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

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)

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: 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

Health Assessment Flashcards by Kaylie Krauzyk

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

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___ 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

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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

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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

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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

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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

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Physical Assessment Techniques

* Four major skills used

Inspection
Palpation
Percussion
Auscultation

Additional clinical skill

Olfaction (sense of smell)

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___ 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

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___ is listening with the help of a stethoscope

Indirect auscultation

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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

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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

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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

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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

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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

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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

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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

? 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

? 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

? 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

? 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

? Are heard with poor inspiratory effort, in the very muscular or obese, or with restricted airflow

Diminished breath sounds

? 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

? 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