Physical Assessment Flashcards
What do we use the physical examination for, what’s the purpose?
Triage for emergency care
Routine screening
To determine eligibility for: Health insurance
Military service
A new job
To gather baseline data
Support or refute subjective data that we’ve obtained
Identify and confirm the nursing diagnosis
Make clinical decisions about patients changing health
How does Cultural sensitive play a part in assessment
Depending on culture, it can influence a patient’s behavior & they might have different approaches
You would need to consider their: nutritional habits, any alternative therapies they prefer, relationship with family, and their comfort zone
You want to avoid stereotypes and gender bias
Gathering data: Sources of data
Examination, Observation, Review of Literature, Consultation, Interviewing
Gathering data: Health History
What info would you look for
Demographic data, why their seeking care, Patient expectations, Present illness, Post health history, Family health history, Spiritual health, Lifestyle, Psychosocial history, review of symptoms, their functional abilities, medications, allergies, immunizations, advance directives, surgeries, nutrition, Elimination
Investigating patient-reported symptoms
Location, does the pain radiate?
Quality, is the pain sharp, dull or throbbing?
Quantity
Chronology, What happens after pain appears
Setting
Does anything aggravate or alleviate the pain?
What do you want the fix to be, medication?
Activity level
Cognitive, is the patient’s alert
What are the 4 components of examination?
Inspect, Palpation, Percussion, Auscultation
What does Auscultation consist of
Looking for pulses, abnormalities
What does palpation consist of
Lightly feeling the surface of the location
What does percussion consist of
lightly tapping on the surface to hear for gases or fluids
What does observation consist of
USING ALL SENSES, besides taste
Observing the color and texture of the skin
Character of respirations
Mannerisms
Mental state
What do you look for in a nonverbal patient
You would look at their expressions or feeling, you can usually tell how someone feels based on how they seem to appear
Where do you begin in collection and assessment
Physiological observation and assessment begin at the head and work down
may be conducted by body systems
must have a system to ensure nothing is overlooked
data collection assessment:
Mental status
Look to see if they are oriented, disoriented, alert, focused, incoherent, unresponsive, or unconscious
data collection assessment:
Emotional state
Look to see their mood, are they anxious? Do they exhibit defense mechanisms, what is their perception of body image, what is their ability to relate to others
data collection assessment:
Head
Look at their hair
thinning?
Alopecia?
clean/dirty?
lice, ringworm, etc?
data collection assessment:
Eyes
Look to see their
visual activity
fields of vision
inspect sclera, lids
check for symmetry
pupil response
do they wear glasses or contacts
data collection assessment:
Ears
can they hear well, do they have hearing aids
data collection assessment:
Nose
check their septum
do they have any discharge
are their frontal and maxillary sinuses alright?
data collection assessment:
Mouth
Inspect the teeth, gums, tongue, condition of teeth and lip moisture
data collection assessment:
Neck
Inspect the lymph nodes
Mobility
symmetry
data collection assessment:
Skin
Look at color, hydration, rashes, edema, wounds, abrasions and scars
Describing skin using ABCD
Asymmetry
Border irregularity
Color
Diameter
data collection assessment:
Thorax
Look at
size
shape
ribs in relation to spine
respiratory movements
can you see the muscles being used? (overused= bad)
data collection assessment:
Lungs
Listen for
wheezes, cracks, breath sounds
quality of breath
data collection assessment:
Cardiovascular
Check:
pulse
blood pressure
veins; Is there varicosities, edema, thrombus?
data collection assessment:
Breasts
size
shape, symmetry
dimpling
striae
nipple retraction
discharge
augmentation or reduction mastectomy
data collection assessment:
Abdomen
GI status
GU status
bowel sounds
tenderness
scars
fat distribution/obesity
data collection assessment:
Musculoskeletal
posture
spine
legs/feet
joints
gait
height and weight
