Anda di halaman 1dari 9

Physical Assessment A dynamic health assessment is the foundation of all nursing care and physical assessment is part of every

holistic health evaluation. A complete yet organized assessment is obtained by using a combination of head-to-toe and body-systems approach in conjunction with the use of the four basic techniques, inspection, palpation, percussion, auscultation (IPPA). IPPA and IAPePa Inspection - cephalocaudal: adults - proximo-distal: child Palpation - light: 1-2 cm - deep: 4-6 cm, not beyond 10 cm Percussion - direct: plexor - indirect: pleximeter and plexor - blunt: wider (kidney punch) Auscultation IPPA/IAPePa Inspection Auscultation Percussion Palpation y dorsal recumbent y 5-35 per minute IPPA and IAPePa Measurements and Overall Observation General Appearance BMI: 19-25 Skin the largest organ system of the body Pallor Anemia decreased hematocrit Shock decreased perfusion, vasoconstriction,Local arterial insufficiency Albinism total absence of pigment melanin Vitiligo a condition characterized by destruction of the melanocytes in circumscribed areas of the skin (may be localizedor widespread) Skin Cyanosis Increased amount of unoxygenated hemoglobin: Central chronic heart and lung disease cause arterial desaturation Peripheral exposure to cold, anxiety Jaundice Increased serum bilirubin concentration (>2 3 mg/100 mL) due to liver dysfunction or hemolysis, as after severe burns or some infections Carotenemia increased level of serum carotene from ingestion of large amounts of carotene-rich foods

Uremia renal failure causes retained urochrome pigments in the blood Skin Erythema Hyperemia increased blood flow through engorged arterial vessels, as in inflammation, fever, alcohol intake, blushing Polycythemia increased red blood cells, capillary stasis Carbon monoxide poisoning Venous stasis decreased Skin Primary Lesions Macule: Flat, nonpalpable skin color change <1 cm in diameter (e.g., freckle) Patch: Flat, nonpalpable skin color change >1 cm in diameter (e.g., vitiligo, stage 1 of pressure ulcer) Papule: solid, elevated lesion <0.5 cm in diameter (e.g., elevated nevi) Plaque: solid, elevated lesion >0.5 cm in diameter (e.g., psoriasis) Wheal: Elevated mass with transient borders caused by movement of serous fluid into the dermis (e.g., urticaria, insect bites) Nodule: Elevated, palpable, solid mass; extends deeper into the dermis than a papule, 0.5 2.0 cm (e.g., erythema, cyst) Tumor: >1 2 cm; tumors do not always have sharp borders Vesicle: elevated mass containing serous fluid accumulation, <0.5 cm (e.g.,herpes simple and zoster, chickenpox, second-degree burns) Bullae: same as vesicle only >0.5 cm (e.g., contact dermatitis, large second-degree burns, bulbous impetigo, pemphigus) Pustule: pus-filled vesicle or bullae, <0.5 cm in diameter (e.g., acne,impetigo) Cyst: subcutaneous or dermis mass Skin Secondary Lesions Scales: flaking of the skin s surface (e.g., dandruff, psoriasis) Crust: dried serum, blood, or pus on skin s surface (e.g., residue after vesicle- herpers) Atrophy: thinning of skin surface and loss of markings (e.g., aged skin) Erosion: loss of epidermis (e.g., ruptured chickenpox vesicle) Fissure: linear crack in the epidermis that can extend into the dermis (e.g., chapped hands or lips, athlete s foot) Ulcer: Skin loss extending past epidermis Scar (Cicatrix): Skin mark left after healing of a wound or lesion;Young scars: red or purple; Mature scars: white or glistening Keloid: Hypertrophied scar tissue; Elevated, irregular, red Lichenificatio/Callus: Thickening and roughening of the skin; May be secondary to repeated rubbing, irritation, scratching (e.g., contact dermatitis) Skin Vascular Lesions Petechia: Round red or purple macule; Small: 1 2 mmAssociated with bleeding tendencies or emboli to skin Ecchymosis: Round or irregular macular lesion; Larger than petechia; Color varies and changes: black, yellow, and green hues; Associated with trauma, bleeding tendencies

