IMM 04 and 08: Introduction to Physical Assessment Flashcards

1
Q

What is a physical assessment?

A

the act of evaluating the body and its functions from head-to-toe

  • tool used to gather objective data required to make informed decisions about a client’s health-related problems
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2
Q

What should you do with your physical exam findings?

A

integrate and correlate the findings and observations with the client’s history and your clinical knowledge and experience

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3
Q

Why is it important for pharmacists to know how to do physical assessments? (3)

A

evolution of the profession and demand for cognitive services

  • pharmacists in some clinical settings routinely use physical assessment skills as they relate to specific disease states and medication therapy management
  • recent rapid expansion of scope of practice (minor ailments prescribing, lab tests)

all pharmacists should have a basic understanding

  • familiarity with common physical assessment terms and acronyms
  • understanding of specific findings documented by others and how to interpret them in the context of medication therapy management
  • need for hands-on proficiency varies depending on the client care setting

pharmacists share the responsibility for client outcomes

  • physical assessment findings can contribute to solving drug therapy problems, making decisions about drug prescribing, and client monitoring
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4
Q

What are some of the barriers to incorporating physical assessment into pharmacy practice? (5)

A
  • need for adequate training – no consensus recommendation exists on performance expectations in Canadian curricula
  • increased workload and lack of infrastructure (ie. remuneration, lack of time, physical layout of the pharmacy) – needs to be a mechanism to allow for time and space to perform physical assessments
  • distraction to traditional pharmacist roles – client concerns about affect on wait times for prescriptions
  • infrequent use of skills to maintain competency – needs to be a mechanism to monitor skill competency
  • conflicts with other health care providers – “professional turf” war
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5
Q

What are some of the benefits of pharmacists’ knowledge of physical assessment?

A
  • understand the significance of information in the client’s chart
  • enhance their assessment of the client and their drug therapy
  • detect medication-related problems requiring treatment
  • improve their ability to prescribe and monitor drug therapy
  • manage common minor ailments
  • refer clients for further evaluation, when necessary
  • enhance communication with the health care team
  • increase their value on the health care team
  • expand their scope of practice
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6
Q

Describe the general approach to conducting a physical examination.

A
  • by convention, the exam is typically done from the client’s right side
  • follows a structured sequence that minimizes the number of changes in position by the client and clinician
  • consider your client through the entire examination – respect their privacy, minimize their discomfort and embarrassment, communicate with them
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7
Q

Describe appropriate bedside manners when conducting a physical examination.

A
  • do your information gathering – read the client’s profile or medical chart (if available) before you see the client
  • respect mask guidelines – watch for infection control precautions
  • practice hand hygiene – before and after the client interaction
  • introduce yourself – your name and your role (ie. “pharmacy student”)
  • confirm the client’s identity – name, birth date, etc.
  • ensure your client is comfortable throughout the examination – maintain privacy for the client, observe the client’s body language, continue to communicate with the client
  • explain what you are going to do and why
  • ask for permission to touch the client
  • be thorough, but don’t waste time
  • remember to thank your client – let them know the examination is over, and give them an opportunity to ask questions
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8
Q

What are the 4 fundamental examination techniques?

A
  • inspection
  • palpation
  • percussion
  • auscultation
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9
Q

What is inspection?

A

observation of physical signs, behaviour, and movement displayed by client

  • may be visual, olfactory, or auditory observations
  • depends on the examiner’s knowledge of what to look for and how it would be manifested in the client (otherwise you may not even detect presence)
  • do not underestimate the power of inspection
  • ie. facial expressions, body shape (ie. chest, abdomen), skin condition, gait, edema)
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10
Q

What is percussion?

A

tapping of fingers on body surfaces to assess density of underlying structures (4-5 cm beneath skin surface)

  • use fingers to indirectly strike the body surface to elicit sounds that vary in quality according to the density of the underlying tissues
  • percussional sounds are described as: tympanic (least dense – hollow, air-filled), hyperresonant, resonant, dull, flat (most dense – thigh)
    ie. lungs (resonant = healthy), liver (dull = healthy)
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11
Q

What is palpation?

