Physical Assessment Flashcards
Why do we assess patients
To establish a baseline & help identifying changes in patient condition
Screen for new symptoms and new health problems
Monitor status of previous problems
Prevent potential problems
Different types of assessments
Comprehensive
Ongoing partial
Focused
Emergency
Comprehensive assessment
Done upon admission of new patient
Ongoing assessment
Done at every beginning of shift
Focuses assessment
Done only 1 area to assess specific area
Normally area where patient has most complain
Emergency assessment
Done to determine life threatening or unstable conditions
What to focus on during assessment
Physical responses to illness
Patient’s functional status(how well they can take care of themselves)
Stressors that may be present (emotional/mental/environmental)
How to prepare for physical assessment
Ask about pain, how strong they feel at that moment, or if they have anxiety
Explain everything as you go
Explain it’s painless
Build a trusting rapport
Use proper positioning patient and you
Preparing environment
Maintain privacy
Lower noise control
Use good lighting
Preparing yourself
Know patients situation and diagnosis before
Ask for help if needed
Speak with patient in a comforting way
Bring all equipment needed
Positions used in physical assessment
Standing Sitting Supine Dorsal recumbent Sims Prone Lithotomy Knee chest
Types of data collected
Subjective
Objective
Subjective data
What patient says
Ex. “I feel short of breath”
Objective data
What is observed or measured
Signs or symptoms seen by nurse
Ex. Lung sounds, X-ray results, labs,
How to assess symptoms
Ask for:
Location(where) Quality Quantity Chronology(how long) Meaning to patient Aggravating or alleviating factors( what makes it feel better) Associated manifestations
OLD CART acronym for symptom assessment
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatment
Groups physical assessment is grouped into
Perfusion (circulation)
Oxygenation (respiratory)
Neurological
Gastrointestinal
Genitourinary
Mobility (musculoskeletal)
Integumentary
Ears, nose, throat
Pain
What to assess in perfusion(circulation)
Auscultaré heart sounds Inspect and touch legs/arms for edema Touch arms/legs for temperature Inspect capillary refill Palpate distal pulses(on feet)
Oxygenation(respiratory)
Evaluate breathing effort
Inspect overall skin color
Listen to lung and breath sounds
Inspect chest shape
Neurological
Evaluate speech
Assess:
level of consciousness
orientation
PERRLA
Gait
PERRLA
Pupils equal round and reactive to light and accommodation
GI
Inspect abdomen for shape:
Flat, scaphoid, or distended
Palpate abdomen for tenderness/distention
Listen to bowel sounds in all 4 quadrants
GI structures at in upper right quad
Pylorous Liver Duodenum Right kidney Right adrenal gland Head of pancreas
Structures in left upper quadrant
Stomach Spleen Left kidney Left adrenal gland Splenic fixture of colon Body of pancreas
Structures in right lower quad
Cecum Appendix Right ureter of kidney Right ovary & Fallopian tube Right spermatic cord
Structures in left lower quad
Sigmoid Colin
Left ureter of kidney
Left ovary & Fallopian tube
Left spermatic cord
Structures along abdomen midline
Urinary bladder
Urethra
Genitourinary
Inspect and gently palpate bladder
Assess & ask about: Bladder of renal pain UTI’s Dysuria Constipation Urinary incontinence Hematuria Urinary retention(in males)
Assess after Foley removal because must per within 6 hrs
Mobility (musculoskeletal)
Palpate extremities for tenderness
Evaluate movement and sensation
Assess muscle strength and symmetry of it
Observe range of motion in joints
Integumentary (skin)
Look for skin lesions or wounds
Color
Types of skin lesions
Fissures
Erosions
Ulcers
1 more
Ears, nose, throat
I
Check eyes using PERRLA
Assess hearing (based on convo & asking of hearing aids)
Check mouth for sores, color, dryness)
Face
Pain Assessment using PQRST
Palliative/provocative factors - what makes it better and worse
Quality - describe pain
Radiation/region - where is the pain
Severity - how does pain compare to other pain or how bad is pain
Temporal factors - does intensity change over time
Inspection part of assessment and what is usually inspected
Use sight, hearing, and smell to gather data
Ex. of what is inspected Skin color Gait Behavior Posture General appearance
Palpation part of assessment & what palpate is used for
Touching to gather data
Begin with light pressure and then go deeper
Exx. Edema Moisture Masses Temperature Turgor
Percussion
Tapping on skin to listen to sound
Used by MDs to assess abdomen, underlying structures and lungs
Auscultation & what it is used for
Hearing and listening for gathering data
Use stethoscope
Always place stethoscope on direct skin
Used for listening to heart, lung, and bowel sounds
What is diaphragm of stethoscope used for
High pitched sounds
What is bell of stethoscope used for?
Low pitched sounds
Factors important to health history
Biographical data
Reason for seeking health care
History of present illness
Past medical history
Family history
Functional health- how good they can take care of themselves
Psychosocial and lifestyle factors
Review of systems - subjective data
Components of a preventative health history
Ask of health history
Check for risk of depression
Functional ability
Level of safety
Physical examination
Patient education & counseling
Cultural considerations go keep in mind
Think of patient in regards to family, culture, and community
Be knowledgeable and nonjudgmental
Beware of health beliefs of their culture
Categories in general survey
Appearance:behavior Grooming/hygiene Body type/posture Mental status Speech Vital signs Nutritional status
Appearance/behavior component of general survey
Signs of distress
Do they look their age
Mood and mental status
Visible skin lesions, skin color
Speech and correct behavior for their age
Symmetrical facial features
Grooming/hygiene
Are they dressed appropriately?
How good is their hygiene
Body type and posture component of general survey
Body size Gait Posture Body movements Use of assistive devices Fall risk?
Mental status component of general survey
Includes level of consciousness and orientation
Levels of consciousness
Normal
Obtunded(stuporous) - not totally asleep but little response
Lethargic - resembling deep sleep, can be aroused but goes back to sleep
Coma - state of unawareness and unresponsiveness
How to assess orientation
Ask for time, place, person(what their name is or age), & situation (what brought them to the hospital)
Levels of orientation
Alert x3
Purpose of documentation
To identity actual & potential health problems
Make nursing diagnosis & interventions
Plan appropriate care
Evaluate patients response to treatment
Always document right away so MD knows patient status & can prevent or detect early