Spider Angioma: Red, arteriole lesion; Central body with radiating branches; Noted on face, neck, arms,trunk; Associated with liver disease, pregnancy, Vitamin B deficiency Telangiectasia (Venous Star): Shape varies: spider-like or linear; Color bluish or red; Associated with increased venous pressure states (varicosities) Hair Thick, evenly distributed Except for the palmar and plantar surfaces, lips, nipples, and the glans penis Vellus: Fine, unpigmented hair that covers most of the body Terminal hair: Coarser, darker hair of scalp, eyebrows, and eyelashes; axillary and pubic hair becomes terminal with the onset of puberty Alopecia vs. Hirsutism; Thin, brittle hair occurs with hypothyroidism Nails Normal nail: Has an angle of approximately 160 between the fingernail and nail base; nail feels firm when palpated. Nails Clubbing: Hypoxia causes an angle greater than 180 between the fingernail and nail base; nail feels springy when palpated. Koilonychia (Spoon nail): Characterized by concave curves;associated with iron deficiency anemia. Beau s line: Characterized by transverse depression in the nails; associated with injury and severe systemic infections. Paronychia: Characterized by an inflammation at the nail base (may be swollen, red, or tender); associated with trauma and local infection. Face COMMON ABNORMAL FACES Exophthalmos - protrusion or bulging of the eye that results from an increased pressure in the eye s orbit Acromegaly - elongated head with prominent forehead, nose, and lower jaw and enlarged nose, lips, and ears; excessive growth hormone. Cushing s syndrome - round or moon face with excessive hair growth (mustache and sideburns);excessive production of adrenal hormones or in clients taking adrenal hormone medications. Clients with chronic renal failure have pale, swollen tissue around their eyes. Parkinson s disease causes decreased facial mobility and expressions, producing a masklike face; results from progressive, degenerative, neurologic disorders. Eye COMMON REFRACTIVE ERRORS Myopia (nearsightedness): elongation of the eyeball or an error of refraction that causes the parallel rays to focus in front of the retina. Hyperopia (farsightedness): an error of refraction in which rays of lightentering the eye are brought into focus behind the retina. Presbyopia: an error of refraction resulting from a loss of elasticity of the lens of the eye. Astigmatism: an unequal spherical curve of the cornea that prevents the light rays from being focused directly in a point on the retina.

Eye N: 20/20 Legally blind: 20/200 PERRLA (pupils equal, round, reactive to light and accommodation) Pupil should constrict quickly in direct response to light and the opposite pupil should also constrict. Pupils should be equal in size. Pupillary accommodation causes constriction in response to objects that are near, and dilation occurs to accommodate distant. Ear Symmetrical, with upper attachment at level of eye s corner (lateral canthus), flesh color.Cerumen, a waxy yellow or brown substance is normal. Ear canal is pinkish and dry. Intact tympanic membrane;translucent or pearly gray. Hearing Loss Ear Weber test: (1) Strike tuning fork against your fist or pinch the prongs together. (2) Hold the base of the vibrating fork with your thumb and index finger and place the base of the fork on center of top of client s head (3) Ask client to describe the sound. (4) Record results. Sound perceived equally in both ears; results indicate a negative Weber test. Ear Rinne test: (1) Vibrate prongs of tuning fork and place base of fork on mastoid process of ear being tested and note the time on your watch until the client no longer hears sound (2) Move the vibrating fork in front of the ear canal, noting the length of time sound is heard (3) Record results. (4) Repeat test, opposite ear. Sound heard longer in front of the auditory meatus than on the mastoid process because air conduction is twice as long as bone. Nose Located symmetrically, midline of the face and is without swelling, bleeding, lesions, or masses. Patent nares. A small amount of clear watery discharge is normal. Rhinitis, red, swollen mucosa with copious clear, watery discharge occurs with a cold. Discharge becomes purulent if a secondary bacterial infection develops. Pale, edematous mucosa with clear, watery discharge occurs with allergies. A normal mucosa with clear, watery nasal discharge that tests positive for glucose following head injury or nasal, sinus, or dental surgery usually indicates the leakage of cerebrospinal fluid. If present, stop the exam and notify the nursing supervisor immediately. Mouth COMMON ABNORMAL BREATH ODORS Halitosis Acetone breath ( fruity smell) is common in malnourished or diabetic clients with ketoacidosis. Musty smell is caused by the breakdown of nitrogen and presence of liver disease.

