPI is a chronological story of what has been happening Must get details of the problem, therefore must be systematic OLFQQAAT (one system there are others): onset, location, frequency, quality, quantity, aggravating factors, alleviating factors, associated symptoms, treatments tried (include all treatments - Rx, OTC, herbal, folk) Lots of systems find one that works, and use it
17 Use whatever system works for you, but use a system pain intensity scales, etc Pain, quality/quantity, radiation, setting, timing Rate pain from 1 to 10 Use age appropriate tools (faces) Culturally appropriate care
18 Exam Order and Documentation Date and identifying data - name, age, sex, race, place of birth (if pertinent), marital status, occupation, religion Source and reliability of history Chief complaint = reason for visit
19 Order & Documentation FH - age and health of parents and siblings or cause of death (genogram); HTN, DM, CVD, Ca, HA, arthritis, addictions ROS (subjective head-to to-toe toe review) General - recent wt. change, fatigue, fever Skin - rashes, lesions, changes, dryness, itching, color change, hair loss, change in hair or nails Eyes - change in vision, floaters, glasses, HA, pain
20 ROS Order & Documentation Ears - pain, loss of hearing, vertigo, ringing, discharge, infections Nose and sinuses - frequent colds, congestion, HA, nosebleed Mouth and throat - condition of teeth and gums, last dental visit, hoarseness, frequent sore throats Neck - lumps, stiffness, goiter Breasts - lumps, pain, discharge, BSE
21 Order & Documentation ROS Respiratory - cough, sputum, wheezing, asthma, COPD, last PPD, last CXR, smoking history (can do here, or with habits ) Cardiac - heart trouble, chest pain, SOB, murmur, h/o rheumatic fever, past EKG, FH of heart disease <50 yrs of age GI - problems swallowing, heartburn, vomiting, bowel habits, pain, jaundice Urinary - frequency, incontinence, pain, burning, hesitancy, nocturia, polyuria
22 ROS Order & Documentation Genitalia - lesions, discharge, sexual orientation, sexual function, menstrual history, contraception, pregnancy history, TSE Peripheral vascular - intermittent claudication, varicose veins, blood clots MS - muscle or joint pain, redness, stiffness, warmth, swelling, family history Neuro - fainting, blackouts, seizures, weakness
23 ROS Order & Documentation Endocrine - sweats, skin change, heat or cold intolerance, excessive thirst (polydipsia), excessive urination (polyuria), weight change, menstrual changes Psychiatric - mental illness, thoughts of harming self or others All of ROS is subjective; ; PE is objective
24 Complete H&P - Objective History is subjective; Physical assessment is objective Objective portion of exam begins with the general survey; ; Each body system reviewed in text has nursing history at the beginning of the procedure for the objective exam In actual practice, you get most of the history before ever touching the client, but there are usually additional history questions to ask during the exam
25 Order of exam - head to toe in systematic order Order of techniques - IPPA (Inspection, Palpation, Percussion, Auscultation) Be systematic, but be flexible based on patient s s needs When might you change order of exam? In practice, you often will do focused PE - examine only the pertinent parts PRIORITIZE (ABC s, Maslow)
26 General Survey General appearance, gait, nutrition status (NOT to be confused with nutrition history), state of dress, body build, obvious disability, speech patterns, affect (mood), hygiene, body odor, posture, race, gender, height, weight, vital signs Height up to age 2 is recumbent Add head circumference if child is less than 2 years old
27 Integumentary System Integument includes skin, hair, and nails Inspect: skin color and uniformity of color, moisture, hair pattern, rashes, lesions, pallor, edema Palpate: temperature, turgor, lesions, edema Percussion and auscultation: rarely used on skin Terminology: pallor, cyanosis, edema, ecchymosis, macule, papule, cyanosis, jaundice, types of edema, vitiligo, hirsutism, alopecia, etc.
