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Module 8

Physical Assessment
Health Assessment
Health Assessment involves collecting, validating and analyzing data
Data includes subjective and objective information
We assess in order to document any changes in pt.s health that have occurred.
Double what they say they smoke, triple what they say they drink
Subjective:
My right arm hurts What the patient says is going on
Objective:
Patient is holding right arm close to body and not moving it. What you observe.
Subjective data is collected via personal communication, while objective data is collected via
observations.
Perception is a reality. If a patient says pain is a 10, treat it as a 10. If they say pain is a 2, but is
curled up in a ball and crying, treat it as a 10.
Elements of Personal Communication55% body language
38% voice, tone
7% spoken words
Purpose of Assessment
Determine overall level of physical, psychological, sociocultural, developmental and spiritual
health
Nursing assessment is a holistic collection of information. Looking at the whole being.
Health History
Use of therapeutic communication skills and interviewing techniques
Note verbal and non-verbal communication
Components of a Health History
Biographical Data
Reason for Seeking Care
History of Present Health Concern
Medical History
Family History

Lifestyle
Types of Assessments
Comprehensive Ongoing
Ongoing Partial
Focused- Used most on patients. At the start of every shift, and every four hours.
Emergency
Physical Assessment Preparation
Positioning the patient- listening to lungs- Head elevated 30-45 degrees. Bowel sounds- lie flat
Draping- Do not expose anything you do not have to.
4 Techniques of assessment
Four Techniques (in sequence) - For Lungs
Inspection
Palpation
Percussion
Auscultation

Abdomen is separate

Inspection
Begins with initial patient contact and continues throughout interview
Inspect each area of the body for size, color, shape, position and symmetry.
Bilateral body parts are compared.
Palpation
Uses the sense of touch
- Dorsum
- Palmar
Assess temperature, moisture, turgor, vibrations, shape & texture
Percussion
Act of striking one object against another to produce sounds
Used to assess location, shape, size and density of tissues
Auscultation
Listen with a stethoscope to sounds produced in the body
Use the diaphragm for lower pitched sounds
Use the bell for higher pitched sounds
4 types of sound
- Pitch- High or sonorous
- Volume

- Quality- How easily it is discernable


- Duration- How long do they last?
Physical Assessment
Equipment
-stethoscope
-ophthalmoscope
-otoscope
-Snellen chart- Checks visual acuity
-nasal speculum
-vaginal speculum
-tuning fork
-percussion hammer- Too much Magnesium dulls the reflexes

Check apical pulse-looking for PMI (Point of Maximal Impulse which is the loudest spot) Located midclavicular, fifth intercostal space. Listen for a full minute.

Checking skin
Turgor Elastic
Tented
Cap refill can be checked on an amputee. Press on radial or brachial pulse site and release.
Pallor can be checked on different ethnicities on the crease of the palm, or oral mucosa.
Check respiratory status
Auscultate6 points on front, 9 on back
RateRhythmQuality- Are they struggling?
SOB Short of Breath
DOE - Dyspnea on exertion
Do you have any trouble breathing/on exertion?
Do you have a cough? How long? Do you bring anything up? What does it look like?

Hearing
Drainage?
Hard of Hearing?
Hearing Aid?
WISER- Wash your hands, Introduce yourself, Screen for privacy, Explain the procedure, Raise
the bed.

Symmetry, Symmetry, Symmetry


In the beginning.......
Always ask if the patient is in pain or has other needs that need to be met before beginning a
physical assessment
Private, warm, well-lit exam room
Screen for privacy (proper draping and assist individual with attire)
Describe/Explain procedures
Wash hands with soap & water
Use gloves as needed during exam
General Observations
Appearance
- Note age, race, sex, body build
- Note any deformities/distinguishing characteristics
- Height/Weight- Always with the same wardrobe, before breakfast, after eliminating bowels.
Most hospitals have a routine of what should be on the bed when weighing a patient.
- Vital Signs
Neurological Assessment
Much of this can be done as you are entering the room
Mentation- Cognitive issues
Orientation
Pupil Size- PERRLA
Motor Function Symmetry
Movement of Extremities (MOE) paraplegic/quadriplegic
Speech
Swallowing
Skin Assessment
Skin colors
- Pink/tan/brown
- Pallor (pale)
- Vitiligo (white patchy)

- Jaundice (yellow)
- Erythema (red)
- Cyanosis (blue)

Skin Temperature/Moisture
- Warm & dry
- Cool & clammy
- Hot & moist
- Hot & dry
Inspection of skin
- Ecchymosis- Bruising
- Petechiae- Areas of bleeding under the skin. Pinpoint.
- Wounds
- Wheals/hives- Raised
- Pressure sores
- Vesicles- Raised with clear liquid
- Pustules- Pus in the center
Skin Turgor
Pitting Edema
- 0 (none)
- 1+ (trace 2mm)
- 2+ (moderate, 4mm)
- 3+ (deep, 6mm)
- 4+ (very deep, 8mm)
Head & Neck Assessment
Symmetry, Symmetry, Symmetry!!!!
What is located in the neck?
- Thyroid
- Trachea
- Esophagus
- Carotid arteries
- Jugular vein
- Cranial nerves
- Spinal cord