Ammonia smell occurs during the end stage of renal failure from a buildup of urea. Mouth COMMON TONGUE ABNORMALITIES Enlarged tongue may indicate glossitis or stomatitis or may occur with myxedema or acromegaly. Deep red, smooth surface occurs with glossitis caused by Vitamin B12, iron, or niacin deficiency or as a side effect from chemotherapy. Thick white coating with red, raw surface is Candidiasis (thrush) indicating immunosuppression. Mouth COMMON LIP LESIONS Herpes simplex (cold sores or fever blisters) are painful vesicular lesions that rupture and crust over. Chancre (primary lesion of syphilis) is a reddish round, painless lesion with a depressed center and raised edges that appears on the lower lip. Squamous cell carcinoma (most common form of oral cancer) usually involves the lower lip and may appear as a thickened plaque, ulcer, or warty growth. Neck and Throat Muscles are symmetrical with head in central position. Movement through full range of motion without complaint of discomfort or limitation. Lymph nodes should not be palpable. Small, movable nodes are insignificant. No distention of Jugular veins with head of bed elevated 45 to 60 degrees. Thyroid cannot be visualized. It should be smooth, soft, non-tender, and should not be enlarged. Chest (LUNGS) Respirations are quiet, effortless, and regular, 12 20 breaths per minute. Thorax rises and falls in unison with respiratory cycle. Ribs slope across and down, without movement or bulging in the intercostal spaces. Eupnea Bradypnea Tachypnea Hypoventilation Hyperventilation Apnea Cheyne-Stokes- regular cycle where the rate and depth of breathing increase, then decrease until apnea (usually about 20 seconds) occurs Biot's respiration- periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10 seconds to 1 minute) Chest (LUNGS) Normal Sounds: Over lung fields: Vesicular : Over main bronchi (1st& 2nd ICS): bronchovesicular Over trachea: tracheal

Over manubrium: bronchial Normal Values: Tidal Volume = 500 ml the volume of air inhaled and exhaled with each breath Vital Capacity = 4, 600 ml the maximum volume of air exhaled from the point of maximum inspiration Total Lung Capacity = 5, 800 ml the volume of air in the lungs after a maximum inspiration Chest (LUNGS) Abnormal (Adventitious) Breath Sounds Crackles/Rales: fluid or mucus Rhonchi/Gurgles: loud, harsh sound with snoring or moaning quality; narrowed air passages (tumor, secretions, swelling) Stridor Wheezes Pleural friction rub: grating Chest Breast BSE performed monthly by women age 20 years and older. From ages 20 to 40, examination every 3 years by a practitioner and yearly after 40 years of age. Regardless of age, women with a family history should have a yearly examination by a practitioner. A baseline mammogram should be performed for women aged 35 to 39. The frequency of diagnostic mammograms is determined by family history and symptoms: yearly for women 35 years of age with a family history and yearly for all women over 40 years of age Abdominal Contour is flat or rounded and bilaterally symmetrical. Umbilicus is depressed and beneath the abdominal surface. Abdomen rises with inspirations and falls with expirations, free from respiratory retractions. Tympany is heard because of air in the stomach and intestines. Dullness is heard over organs (e.g., the liver). External Genitalia FEMALE Skin over the mons pubis is clear except for nevi and hair distribution. The labia majora and minora are symmetrical, with a smooth to wrinkled, unbroken, slightly pigmented skin surface, free from ecchymosis, excoriation, nodules, swelling, rash, and lesions. External Genitalia MALE TS E Foreskin retracts easily. Glans penis varies in size and shape. The meatus is centrally located and pink. Scrotal skin appears rugated and thin and hugs the testicles firmly in the young male and becomes elongated and flaccid in the elderly. The left scrotal sac is lower than the right.

