The Nursing Physical

Assessment

Health\Medical History
2

Provides guidance for care

Includes subjective and objective

data

Nursing Health History

3

Biographical Information
Chief complaint/ reason for seeking

care
History of present illness
Perception of health status
Expectations for care
Past medical history

Nursing Health History

4

Family history
Social history
Medications
Complementary therapies
Review of systems
Functional abilities

The Nursing Physical Assessment

5

Used to gather data about the

patient
Focuses on functional abilities

and responses to illness/stressors

Purposes of Physical Assessment

6

Identify nursing diagnoses and

collaborative problems
Monitor the status of an
identified problem
Screen for health problems
Evaluate nursing care

Types of Physical Assessments

7

Comprehensive
Focused
Ongoing
Emergency

Preparing for the Assessment

8

Develop rapport
Explain the procedure
Respect cultural differences
Use proper positioning and draping
Promote comfort
Provide privacy
Limit noise
Enable visualization

Integration of Assessment
9

Integrate exam during routine

nursing care
Vital

signs
Bathing
Range of motion
Activities of daily living

Inspection
10

Uses vision to assess data

Recognizes normal and

abnormal
Used throughout physical
examination

Facial Droop
11

Palpation
12

Use of touch to gather data

Use different parts of hands to

distinguish texture, temperature

and movement
Hands should be warm, wear
gloves, fingernails should be
short
Light palpation to deep palpation

Palpation
13

Percussion
14

Tapping on skin to elicit sound

Sound

determines location, size,

and density of structures

Direct and indirect techniques

Useful for assessing abdomen,

lungs, underlying structures

Percussion
15

Auscultation
16

Listening to sounds to gather data

Direct and indirect techniques
Requires a good stethoscope
Diaphragm

- high-pitched sounds
Bell low-pitched sounds

Requires concentration and

practice

Auscultation
17

Olfaction
18

Using the sense of smell to gather

data
Not typically considered a formal
assessment skill
Still useful in the clinical setting

Assessment Parameters for Older Adults

19

Basic Activities of Daily Living (ADL)

Bathing,

Dressing, Grooming, Eating,

Continence, Transferring

Instrumental Activities of Daily Living

(IADL)
Meal

preparation, Shopping, Medication

Administration, Housework,
Transportation, Accounting, Mobility,
Ambulation, Pivoting

Older Adult
20

May need special positioning related

to mobility
Adapt examination to vision and
hearing changes
Assess for change in physical ability
Assess for ability to perform activities
of daily living
Provide periods of rest as needed

Aspects of the General Survey

21

Appearance/behavior/affect
Body type/posture
Speech
Grooming/hygiene
Vital signs
Height/weight/BMI

Head to Toe Assessments

22

Neurological
Skin
HEENT
Cardiovascular (CV)/Peripheral vascular (PV)
Respiratory
Gastrointestinal (GI)
Genitourinary (GU)
Musculoskeletal
Include safety/environment/needs & concerns

Basic assessment responsibilities

23

Neuro

LOC-Level or Loss of Consciousness

Orientation
Emotional/behavioral
PERRLA-Pupil equal round reactive to light & accommodation
Grips/pushes/pulls
Intro to cranial nerves

Complete Neuro Assessment

24

Cerebral function (mental status)

Cranial nerves
Reflexes
Sensory function
Motor and cerebellar function

Cerebral Function
25

Level of consciousness (LOC)

Arousal
Orientation

_______________________________
_______________________________
_______________________________

Mental status
Communication

Cerebral Function: LOCLevel of Consciousness

26

Alert

Vigilantly attentive, keen

Lethargic

Drowsy, sluggish, half asleep

Obtunded

Mentally dulled, responds slowly, decreased interest

Stuporous

Near unconsciousness, reduced ability to respond

Coma

Unconscious, unresponsive

Cerebral Function: LOCGlasgow Coma Scale (GCS)

27

Three parameters of consciousness

Eye

opening
Verbal response
Motor response
High Score: 15 (fully alert & oriented)
Score of 8 or less reflects coma