A

using sense of touch and tactile pressure to feel areas that cannot be seen

  • use pads of fingertips to distinguish hard and soft areas (ie. evaluating a mass)
  • use palm of hand is used to detect presence or absence of vibrations (ie. lungs)
  • use backside of fingers to evaluate temperature (ie. demarcating limits of a superficial cellulitis)
  • ie. areas of skin elevation or depression
    tenderness, temperature of skin (cold, clammy vs. warm), sizes of organs and masses, crepitus in the joints
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12
Q

What is auscultation?

A

listening to sounds originating from within an organ or body cavity by use of a stethoscope

  • auscultatory findings usually generated by substances (ie. air, fluid, etc.) moving through body systems
  • identify presence or absence of sounds
  • effectiveness of the auscultatory exam is determined by the quality of the stethoscope and skill of examiner
  • ie. blood pressure (blood flow through blood vessels), pulmonary (air flow through the tracheobronchial tree), GI system (bowel contents as they traverse the stomach and intestines)
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13
Q

In what order should the 4 fundamental techniques be performed?

A

order varies depending on the area of the body being examined

  • for most areas: inspection → palpation → percussion → auscultation
  • for abdomen: inspection → auscultation → percussion → palpation
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14
Q

Why is auscultation performed right after insepction?

A

need to do this before pushing the GI tract around during palpation to hear the proper bowel sounds

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15
Q

What is the scope of the physical exam determined by? (6)

A
  • client history
  • previous knowledge of client
  • magnitude & severity of client’s problem
  • need for thoroughness
  • clinical setting (inclient vs. outclient)
  • time
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16
Q

What is the scope of a physical examination for most pharmacists?

A

a general understanding of physical exam findings is sufficient

  • some require more extensive knowledge and ability to apply physical exam skills in order to care for their clients
17
Q

What measurements are included in vital signs assessment?

A
  • heart rate
  • respiratory rate
  • blood pressure
  • temperature
  • height
  • weight

provides critical information that may influence the remainder of physical examination and clinical assessment

18
Q

What are the fundamental examination techniques used to assess psychiatric (PSYCH)?

A

INSPECTION – conduct mental status exam (MSE)

  • appearance and behaviour – level of consciousness, posture and motor behaviour, dress, grooming, personal hygiene, facial expression, manner, affect, relationship to stimuli
  • speech and language – characteristic of speech including quantity, rate, loudness, articulation of words, fluency
  • mood – current and usual mood, fluctuations in mood, suicidality
  • thoughts and perceptions – thoughts (process and content), perceptions (ie. hallucinations), insight and judgement
  • cognition – orientation, attention, remote and recent memory, new learning ability, higher cognitive function (ie. calculating ability)
19
Q

What are the fundamental examination techniques used to assess neurologic (NEURO)?

A

INSPECTION and PALPATION

  • mental status exam (MSE)
  • cranial nerve function (ie. CN II and III: miosis with opioid narcotics and benzodiazepines)
  • motor function (ie. involuntary movements, coordination)
  • sensory function (ie. pain, temperature, discriminative sensations)
  • reflexes (ie. patellar reflex)
  • appropriate amount of detail varies widely, depending on client
  • often integrated with the physical examination of other organ systems – ie. HEENT: may assess cranial nerves relating to head and neck
20
Q

What are the fundamental examination techniques used to assess skin, hair, and nails (DERM)?

A

PALPATION

  • skin turgor
  • moisture
  • temperature
  • texture
  • edema
  • ie. loss of skin turgor in dehydration, skin warmth in cellulitis
21
Q

What are the fundamental examination techniques used to assess head, ears, eyes, nose, throat (HEENT)?

A

INSPECTION

  • skull – size, contour, shape, evidence of trauma
  • scalp – lesions and scales
  • face – expression, symmetry, movement, lesions, edema
  • neck – symmetry, masses, enlargement of glands and lymph nodes, position and size of sternocleidomastoid muscles
    external nose and nasal cavity – symmetry, inflammation, lesions
  • sinuses – via transillumination
  • external ear – lesions, trauma, size, contour
  • ear canal (using otoscope) – foreign bodies, discharge, edema
  • tympanic membrane (using otoscope) – colour, bulging, perforations, air-fluid level
  • mouth (lips and mucosa, teeth, gums, hard palate, tonsils, tongue, breath – symmetry, colour, bleeding, inflammation, caries, missing teeth, ulcerations, lesions, edema
  • conjunctiva and eyelids – colour, edema
  • cornea and lens – opacities
  • iris and pupil – size, shape, equality
  • fundi – retinal blood vessels, optic disc, retina, etc. using an ophthalmoscope
  • ie. scalp lesions and plaques in psoriasis, otitis media with perforation, white plaques on tongue in oral candidiasis, eyelash growth with opthalmic prostaglandins (ie. latanoprost)