28 Integumentary System Hair - texture, distribution, scalp, critters Nails - inspect and palpate Why palpate? Cyanosis - is it true or d/t cold? Blanch test (aka capillary refill or CFT): delayed return of color indicates poor arterial circulation Clubbing - loss of normal angle between nail and nail bed d/t chronic oxygen deprivation Skin know terminology, draw diagrams, take pictures
29 HEENT Head - inspection and palpation Size, shape, symmetry Eyes - inspection and palpation Inspect and palpate lids, lashes, inspect eye position and symmetry and position, symmetry and size of pupils Visual acuity with Snellen chart 20/20 - first number (numerator) is distance from chart Second number is distance at which a normal eye could have read that line (OU, OD, OS) Always record if tested cc (with correction)
30 Eyes Visual acuity (Snellen for distance, Rosenbaum for near vision) Visual fields - assess peripheral vision EOMs - checks 6 ocular movements; tests CN 3, 4, and 6 Pupil response to light and accommodation; Pupils constrict o light, and also to accommodate for near vision (dilate for dimness and distance) Direct and consensual pupil response Corneal light reflex - checks eye alignment Fundoscopic exam - ophthalmoscope Terminology - myopia, presbyopia, ptosis, etc
31 Ears Inspection and palpation Inspect size, shape, position, discharge, lesions Palpate for tenderness, any lesions Review anatomy of ear and inner ear Gross hearing acuity: normal voice, whisper test, Weber and Rinne Internal ear (behind tympanic membrane) otoscope can look through TM
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33 Nose and Sinuses Inspection, palpation, percussion Inspect color of mucosa, presence of discharge There is a nasal speculum most people don t t like it Assess for patency Palpate for tenderness Percuss for tenderness over frontal and maxillary sinuses (Procedure 28-8) 8)
34 Mouth and Throat Inspection, palpation, auscultation Inspect and palpate lips, tongue, oral cavity, tonsils, pharynx (color, moisture), teeth, breath, presence of exudate, erythema, lesions, palate Read differences in oral exam for elderly clients Enlarged tonsils are graded Grade 1 wnl Grade 2 tonsils b/w pillars and uvula Grade 3 tonsils touching uvula Grade 4 tonsils touching each other (kissing tonsils)
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36 Throat and Neck Inspect and palpate neck for trachea (should be at midline), thyroid, lymph nodes Auscultate carotids for bruits (bell) If bruit is heard, palpate for carotid thrill Palpate one side at a time Perform ROM on neck (active and passive)
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39 Assess size and shape of thorax Look for deformities (Fig , p. 574) Barrel chest from asthma or COPD Presence of supernumery nipples For efficiency, you usually assess posterior chest first Intercostal spaces (ICS) are names according the rib they lie beneath 4 th rib lies superior to 4 th ICS Posterior, you have to count spinous processes to name ribs and ICSs
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42 Lungs Inspect, Palpate, Percuss (normal note is resonance), Auscultate (normal is clear and equal bilaterally) Auscultate using diagram Assess and document respiratory rate, rhythm, and effort
43 Respiratory Terminology Eupnea Tachypnea Bradypnea Apnea Hyperventilation Hypoventilation Dyspnea
44 Respiratory Warning Signs Anxious expression Suprasternal & intercostal retractions Nasal flaring Circumoral cyanosis Hyperexpanded chest ALWAYS REMEMBER YOUR ABCs
45 Breath Sounds Auscultate using diaphragm, use a systematic approach, compare each side to the other,, document when and where sounds are heard Normal breath sounds: bronchovesicular, bronchial, and vesicular Abnormal breath sounds are called adventitious sounds
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48 Breath Sounds Stridor - may be heard without stethoscope, shrill harsh sound on inspiration d/t laryngeal obstruction Wheeze - may be heard with or without stethoscope (document which), high-pitched squeaky musical sound; usually not changed by coughing; Document if heard on inspiration, expiration, or both; May clear with cough Noise is caused by air moving through narrowed or partially obstructed airway Heard in asthma or FBA
49 Breath Sounds Crackles - heard only with stethoscope (formerly called rales): fine, medium, coarse short crackling sounds (think hair); May clear with cough Most commonly heard in bases; easier to hear on inspiration (but occurs in both inspiration and expiration)
50 Breath Sounds Gurgles - heard only with stethoscope (formerly called rhonchi): Low pitched, coarse wheezy or whistling sound - usually more pronounced during expiration when air moves through thick secretions or narrowed airways sounds like a moan or snore; best heard on expiration (but occur both in and out)
51 Friction rub Grating, creaking, or rubbing sound heard on both inspiration and expiration; not relieved by coughing; due to pleural inflammation Document breath sounds as clear, decreased or absent, compare right to left, and describe type and location of any adventitious sounds CTAB or BBS cl + = NOT BS clear (BS could be bowel sounds.)
52 Breasts and Axillae Inspection and palpation Instruct female clients to perform BSE q month Men have some glandular tissue beneath nipple; women have glandular tissue throughout breast and into axilla Largest portion of glandular tissue in women in in upper outer quadrant See breast health guidelines Inspect for symmetry, contour (shape), look for any areas of hyperpigmentation, retraction or dimpling, edema Palpate breasts, areolae, nipples and axillary lymph nodes in both men and women Be sure to include tail of Spence
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54 Any Questions?
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