28

Cerebral Function: Mental Status/Cognitive Function

29

Behavior
Mood/affect
Speech
Memory
Thought processes
Judgment/Insight

Cranial Nerves
30

I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII

Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Auditory (Vestibulocochlear)
Glossopharyngeal
Vagus
Accessory
Hypoglossal

Fun Way to Remember

31

Assessment of Sensory Function

32

Patient keeps eyes closed as you apply

various stimuli
Have pt indicate when he/she feels
sensation
Vary location and approach
Usually test upper and lower extremities
and trunk

Motor/Cerebellar Function
33

Movement/coordination
Tone
Posture
Equilibrium

Neuro Related Data

34

Headache
Head Injury
Dizziness/Vertigo
Seizures
Tremors
Uncoordinated
Numbness or

tingling

Weakness
Difficulty swallowing
Difficulty speaking
Significant history
Environmental/

occupational hazards

Abnormal Neuro Findings

35

Cerebral Function
Cranial nerves
Reflexes
Sensory function
Motor & Cerebellar Function

Gait
Grips/pushes/pulls

Skin
36

Skin
37

Membrane barrier
Responds to changes
Gives clues about our general state of health
Largest body organ

Why do a Skin Assessment?

38

Can tell us about

Local

problems
Systemic problems
Gives data about
Patients

health

Hygiene
Nutritional

habits

Skin Assessment
39

Inspect and Palpate

Note:
Color
Temperature
Moisture
Texture
Vascularity
Lesions
Distinguishing marks
Turgor
Edema

Skin Assessment: Color

41

Expected findings
Uniform

color
Mucous membranes and conjunctiva are pink
and moist
Abnormal findings
Pallor
Jaundice
Cyanosis
Erythema

Skin Assessment: Temperature

42

Assess with dorsum of hand

Compare right & left sides
Compare temperatures of hands & feet
Should be warm but consistent with room

temp & activity level

Skin Assessment: Moisture

43

Normally skin is warm and dry

Excessive moisture
Hyperthermia
Anxiety
Overactive

thyroid

Dry skin
Dehydration
Hypothyroidism

Skin Assessment: Texture

44

Usually smooth and soft

Factors affecting texture:
Exposure
Age
Endocrine

disorders
Impaired circulation

Skin Assessment: Vascularity

45

Inspect for bleeding/bruising

May indicate various systemic problems
Cardiovascular
Hematologic
Liver

Problems r/t Vascularity: Ecchymosis

46

Extravasation

(leakage) of blood
into the skin or
mucous membrane
Purple discoloration
Ecchymosis

Problems r/t Vascularity: Petechia

47

Small hemorrhagic

spots caused by
capillary bleeding
Common in blood
clotting disorders
Petechiae

Skin Assessment: Lesions

48

Normal variations
Moles
Freckles
Birthmarks
Skin

tags
Striae- stretch marks

Skin Assessment: Lesions (cont.)

49

Abnormal Lesions
Primary

Result of disease or irritation

Ex. Acne

Secondary

Develop from primary lesions as a result of continued

illness, exposure, or infection
Ex. Crust that forms from ruptured pustules

Skin Assessment: Lesions (cont.)

50

Assess
Size
Shape
Pattern
Color
Distribution
Texture
Exudate
Pain
Itching

Skin Assessment: Lesions (cont.)

51

Describe lesions in terms of:

Type
Size
Elevation
Coloring
Presence

of drainage

Itching

MANY different skin lesions-Dont diagnose;

just describe

Abnormal Skin Lesions: Contusion

52

Bruise
Caused by blunt force

trauma
Injury where skin is
discolored, but not
broken
Contusion

Abnormal Skin Lesions: Rash

53

Change in skin which

affects its color,

appearance, or
texture
May be localized or
may affect all skin
Usually itchy
May blister
Rash

Abnormal Skin Lesions: Abrasion

54

Superficial damage to

skin
Generally not deeper
than the epidermis
Often occurs when
exposed skin comes
into moving contact
with a rough surface

Abrasion

Skin Assessment: Turgor

55

Degree of skins resistance to deformation

Determined by factors
___________
___________
Tested on back of hand or over sternum

