Module 2 Physical Assessment Flashcards
What is involved in a comprehensive assessment?
A comprehensive health assessment includes obtaining information about the
following areas: biographical data, reason for seeking care, past and present health,
family history, psychosocial history, activities of daily living and physical assessment
findings
History assessment
P-Q-R-S-T-U:
* P: What precipitated the problem?
* Q: What is the quality or quantity of the symptoms?
– What does it feel like?
– Is it worse now than before?
* R: What region in the body is the problem in?
* S: How severe are the symptoms?
– 1-10 pain scale.
– Pain getting better or worse?
– Anything make it better or worse?
* T: When did symptoms begin? Onset time?
– Was onset sudden or gradual?
* U: Does patient have an understanding of the disease or of a possible cause?
* V: vital signs: Tell a lot of what is potentially going on! Even if the paramedic just
took them in the ambulance – you do need to take them for yourself
Assessment
Order of exam:
– Most use ‘head-to-toe’:
* For example: Neurological, EENT, respiratory, etc.
– In emergency situations a focused assessment will be used rather than
head-to-toe.
* For example: if a person has chest pain – focus the assessment on
the cardiac system first
Look - Inspect - first look sick/not sick, ABCD’s, symmentry, deformity, bleeding
Listen - Ascultate
Feel - palpate - skin temp, pulses, lumps
Percuss
Inspect
First part of assessment – general survey.
– Observation of patient.
* Be organized and systematic.
* Maintain objectivity – make no assumptions!
– You need to maintain objectivity:
* Even if you have seen the same person many times;
* Do not stereotype;
* Maintain professional approach.
* In triage it’s called ‘the first look’.
* When you first meet your patient you ask
yourself:
* Is his airway patent?
* Is the patient in respiratory distress? SOB?
* Colour of skin?
* Level of consciousness?
– Basically the A-B-C-D’s!
* How does the patient look to you?
Ascultate
When listening to the lungs:
– Listen both anterior & posterior lung areas.
* When listening to the heart:
– You will use both the bell and diaphragm.
* When listening to the abdomen:
– Start at the lower right quadrant for bowel sounds.
– Know where to listen for vascular sounds.
* Interference of sound during auscultation may be due to:
– Hairy chest;
– Muscle contraction, shivering;
– Friction of the stethoscope;
– Clothing (never listen over clothes!);
– Tubing size (longer or wider the tube, the less sound you
hear – it diminishes along the tube).
Palpate
Using sense of touch to determine:
– Firmness: soft or hard/taunt (as in belly);
– Quality of pulses;
– Bone/joint abnormalities, lumps, bumps;
* Use fingertips
– Extent of tenderness, swelling or size of joints;
* Use fingertips,
* Always palpate non-tender area first then proceed
towards tender area.
To assess for:
– Skin temperature/moisture;
* Use back of hand.
– Fluid accumulation and edema;
– Chest wall vibrations
* Use base of fingers.
Percussion
Sounds of Percussion:
* Resonance:
– Low pitch, sounds hollow-like
– Heard over normal lung tissue
* Hyper-resonance:
– Lower than resonance
– Very loud – booming sound
– Found in over-inflated lung (COPD), pneumothorax or in children.
* Dull:
– Muffled sound of short duration
– Found over solid organs: liver, spleen, heart, or pleural effusion.
* Flat:
– Thud like sound of short duration.
– Found over bone or muscle.
* Tympany:
– Very high sound
– Loud
– Sounds musical or drum like
– Long duration
– Found over stomach or air distended abdomen.
Respiratory System
The body depends on the respiratory system for maintenance of adequate gas
exchange, the removal of carbon dioxide, and the replenishment of the oxygen
required by every cell. Changes in this system usually results in alterations to other body systems.
Resp Assessment
Health history - Acute/Chronic
Resp history - treatments medications
Inspection -symmetry/chest deformities/
WOB/resp pattern/landmarks
Palpation crepitus/tenderness/retractions/ symmetry
Percussion-Resonant sounds:
◦ Heard over normal lung tissue.
Hyperresonance:
◦ Heard over areas of increased air in the lung or pleural space -
emphysema, pneumothorax.
Dullness:
◦ Found over areas of decreased air entry in the lungs - atelectasis,
pneumonia, hemo-pneumothorax.
Flatness:
◦ Is found over areas of consolidation – atelectasis or pleural effusion.
Tympany:
◦ Is found over areas where air has collected – large pneumothorax
Ascultation-Bronchial (tracheal):
◦ Harsh, Loud, high-pitched
◦ Heard over trachea/larynx
Bronchovesicular:
◦ Medium pitched
◦ Heard over main airways, little alveoli in areas.
Vesicular:
◦ Soft & low pitched.
◦ Heard over rest of lung fields
Adventitious-Wheezes: high pitched musical sounds
◦ Narrowed airways
Generally found in expiration, but can be heard upon inspiration.
Heard in:
Asthma, or narrowed airway passages due to allergic
reactions.
Crackles: crackling popping sounds
◦ Fluid in the airways
Fine crackles are heard during inspiration, not cleared by coughing.
Coarse crackles are loud, low-pitched, bubbling and gurgling
sounds that start in inspriation & may be present in expiration.
Heard in:
Pneumonia, pulmonary edema
Pleural Friction Rub:
◦ Inflamed visceral & parital pleural coverings.
Cardiovascular Assessment
History-Obtain a health history – ask about the following:
◦ Risk factors;
◦ History:
Is there a history of cardiac problems?
Medications
Co-mobidities (diabetic, hypertension)
◦ Family history;
◦ Lifestyle (i.e.: smoker?):
Sedentary or active?