Testicles are sensitive to pressure, firm, ovoid, smooth, and equal in size bilaterally. The epididymis should be distinguishable from the testicle, and the spermatic cord feels smooth and round. Musculoskeletal System Range of Motion A goniometer is a protractor with two movable arms used to measure the angle of a skeletal joint during range of motion. Musculoskeletal System Muscle strength 5 full range of motion against gravity and resistance 4 full range of motion against gravity and a moderate amount of resistance 3 full range of motion against gravity only 2 full range of motion when gravity is eliminated 1 a weak muscle contraction when muscle is palpated, but no movement 0 complete paralysis Neurological System Reflexes are graded on a scale of 0 to 4: 0 No response 1+ Diminished (hypoactive) 2+ Normal 3+ Increased (may be interpreted as normal) 4+ Hyperactive (hyperreflexia)

Vital Signs Temperature Normal Fever/Pyrexia -Intermittent -Remittent: fluctuations within a 24hrs -Relapsing: 1-2d -Constant Hypothermia Pulse The measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta Warm the bell of the stethoscope with your hands prior to placing it on the client s chest. Take a carotid pulse on only one side of the neck at a time in order to prevent cerebral blood flow impairment When taking pedal pulses, a firm touch is generally preferable to reduce any tickling sensations. A Doppler device may be necessary to detect a pulse on elderly or obese clients.

Do not palpate a pulse site with your thumb because your own pulse may be felt. Respiration The measurement of the breathing pattern Infants and children: count a full minute. Adults: count for 30 seconds and multiply by - If an irregular rate or rhythm is present, count for one full minute. Observe character of respirations: Depth of respirations by degree of chest wall movement (shallow, normal, or deep) Rhythm of cycle (regular or interrupted) Blood pressure the pressure exerted on the walls of the arteries during ventricular systole and diastole Hypotension is defined as a systolic blood pressure less than 100 mm Hg or 20 to 30 mm Hg below the client s normal systolic pressure Orthostatic hypotension or postural hypotension refers to a sudden drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when the client moves from a lying to a sitting position or from a sitting to a standing position Hypertension refers to a persistent systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg Blood pressure Do not take an apical blood pressure on an arm with an AV shunt, IV, or if the client has a history of surgery or injury to the breast, axilla, or arm. False high readings occur when the mercury column in the manometer is not positioned flat on a firm surface, when it is read above eye level, or when the extremity is below the heart s apex level. False low readings occur when the extremity is above the heart s apex level, when the cuff is too wide for the extremity, or when the mercury column in the manometer is read below eye level. Weighing Weigh clients at the same time each day to enhance accuracy. Weigh clients in similar clothing each time to avoid unnecessary discrepancies. Collecting a Urine Specimen Measuring Blood Glucose Levels Lateral aspect of the fingertips Wipe away the first drop of blood from the site. This drop may impede accurate results because it may contain a large amount of serous fluid. Transfer the drop of blood to the reagent strip by carefully moving the site over the strip. The droplet should transfer without smearing Measuring Blood Glucose Levels Collecting Sputum Specimens Have the client take several deep breaths and then cough deeply. Have client expectorate the sputum into the sterile cup without touching the inside of the cup. Unable to expectorate: Obtain a sterile suction catheter and an inline sputum collection container. Hook the suction catheter to the sputum collector. Insert the catheter either orally or nasopharyngeally into the back of the throat and suction the sputum into the specimen container.