Normal turgor
Skin

rapidly snaps back into position

Tenting
Skin

takes time to return to normal position

Testing Skin Turgor

56

Skin Assessment: Edema

57

Swelling caused by excessive amt of fluid in

tissues
Pitting edema:
+1

trace-2mm depression
+2 moderate-4mm depression
+3 deep-6mm depression
+4 very deep-8mm depression

Example of Edema called Acities

58

Pitting Edema
59

Pitting Edema
60

Gravitational
Will

develop in
dependent areas of
the body
What does that
mean for the
bedridden pt?
Pitting Edema

Nails
61

Color
Angle of Nail Bed
Texture
Smooth,

spongy

Capillary Refill
Measures

amount of
blood flow to tissue
Normal is less than
3 seconds

Measuring Capillary Refill

62

Clubbing
63

Abnormal Nail Findings

64

Zinc Deficiency

Iron Deficiency

Head and Neck

65

Head
66

Inspect head for:

Size
Shape
Facial

features
Lesions
Palpate for:
Nodules
Tenderness
Lesions

Hair
67

Color
Quality
Soft,

shiny, brittle

Quantity
Thick,

thinned

Texture
Coarse,

fine

Distribution

Neck
68

Inspect for flexion

and extension
Inspect and Palpate
Lymph

nodes
Thyroid enlargement
Carotid pulses
Trachea position

Lymph Nodes
69

Inspect and Palpate

for:
Enlargement
Warmth
Tenderness

JVD (Jugular Vein Distention)

70

Eyes
71

Structures of the Eye

72

Eyes
73

Inspect:
Eye

lids
Conjunctiva
Iris
Sclera
Cornea
Pupils

Pupils
74

PERRLA

Pupil constriction

Consensual Reaction

75

Eye Assessment
76

Field of Vision
Normal Conjunctiva

Visual Acuity

Eye Assessment
77

Gross Vision assessed with Snellen Chart

Visual Field
78

Ears
79

Ears
80

Inspect and Palpate:

Alignment
Auricles

Hearing

Otoscope
81

Nose
82

Nose
83

Inspect:
Shape
Symmetry
Septum
Mucosa

Palpate:
Sinuses

Palpate Sinuses
84

Nose Abnormalities
85

Nasal Polyp
Deviated septum
No septum
Associated

with drug use

Nasal Polyp
86

Deviated Septum
87

Throat and Mouth

88

Throat and Mouth

89

Inspect:
Breath

odor
Buccal mucosa, Lips,
Gums, Teeth, Palate,
Tonsils, Uvula, and
Throat
Clients ability to move
tongue
Clients ability to
pronounce sounds

Throat and Mouth

90

Assessing tongue
Normal Gums

Assessing Palate

Abnormal Findings for the HEENT

91

Tenderness or lesions to head, face, neck,

mouth
Asymmetry of facial features
Uneven or abnormally large or small pupils
Sinus tenderness
Hearing or vision loss

Cardiovascular & Peripheral

vascular
92

The Heart
93

Base & Apex

94

Cardiac anatomy
95
4 chambers
Right and left atria
Right and left ventricles
3 layers
Endocardium
Myocardium
Epicardium
Heart valves

Atrioventricular valves (A-V)

Tricuspid
Mitral

Semilunar valves

Pulmonic
Aortic

Heart Valves
96

Data Collection
98

Chest pain/tightness?
SOB?
Fatigue?
Cyanosis or pallor?
Cardiac history?
Family history?
Edema
Medications?
Cardiac risk factors?