Diet
Smoker?
Inspection
Body type:
◦ Average, thin, obese?
Skin:
◦ colour, temperature, moisture
Obvious distress or pain?
Presence of central cyanosis?
Apical impulse:
◦ Normally 5th left intercostal space (ICS), mid-clavicular line.
◦ May see in thin adults, and in children.
◦ If displaced to 6th left ICS and downward – can indicate enlarged heart
Pulsations
Finger clubbing: present?
◦ Other health problem such as COPD present?
Hair distribution on legs, feet.
◦ Decreased hair on limbs could indicate insufficient blood flow to area
JVP - can indicate R ventricular failure
Palpate the apical pulse:
◦ Apical impulse is associated with first heart sound and carotid pulsation.
Check carotid pulse and apical impulse at same time – they should coincide
with each other.
Palpate for a heave:
◦ A heave is the lifting of the chest wall.
◦ Felt during palpation.
◦ Can indicate:
Ventricular hypertrophy (felt over sternal border)
Ventricular aneurysm (felt over left ventricle)
Is skin turgor normal?
Dehydrated?
Renal failure present?
Is edema present? Palpate edema.
◦ Type: pitting, non-pitting, weeping.
◦ Grade for pitting edema: 1+ to 4+:
> 2mm = 1+ pitting edema
>4 mm = 2+ pitting edema
>6mm = 3+ pitting edema
>8 mm = 4+ pitting edema
Take blood pressure: both sides, sitting/lying.
Capillary refill:
◦ Depress & blanch the nail bed. Release & note time for colour to return.
Normal is < 3 seconds. >3 seconds can indicate decreased cardiac output or
cold.
Pulses: Assess rate, rhythm & force
Percussion may help you locate cardiac borders.
◦ Percussion over the heart will produce a dull sound – sound produced with a
blood filled ogran.
◦ Can only percuss left side of heart as right side is under sternum.
Ascultation
◦ Listen for S1 & S2 until your are familiar with them.
◦ Read the patient’s chart to see if they have extra heart sounds – then listen for
them.
Neurological Assessment
Health history
Assess mental status –
◦ LOC, appearance, behaviour, speech
Assess cranial nerve function
Assess sensory function
◦ Pain, light touch, position, discrimination
Assess motor function
◦ Strength, tone
Assess reflexes
Assessment of the neurological system begins as soon as you see the patient.
You may ask yourself the following questions:
◦ Do they respond to my voice?
◦ Can they communicate with me?
◦ Are they responding appropriately to my questions?
Assess for orientation to person, place and time.
◦ What is your name?
◦ What year/month/date/day of the week is it?
◦ Where are you now?
If response is appropriate, document as “Patient is orientated to person,
time and place”.
If a patient answers incorrectly it may indicate a need for a more in-depth
mental status exam
Assessed by applying stimuli:
◦ Auditory – voice, questions & responses;
◦ Supra-orbital pressure;
◦ Tactile – no response to voice – gentle stimulate patient for response:
Pressure to nailbed: peripheral response – could receive reflex response.
Pressure to trapezius or pectorial muscles – could be more reliable, as is a
central response.
The GCS is used to assist in assessing LOC.
◦ Scores LOC: 15 being best score, 3 worst.
◦ Score <8 usually indicates coma &patient will be unable to protect own
airway. The patient needs airway protection & probable intubation
Look for symmetry between sides!
Purposeful
◦ Withdrawals from painful stimuli & may push examiner’s hand away – light
coma
Non-purposeful
◦ Stimulated area moves slightly, may attempt to grab your hand, but does not
get near it.
Unresponsive
◦ No reaction – deep coma
LOC Pneumonic AEIOU & TIPPS
To help determine the cause of the LOC:
A-E-I-O-U: alcohol, epilepsy, insulin, opium, uremia
TIPPS: tumor, injury, psychiatric, stroke, sepsis.
Psychiatric causes should be considered only after all other possibilities
have been ruled out
Motor Assessment
◦ Arms:
Flex each arm, ask them to resist or pull against this movement.
Repeat procedure by having patient resist extension.
◦ Legs:
Ask patient to raise each knee against the resistance of your hands.
Have them straighten their knee & leg against resistance.
Have patient dorsi-flex & plantar flex feet against the resistance of your
hands.
Observe for arm drift:
◦ Ask patient to close eyes - hold out both arms with palms up.
◦ Drifting of an arm downward may indicate a neurological injury.
Evaluate hand strength:
◦ Patient grasps two fingers of nurse’s hands & note if strength in both hand is
equal.
◦ Unequal strength is abnormal
Sensory Assessment
Check for ability to feel sharp or dull:
◦ Check distal portion of limb first – if the person can feel sharp or dull distally
then can feel through the length of the limb.
◦ Numbness or tingling in hands or feet:
◦ Check for symmetry in both limbs;
Pupil Assessment
Normal size: 2-6 mm in diameter.
Shape: normally round, abnormal is oval, keyhole, or irregular.
Reaction to light: direct light reflex:
◦ Note whether they react briskly (normal) or are sluggish to react or are fixed.
◦ Cranial Nerve III is involved in reaction to light.
◦ With increasing neurological dysfunction may become sluggish, fixed or no
response.
Pupil Assessment: PERLA – Pupils Equal & Reactive to Light and Accommodation
Consensual response:
◦ A light is shone in one eye will not only constrict that pupil (direct light reflex)
but also in the other eye (consensual response).
Accommodation:
◦ Have your patient focus on your finger, held a couple of feet away from
her/his eyes. Notice that the pupils constrict as your finger moves closer and
converge inwards
