Health Assessment Flashcards
The Nursing Physical Examination
- Used as part of a general health assessment
- Used to gather data about the client
- Focuses on functional abilities and responses to illness/stressor
___ assessments focus on the client’s functional abilities and physical responses to illness and other stressors
Nursing
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Is an assessment of the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community
General health assessment
The nurse performs a physical examination to;
- Establish baseline data
- Identify nursing diagnoses, collaborative problems, or wellness diagnoses
- Monitor the status of an identified problem
- Screen for health problems
A comprehensive physical assessment includes a health history interview and a complete head-to-toe examination of every body system
Types of Physical Examinations
- Comprehensive physical exam or physical assessment
* Interview plus complete head-to-toe examination (i.e. annual physical, on admission) - Focused
* “Focused” on presenting problem
Types of Physical Examinations
- System-specific
* Limited to one body system - Ongoing
* Performed as needed to assess status
* Evaluates client outcomes
Preparing Yourself: What the Nurse Needs
- Theoretical knowledge
- Self-knowledge
- Knowledge about client situation
Preparing the Environment
- Privacy is key
- Noise control
- Enable visualization
- Temperature
- Equipment
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- A&P, techniques, therapeutic communication, & documentation
Theoretical knowledge
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- Skill and comfort level
- Willingness to seek help
Self-knowledge
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- Skill and comfort level
- Willingness to seek help
Self-knowledge
Preparing the Client
* Promote client comfort
- Develop rapport
- Explain the procedure
- Respect cultural differences
Preparing the Client cont’d
- Use proper positioning (know when to use each position)
- Standing
- Sitting
- Supine
* Fowlers (HOB elevated 60°) & Semi-Fowlers (HOB elevated 30-45°) - Dorsal recumbent
- Lithotomy
- Sims’
- Prone
- Lateral recumbent
- Knee-chest
Physical Assessment Techniques
* Four major skills used
- Inspection
- Palpation
- Percussion
- Auscultation
Additional clinical skill
- Olfaction (sense of smell)
___ is listening without using an instrument
If you’ve heard wheezing or chest congestion without the use of a stethoscope, you have already performed ___
Direct auscultation
___ is listening with the help of a stethoscope
Indirect auscultation
Age Modifications for the Physical Examination
Infants
* Have parents hold
* Attend to safety
Age Modifications for the Physical Examination
Toddlers
* Allow to explore and/or sit on parent’s lap
* Perform invasive procedure(s) last
* Offer choices
* Use praise
Age Modifications for the Physical Examination
Preschoolers
* Use doll for demonstration
* Child may still want parental contact
* Allow child to help with examination
Age Modifications for the Physical Examination
School-age children
* Show approval and develop rapport
* Allow independence
* Teach about workings of the body
Age Modifications for the Physical Examination
Adolescents
* Provide privacy
* Address concerns that they are “normal”
* Use examination to teach healthy lifestyle
* Screen for suicide risk
Age Modifications for the Physical Examination
Young/middle adults
* Modify in presence of acute or chronic illness
Age Modifications for the Physical Examination
Older adults
* 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 ADLs
* Provide periods of rest as needed
“SPICES”
S = Sleep disorders
P = Problems with eating or feeding
I = Incontinence
C = Confusion
E = Evidence of falls
S = Skin breakdown
Basic Components of a Comprehensive Examination: The General Survey
* Begins at first contact
* Overall impression of client
* Deviations lead to focused assessments
- Appearance/behavior
- Body type/posture
- Speech
- Mental state (LOC and interaction)
- Dressing/grooming/hygiene
- Vital signs
- Height/weight (calculate BMI)
Basic Assessments: Skin, Head
Integumentary
* Color
* Skin characteristics
- Temperature - warm to touch
- Moisture - oily, diaphoresis, dry and scaly
- Edema - assessing for edema and grading scale
- Texture - smooth, coarse, cracked, rough, dry, shiny
- Turgor - tenting versus increased turgor
* Lesions
- Malignant lesions (Asymmetry, Border, Color, Diameter, Evolving)
* Hair
* Nails
Basic Assessments: Skin, Head (HEENT)
Head (Head, eyes, ears, nose, throat)
* Skull and face
- Size
- Shape
* Eyes
- Visual acuity
- Visual examinations (acuity, distance, near, color, visual fields)
- External eye (sclera, pupils)
- Internal structures
Basic Assessments: Ears, Nose, Mouth
* Ears/hearing
- External ear
- Middle ear
- Inner ear (tympanic membrane)
- Hearing (Weber’s test, Rinne’s test)
- Balance (Romberg’s test)
Basic Assessments: Ears, Nose, Mouth cont’d
* Nose
- Smell
* Mouth and oropharynx
- Lips
- Buccal mucosa
- Gingiva
- Teeth
- Tongue and oropharynx
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Place a vibrating tuning fork on the center of the client’s head. He should be able to sense the vibration equally in both ears. Record a positive test if the vibration is louder in one ear.
