Health and Physical Assessment of the Adult Flashcards
SOAP
Subjective
Objective
Assessment
Plan
Subjective
Identifying client information Problems, allergies, medications, immunizations (PAMI) General client information Chief complaint or reason for seeking care History of present illness (OLDCARTS) Past medical history Family history Personal and social history Review of systems
OLDCARTS
Onset Location Duration Character Aggravating/associated factors Relieving factors Timing Severity
Objective
General statement: age, race, gender, general appearance, weight, height, body mass index, vital signs.
Physical assessment from head to toe and mental status
Assessment
- diagnose with rationale
- rationale derived from subjective and objective data
- symptoms can be listed as diagnoses
- there may be a list of differential diagnoses, which are suspected and are yet to be confirmed
- may include anticipated problems such as progression of disease or complications.
Plan
Typically denoted in the following order:
- Diagnostic tests, treatment plan with rationale
- client education and counseling
- referrals
- follow up or dates for re-evaluating results of plan
Assessment techniques
Inspection, palpation, percussion, and auscultation (this order, except abdominal).
Vital signs.
Body assessment: Integumentary
Involves inspection and palpation of skin, hair and nails.
Color, temp, dryness or moisture, turgor, texture, bruising, itching, rash, hair loss, nail abnormalities, lesions, scars, birthmarks, edema, capillary filling time (less than 3 seconds).
Characteristics of skin color
Cyanosis: mottled bluish coloration.
Erythema: redness.
Pallor: Pale, whitish, coloration.
Jaundice: yellow coloration.
Pitting Edema Scale
1+ a barely perceptible pit (2mm);
2+ a deeper pit, rebounds in a few seconds (4mm);
3+ a deep pit, rebounds in 10-20 seconds (6mm);
4+ a deeper pit, rebounds in > 30 seconds (8mm).
Body assessment: head, neck, and lymph nodes
Head - inspect size, shape, edema; palpate temporal arteries, frontal and maxillary sinuses. Ask the client to open and close mouth and move side to side (note crepitation, tenderness or limited motion) to test nerve V (trigeminal).
Neck - Inspect symmetry of muscles, range of motion. Palpate the trachea and thyroid gland while the client takes a sip of water (usually cannot be palpated, unless it is enlarged).
Lymph nodes: palpate with both hands, comparing sides.
Body assessment: eyes
Includes inspection, palpation, vision testing and use of ophthalmoscope.
- Inspect: eye structure, eyelids (ptosis), and eyeballs (exophthalmos or enophthalmos). Conjunctiva, sclera, lacrimal apparatus, cornea, lens, iris and pupils.
- Snellen eye chart: with chart at eye level and 20 feet away, ask to read the smallest line they can discern. 1 eye at a time, keep glasses (except reading glasses) or contacts. Record the result using the fraction at the end of line read. Normal is 20/20. This tests cranial nerve II (optic).
- Near vision: test nerve II, normal 14/14.
- Confrontation test: peripheral vision compared to nurse’s. Nerve II.
- Cover-uncover test: check deviated alignment.
- Diagnostic positions test: 6 cardinal positions of gaze. Test cranial nerves III (oculomotor), IV (trochlear), VI (abducens).
- Color vision: Ishihara chart, test red and green blindness.
- Pupils: round and equal, use o direct light with normal constriction.
- Sclera and cornea: assess color and characteristics.
- Fundoscopy (other card)
Documenting pupillary normal findings
PERRLA
Pupils Equal Round Reactive to Light reactive to Accommodation.
Ophthalmoscopy or Fundoscopy
- dark room so pupil will dilate.
- instrument on right hand for right eye, left for left.
- client must look straight ahead.
- examiner approach 15 degrees lateral and 12-15 inches away (30-38cm).
- look for the red reflex (absence may indicate opacity of the lens).
- examine the optic disc, retinal vessels, general background and macula.
Body assessment: Ears
Inspection, palpation, hearing tests, vestibular assessment, and use of otoscope.
- Inspect and palpate external ear and auditory meatus.
- Auditory assessment: conductive (physical obstruction to sound waves), sensorineural (defect in cochlea, VIII nerve or brain), or mixed (both).
- Voice (whisper) test: whisper 30-60 cm away two syllabe-word while covering the mouth.
- Watch test: hold watch 5 inches (12.5cm) from each ear and ask if client can hear.