Inspection
99

Neck
JVD
Extremities
Edema
Clubbing
Cap refill
Chest
Apical impulse (PMI)

Edema
100

Clubbing
101

Capillary refill test

102

Palpation
103

Pulses
Apical impulse
Assess for pulsations, thrills, heaves

Palpate Apical Impulse

104

Auscultation
105

Heart sounds
Use

diaphragm and bell of stethoscope

S1 & S2
Lub-Dub
Carotid artery
Use bell of stethoscope

Patient Positioning for Auscultation

106

Supine
Left lateral
Sitting up leaning forward

Where to Listen for Heart Sounds

107

AORTIC

2 ICS, R

PULMONIC

-5ICS, L

MITRAL

Enjoy

-3ICS, L

TRICUSPID

People

2ICS, L

ERBs Point

All

5ICS,LMCL

Time
Magazine

Abnormal Heart Sounds

109

Murmurs

Blowing or swooshing sound occurring with blood flow in the

heart (valve mechanics)

Friction rub

High pitched, scratchy, like sandpaper

Prosthetic heart valves:

Click or ping

S3 and S4

Pulses
110

Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Pedal (Dorsalis Pedis)

Peripheral Pulses
111

Tells us about arterial blood supply to extremities

Characteristics

Rate
Rhythm
Amplitude
Symmetry

Carotid Pulse
112

Brachial Pulse
113

Radial Pulse
114

Femoral Pulse
115

Popliteal Pulse
116

Posterior Tibial Pulse

117

Pedal Pulse
118

Assessment of Peripheral Perfusion

119

Evaluate
Color
Clubbing
Capillary refill
JVD
Skin temperature
Edema
Ulcerations
Hair distribution

Assessment of Peripheral Perfusion (cont.)

120

Homans sign
An

indicator of deep venous thrombosis (DVT)

Present when passive dorsiflexion of the foot
produces pain in the calf

Homans Sign
121

Normal CV/PV Findings

122

Heart rate 60-100 beats per minute (adults)

S1,S2
Regular rhythm
Peripheral pulses palpable
Capillary refill <3 seconds
Negative Homans sign

Respiratory System
Assessment
123
PRIMARY PURPOSE=GAS EXCHANGE

Transfer of O2 and CO2

2 PARTS

Upper respiratory tract

Lower respiratory tract
RIGHT LUNG

Three lobes
LEFT LUNG

Two lobes
STRUCTURES OF CHEST WALL

Structures of the Respiratory System

124

Normal Assessment Findings

125

Chest symmetrical
Respiratory rate 12-20 per minute
Respirations regular, even, unlabored
O2 Sats >92% on RA
Lungs clear to auscultation

Chest & Lung assessment

126

Assess respiratory rate, rhythm, depth, and

symmetry
Inspect

__________________________

Palpate

__________________________

Percuss

__________________________

Auscultate lung fields

Inspection
127

Overall shape of the thorax

Chest symmetry
Trachea
Color & skin condition
Respiratory effort
Respiratory muscles
Presence and color of sputum

Problems with Chest Shape

128

Barrel Chest
Kyphosis

humpback

Scoliosis

Accessory muscles
129

Palpation
130

Areas of tenderness
Crepitus
Chest excursion
Tactile fremitus

Palpating Chest Excursion

131

Percussion
132

Percuss over intercostal spaces-not ribs

A

resonant sound
Air space
Diaphragm and heart produce dull sounds
Hyperresonance
Too

much air space

Specific disease processes

Anterior Percussion Sounds

133

Posterior Percussion Sounds

134

Auscultation
135

Use diaphragm of stethoscope

Instruct patient to breathe through

mouth
Listen to all lobes (anterior &
posterior)

Where to Auscultate
136

Auscultation of Breath Sounds

137

Pitch
Quality
Duration
Location
visualize

Breath Sounds
138

Bronchial
Bronchovesicular
Vesicular

Normal breath
sounds

Adventitious-abnormal sounds
Diminished

Normal Lung Sounds: Bronchial

139

Sound

High pitched
Harsh
Hollow
Tubular

Heard over trachea

Louder on expiration

Normal Lung Sounds: Broncho vesicular

140

Medium intensity
Heard at 1st & 2nd IC spaces anteriorly
Heard at T4 medial to scapula posteriorly

Normal Lung Sounds: vesicular

141

Low pitch
Soft intensity
Over peripheral lung fields
Sounds like wind rustling in trees
Louder on inspiration

Normal Breath Sounds

142

Adventitious Breath Sounds

143

Crackles or Rales

Fine
Coarse

Wheezes
Rhonchi
Pleural friction rub
Stridor