Weber’s test
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The client should be able to stand with feet together and eyes closed and maintain balance with minimal swaying. Swaying and moving (positive test) may indicate a vestibular or cerebellar disorder.
Romberg’s test
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If the Weber’s test is positive, you will need to perform this test to assess the type of hearing problem. This test also uses a tuning fork to compare air conduction (AC) and bone conduction (BC). Normally AC is twice as long as BC.
Rinne’s test
Basic Assessments: Neck, Breasts
* Neck
- Musculature
- Trachea
- Thyroid gland
- Cervical lymph nodes
* Breasts
- Size, shape, nipple characteristics, tissue, include axillae
Basic Assessments: Lungs
* Chest and lungs
- Describe size and shape of chest
- Relate findings to landmarks
Basic Assessments: Lungs
* Breath sounds
- Bronchial
- Bronchovesicular
- Vesicular
- Adventitious
- Diminished or displaced
- Abnormal vocal sounds
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Are loud, high-pitched, tubular sounds; expiration is of longer duration than inspiration
Air moving through the trachea produces these sounds, which you’ll hear best over the trachea on the anterior chest and below nape of neck on posterior chest
Bronchial breath sounds
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Are medium-pitched with an equal inspiratory and expiratory phase
Air moving through the large airways of the bronchi produces these sounds, which you’ll hear best over the 1st and 2nd ICS adjacent to the sternum on the anterior chest and between the scapula on the posterior chest
Bronchovesicular breath sounds
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Are soft, low-pitched, breezy sounds with a lengthy inspiratory phase and a short expiratory phase
Air moving through the smaller airways produces these sounds, which you’ll hear best over the lung fields
Vesicular breath sounds
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Are heard with poor inspiratory effort, in the very muscular or obese, or with restricted airflow
Diminished breath sounds
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Examples of these sounds include wheezes, rhonchi, and rales
They are sounds heard over normal breath sounds
If an abnormal sound is heard, have the client cough and listen again
Adventitious breath sounds
Basic Assessments: Heart, Vessels
* Cardiovascular: Heart
- Inspection (point of maximal impulse, PMI; heaves/lifts)
- Palpation (thrill)
Basic Assessments: Heart, Vessels
* Heart sounds
- Location (aortic, pulmonic, tricuspid, mitral)
- Components (S1, S2, S3, S4)
- Murmurs
The first heart sound (___ or ___) results from the closure of the valves between the ___ and ___.
___ (“___”) is a dull, low-pitched sound, loudest over the ___ and ___ areas.
___ marks the beginning of ___.
S1, lub, atria, ventricles
S1, lub, mitral, tricuspid
S1, systole
The second heart sound (___ or ___) corresponds to closure of the ___ (between the ventricles and the great arteries exiting the heart).
“___” is higher in pitch and shorter than the S1 “lub”. The ___ is loudest at the ___ and ___ areas. ___ marks the beginning of ___.
S2, dub, semilunar valves
Dub, S2, aortic, pulmonic, S2, diastole
A third heart sound (___), heard immediately after S2, has a gallop cadence that follows the rhythm of the word KenTUCKy.
It is best heard at the ___ site with the client lying on his or her left side.
S3
apical
A fourth heart sound (___), heard immediately before ___, has a rhythm that follows the word FLOrida.
___ is best heard at the ___ site, using the bell of the stethoscope, with the client lying on his or her side. An ___ is normal in athletes and some older clients. It may also be heard in adults with CAD, htn, and pulmonary stenosis.
S4, S1
S4, apical, S4
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These are additional sounds produced by turbulent flow through the heart.
Some are “innocent,” but others represent pathology such as alteration in valve structure.