A good time to ask about glasses and reading abilities


Inspect
- Eyes
- Eyelashes (curl upward)
- Eyebrows (equal distribution)
- Eye lids (Ptosis- When eyelids start to droop)
- Lacrimal glands (tear ducts) (edema & pain)
- Pupils (black, equal in size, round & smooth)
- Iris
Measuring Pupillary Reaction- Brisk, sluggish, or none
Measuring Accommodation
Measuring Convergence
Extraocular Movements
Peripheral Vision
A good time to ask about hearing aids or hearing problems
Ears
- External (note pain, edema, lesions)
- Ear canal (note redness, edema, pain)
- Tympanic membrane (shiny, gray, translucence)
Hearing
- Whisper test/Watch tick
- Weber Test
- Rinne Test
Inspect Nose
- Swelling of mucosa
- Bleeding
- Discharge
- Polyps
- Deviated septum
Palpate sinuses
Inspect Mouth/Pharynx
A good time to ask about chewing/swallowing problems and appetitekeep the patient involved
with the process
- Use penlight, tongue blade, gauze pad, and gloves
- Note teeth, tongue, hard/soft palates, and lips
Palpate trachea/lymph node

Thorax and Lung Assessment


Respirations/oxygenation TABLE 25-6 Adventitious Breath Sounds
- Normal respirations
-bradypnea
-tachypnea
-apnea
-SOB- Activity related
-Dyspnea- Physiological change. Not associated with activity. Associated with respiratory
diseases.
-Wheezing is caused by inflammation. Reaction to an allergen. If not treated, the airways will
collapse, leaving no way for oxygenation. Only help will be bronchodilators.
-Crackles- Expiratory sound. Similar to bubble wrap pops. Bubbling, crackling, popping. Lowto high-pitched, discontinuous sounds. Auscultated during inspiration and expiration. Opening
of deflated small airways and alveoli; air passing through fluid in the airways. Treated with
diuretics.

If you lack enough data or information then you need to assess further

Pain medication contains narcotics which decrease the respiratory drive.

Tachypnea during fever is due to the body trying to push the heat out. It is an adaptive feature.

Anything that has to do with safety has to be prioritized.

Thorax and Lung Assessment


A good time to ask about cough, orthopnea, activity tolerance
Inspection
- Color, shape, contour
Palpation
- Chest expansion, sensitivity, fremitus
Percussion
- Used to detect air, liquids or solids
Auscultation
Patterns used for Palpation, Percussion and Auscultation- page 11 of handout.

The nurse is assessing the clients O2 sat. Factors that may impair accurate measurement of the
pulse ox include? Select all that apply
A.
B.
C.
D.
E.

Respiratory insufficiency- No, the reading will just be low.


Ambient temperature
Client movement
Diabetic neuropathy- Involves the nerves, not the circulatory.
Artificial nails- There are other areas that can be used to check O2 sat.

Cardiovascular Assessment
PMI
Heart rate
Heart Rhythm
Amplitude (Peripheral)
- 0 absent
- 1+ thready
- 2+ weak
- 3+ normal
- 4+ bounding
Normal B/P range
JVD
Capillary refill
Peripheral pulses
Pitting edema
Carotid artery bruits- Gushing sound heard through auscultation
Factors that Increase Heart Rate
Assessment of extremities
Strength
Movement
Range of motion
Nail beds
- Note color, shape, and texture
- Capillary refill< 3 seconds
Abdominal Assessment
A good time to ask about last bowel movement, bowel patterns
Abdomen
(RUQ, LUQ, RLQ, LLQ)
Bowel Sounds- You should hear bowel sounds within one minute of listening. If not heard, listen
for up to five minutes more. The day after surgery bowel sounds should be normal. Hypo sounds

will be infrequent. Wide gap between first and second sounds. Hyper bowel sounds occur when
one is becoming hungry.
Inspect
Auscultate
Percuss
Palpate

Rectal Assessment
Check for hemorrhoids
Vagus nerve considerations- Always have a reason to check. Make sure pt. has no cardiac
conditions.
Older men have larger prostates because they have less sex. The less you use it, the larger it gets.
Genitourinary Assessment
A good time to ask about voiding patterns, dysuria, hematuria
Urine Color/Consistency- The darker the urine, the less volume.
Urine Amount
Incontinence
Urinary retention/suppression
Urine specimen should reach the lab within an hour of collecting.
Musculoskeletal Assessment
Muscle, bones and joints
Atrophy
Hypertrophy
Skeletal deformities
-scoliosis
-kyphosis
-lordosis
ROM
Neurovascular Assessment
Neuro
- tingling
- Numbness
- Pain
Movement
Vascular
- Distal pulse
- Capillary refill

- Skin color
- Skin temperature
- Pain
- Edema

Pain assessment (0-10)


PQRST- What provokes the pain? What is the quality of the pain? Does the pain radiate? What
is the severity of the pain? What is the timing of the pain?
- Location
- Quality
- Duration
Nutritional Assessment
Hair
Skin
Teeth/gums
Anthropometric measurements- Measurement of body parts
Lab Value