- otoscopic exam
Vestibular assessment
- Test for falling (Romberg’s): stand, feet together, arms loosely, eyes closed. Significant sway means is positive.
- Test for Past Pointing: eyes closed, arms extended, pointing index fingers, raise both arms and lower back to point of reference (examiners own index fingers). Client with vestibular problem lacks normal sense of position, deviating to the left or right.
- Gaze Nystagmus evaluation: eyes are examined as the client looks straight ahead, 30 degrees to each side, upward and downward. Shouldn’t present nystagmus.
- Dix-Hallpike Maneuver: client is in sitting position, turn head to a 45 degree angle an then lower client to “supine”, observe eyes for 30 seconds and repeat on other side if negative. Positive if shows nystagmus.
Body assessment: nose, mouth, and throat
Inspect: nose (could use otoscope), lips, teeth, gums, tongue, uvula and tonsils (use tongue depresser).
Palpate: frontal sinuses.
Test gag reflex (nerve IX glossopharyngeal)
Tonsils grade scale:
- 0 surgically removed
- 1+ tonsils hidden within pillars
- 2+ tonsils extending to the pillars
- 3+ tonsils extending beyond pillars
- 4+ tonsils extending to the midline.
Test nerve XII (hypoglossal) by asking the client to stick out the tongue (should protrude in the midline).
Body assessment: Lungs
-Inspection: color, rate, quality, shape, position.
-Palpation: entire chest and look for abnormalities. Assess chest excursion and tactile or vocal fremitus.
-Percussion: Resonance is noted in healthy lung tissue. Hyperresonance when excessive air is present and dull note indicates lung density.
-Auscultation: vesicular, bronchial and bronchovesicular arr normal breath sounds.
Adventitious sounds: crackles (fine, medium or coarse), wheeze, rhonchi, and pleural friction rub.
Body assessment: Heart
- Inspect: chest and apical impulse (not always visible), check for pretibial edema, BP.
- Palpations: apical pulse (4-5th space LMC). Inguinal nodes, carotid and peripheral pulses.
- Percussion: may be performed to outline heart and check enlargement.
- Auscultation: aortic (2R), pulmonic (2L), erb’s point (3L), tricuspid (4L), mitral (5L LMC). Carotid artery.
Body assessment: Breast
Inspect: symmetry, masses, retraction, color, venous pattern, shape, discharge of nipple and areola.
Palpation: entire breast and noting consistency. Compress the nipple to evaluate discharge. Assess axillary lymph nodes (normally not palpable).
Body assessment: Abdomen
- Inspection: describe as flat, rounded, concave, or protuberant. Observe symmetry (masses), umbilicus (midline), skin, pulsation (aorta may be noted on epigastric area).
- Auscultation: listen 4 quadrants, begin right lower. Normal if 5 to 30 sounds per minute. Absent if no sound for at least 5 minutes. Auscultate aorta, renal arteries, and femoral.
- Percussion: all 4 quadrants. Tympany should be predominate, with dullness over the liver and spleen.
- Palpation: all 4 quadrants, liver, spleen (may not be palpable), and aortic pulsation (expands laterally if an aneurysm is present).
Body assessment: musculoskeletal system
Inspection and palpation.
Assess range of movement, muscle tone and strength.
Body assessment: neurological system
Assessment of cranial nerves, level of consciousness, pupils, motor function, cerebellar function, coordination, sensory function, and reflexes.
Vital signs.
Body assessment: neurological system
Sensory Function
- Pain: apply a sharp object and a dull point to the body in random order and ask the client to identify each.
- Light touch: brush piece of cotton over skin in various locations and ask the client to say when the touch is felt.
- Position sense (kinesthesia): move the client’s finger or toe up or down and ask which way it has been moved.
- Stereognosis: ability to recognize object placed in the hand.
- Graphesthesia: ability to identify a number traced on the client’s hand.
- Two-point discrimination: ability to discriminate 2 simultaneous pinpricks on the skin.
Reflexes
- Deep tendon: biceps, triceps, brachioradialis, patella, achilles.
- Plantar reflex: Babinski’s sign - toes down is the normal response (older than 2 years)
Testing meningeal irritation
- Brudzinski’s sign: supine position, flex the head toward chest. Positive if client flexes the hip and knee and reports pain.
- Kernig’s sign: supine position, flex the leg at the hip and knee. Complains of pain along the vertebral column when leg is extended.