Murmurs
Cardiac Auscultation Sites
Basic Assessments: Heart, Vessels cont’d
* Cardiovascular: Vessels
Central vessels
- Carotid arteries
> Palpate pulsation
> Special precautions
> Ausculate for bruit
- Jugular veins
Basic Assessments: Heart, Vessels cont’d
* Peripheral vessels
Blood pressure
Peripheral pulses
- Arteries (away from heart) versus veins (back to heart)
Signs of inadequate oxygenation
Varicosities
Central vessels
The carotid arteries and internal jugular veins run alongside the ___ muscle on both sides of the neck
These central vessels provide circulation to the brain
The ___ ___ return blood from the brain to the superior vena cava
The external jugular veins are superficial; the internal jugular veins are deep
Normally, the jugular veins are flat when the client is in an upright position and distend when the client lies flat
sternocleidomastoid
jugular veins
___ (___) is seen when the right side of the heart is congested due to inadequate pump function
The best assessment of ___ is semi-Fowler’s (30°-45° angle)
Jugular venous distension, JVD
JVD
___ vessels supply blood to all the body cells
The ___ are a high-pressure system with several palpable pulse sites
The ___ are a low-pressure system with valves to prevent backflow due to gravity
Peripheral
arteries
veins
The veins ___ blood to the heart via the continuing pressure from the arterial system and pumping action of the adjacent skeletal muscles
return
Basic Assessments: Abdomen
Different order for assessment skills
* Inspect
* Auscultate
* Percuss
* Palpate
Basic Assessments: Musculoskeletal System (Bones, Muscles, Joints)
Body shape/symmetry
- Posture, gait, spinal curvature
Balance
- Romberg’s test
Coordination
- Finger-thumb opposition, movement
Basic Assessments: Musculoskeletal System (Bones, Muscles, Joints)
Joint mobility
- Color change, deformity, crepitus
Muscle strength
- Range of motion, resistance
___ ROM requires the client to move the joint through its full ROM
Active
___ ROM is used when the client is unable to exercise each joint independently; instead, you support the body and move each joint through its ROM
Passive
Basic Assessments: Neurological
The staff RN uses a focused neurological assessment
Cerebral functioning
> Level of consciousness
- Arousal: response to stimuli
- Orientation: time, place, person
Basic Assessments: Neurological
> Mental status/cognitive function
- Behavior, appearance, response to stimuli, speech, memory, communication, judgement
> Cranial nerve assessment
___ refers to the client’s intellectual and behavioral functioning; includes level of consciousness, orientation, mental status, cognitive function, and communication
The ___ evaluates eye opening, motor responses, and verbal responses; its limitations are that it relies heavily on vision and verbal interaction and does not evaluate brainstem reflexes
Cerebral functioning
Glasgow Coma Scale (GCS)
Basic Assessments: Neurological cont’d
Reflexes
> Automatic responses
> Responses on a graded scale
- 0 = no response
- +1 = diminished response
- +2 = response normal
- +3 = response somewhat stronger than normal
- +4 = response hyperactive with clonus
> Example: Deep tendon reflexes
___ are automatic responses that do not require conscious thought from the brain
A ___ produces a rapid, involuntary response that occurs at the level of the spinal cord
Because the brain is not involved, muscle response is instantaneous
Intact sensory and motor systems are required for a normal ___ response; each one corresponds to a certain level of the cord
Deep tendon reflexes (DTRs)
reflex
reflex
Motor/cerebellar function: Motor pathways transmit information between brain and muscles, and the muscles control movement of the skeleton
The ___ helps coordinate muscle movement, regulate muscle tone, and maintain posture and equilibrium
The ___ is also largely responsible for ___, or body positioning
cerebellum
cerebellum, proprioception
Basic Assessments: Neurological cont’d
Motor/cerebellar function
- Movement/coordination
- Tone
- Posture
- Equilibrium
- Proprioception (body positioning; easily impaired with alcohol)
Basic Assessments: Neurological cont’d
Sensory function
- Stereognosis
- Graphesthesia
- Two-point discrimination
- Point localization
- Extinction
Genitourinary Assessment
Male
- Includes reproductive information
- External genitalia: penis, urethral opening, scrotum, lymph nodes, pubic hair
- Examine for presence of a hernia
Female
- Female external genitalia: labia, clitoris, urethral opening, vaginal orifice, pubic hair, lymph nodes
Genitourinary Assessment cont’d
Other
- Kidneys (CVA tenderness)
- Bladder (palpation of abdomen)
- NP/MD responsible for anus, rectum, prostate, pelvic examination