PALPATION

  • skull – lumps, bumps, trauma
  • hair – texture (coarse, fine, dry, oily)
  • thyroid gland – size, shape, symmetry, tenderness, nodules
  • lymph nodes – size, shape, mobility, tenderness
  • sinuses – tenderness
  • external ear – nodules
  • ie. sinuses tender on palpation in sinus infection
22
Q

What are the fundamental examination techniques used to assess respiratory (RESP)?

A

INSPECTION

  • through one inspiratory-expiratory cycle
  • shape and movement of chest, use of accessory muscles, body position

PALPATION

  • test chest expansion and tactile fremitus (vibrations)

PERCUSSION

  • assesses underlying tissues to see if they are filled with air or fluid

AUSCULTATION

  • assesses air flow through tracheobronchial tree
  • assesses for breath sounds and adventitious sounds
23
Q

What are the fundamental examination techniques used to assess cardiovascular (CV)?

A

INSPECTION

  • inspect for visible cardiac motions
  • estimate jugular venous pressure (JVP)
  • ie. ↑ JVP = fluid overload in heart failure, ↓ JVP = dehydration

PALPATION

  • point of maximal impulse (PMI)
  • assess pulses – radial, carotid, brachial, femoral, popliteal, posterior tibial, dorsalis pedis
  • ie. peripheral artery disease = decreased popliteal, posterior tibial, dorsalis pedis pulses

AUSCULTATION

  • assess heart sounds – S1 (mitral and tricuspid valve closure), S2 (aortic and pulmonic valve closure), S3 and S4 (abnormal heart sounds)
  • assess for other abnormal heart sounds – gallops (exaggerated normal diastolic sounds), friction rubs (pericarditis), murmurs (turbulent blood flow across a valve or septum)
24
Q

What are the fundamental examination techniques used to assess gastrointestinal (GI)?

A

INSPECTION

  • appearance of skin, umbilicus, abdominal contour

AUSCULTATION

  • bowel sounds (produced by movement of fluid and air in bowel) – normal bowel sounds = normal peristaltic movements, absence of bowel sounds = no peristalsis
  • ie. ↑ bowel sounds in diarrhea (ie. gastroenteritis), ↓ bowel sounds in constipation (ie. opiates, 1st generation antihistamines)

PERCUSSION

  • assess liver span (= size of liver)
  • assess all 4 quadrants

PALPATION

  • assess all 4 quadrants
  • use light palpation for tender or rigid areas
  • use deep palpation to determine the outlines of abdominal organs and kidneys
25
Q

What are the fundamental examination techniques used to assess genitourinary (GU)?

A

INSPECTION

  • sacrococcygeal and perianal areas
  • external genitalia
  • pelvic exam (females)

PALPATION

  • anus and rectal wall
  • prostate
  • penis
  • uterus and ovaries
26
Q

What are the fundamental examination techniques used to assess musculoskeletal (MSK)?

A

INSPECTION

  • symmetry, proportion, and muscular development
  • curvature of spine
  • observe gait, stance, ability to stand/sit/rise from sitting position, ability to grasp objects

PALPATION

  • palpate large and small joints
  • warmth, tenderness, crepitation, and deformities
  • assess joint range of motion – limits or extension of the range of motion of a joint are reported in degree
27
Q

What are the fundamental examination techniques used to assess the peripheral vascular system (PVS)?

A

INSPECTION

  • size, symmetry, swelling, and skin colour of arms and legs
  • ie. bilateral leg edema in heart failure

PALPATION

  • arms – brachial and radial pulses
  • legs – femoral, popliteal, dorsalis pedis, posterior tibial pulses

AUSCULTATION

  • abdomen – aortic, renal, femoral bruits