Physical Assessment Flashcards
Nursing Physical Assessment
- part of a general health assessment
- used to gather data about the client
- focuses on functional abilities and responses to illness/ stressor
Key Concept
a comprehensive assessment of the physical, mental, spiritual, socioeconomic and cultural status of an individual, group or community
Nursing Assessment
focus on the clients functional abilities and physical responses to illness and other stressors
Purpose of a Nurse to Perform a Physical Examination
- Establish baseline data about physical status and functional ability to serve as a comparison to a patients health condition
- Identify nursing diagnoses, collaborative problems, or wellness diagnoses that form a basis for plan of care
- Monitor the status of an identified problem
- Screen for health problems i.e. regular checkups, health screenings, colonoscopy
Comprehensive Physical Examination
health history interview plus complete head-to-toe examination
-when you get admitted
Focused Physical Examination
- “focused” and limited to presenting problem or body part
- can be done during emergent situation; chest pain during ER assessment
- system specific
- limited to one body system
Ongoing Physical Examination
- performed as needed to assess status once initial is done
ex: lung sounds after respiratory treatment given - evaluates client outcomes and or changes
ex: reassess 30 minutes after pain meds given
Prepare to Perform a Physical Examination?
- develop a systematic approach and follow same order each time (will help you recall the steps and establish a routine)
- you will gain knowledge and experience as you do more and more
- you will learn to start your assessments as they get off the elevator or you see them coming down the hall
Organizing the Examination
Head-to-Toe -start at head and neck -progresses "down" the body -body-system approach-related data found throughout system >Neurological- mental status >Heart Sounds- chest + lungs >Pulses- periphery up to core pulses
Preparing Yourself: What the Nurse Needs
- Theoretical Knowledge: A+P, proper equipment, techniques, therapeutic communication
- Self Knowledge: skill + comfort level, willingness to seek help, help with documenting, terms, subjective/ objective
- Knowledge about Client Situation: purpose of examination, client diagnosis, background info, patients main health concerns, review previous findings if available
Preparing the Environment
>Privacy is Key -draping, uncover only the part you are examining, use of curtains, ask family/ visitors to step out >Noise Control -TV/ radio/ computer off, close door if needed >Enable Visualization -adequate lighting, flashlight if needed >Temperature >Equipment
Physical Assessment Skills
IPPA
- Inspection
- Palpation
- Percussion
- Auscultation
Inspection
use of sight to gather data -used throughout physical examination -tools to enhance inspection: >otoscope >ophthalmoscope >penlight ex: skin color, gait, general appearance, behavior
Palpation
use of touch to gather data
-begin with light pressure, moving to deep palpation
-use caution with deep palpation
.>Parts of hand used:
-Fingertips: tactile discrimination
-Dorsum: temperature determination
-Palm: general area of pulsation
-Grasping: (fingers+thumb): mass evaluation
ex: edema, moisture, anatomical landmarks, masses
Percussion
Tapping on skin to elicit sound as it produces vibrations, and the resulting sound allows you to determine location, size, and density of underlying structures
- direct
- indirect
- useful for assessing abdomen, lungs, underlying structures
ex: distended bladder
Auscultation
Use of hearing to gather assessment data
-Direct Auscultation: listening without a instrument, wheezing or chest congestion
-Indirect Auscultation: use of a stethoscope to listen
>Diaphragm- high-pitched sounds
>Bell- low-pitched sounds
ex: heart + lung sounds
Age Modification for Physical Examination: Infants
- parent holds the infant
- attend to safety
Age Modification for Physical Examination: Toddlers
- allow to explore and/ or sit on parents lap
- invasive procedures last
- offer choices
- use praise
Age Modifications for Physical Examination: Preschoolers
- use doll for demonstration
- still may want parent contact
- allow child to help with examination
Age Modifications for Physical Examination: School-age Children
- show approval + develop rapport
- allow independence
- teach about workings of the body
Age Modifications for the Physical Examination: Adolescence
- provide privacy
- concerned 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
Age Modifications for the Physical Examination: Older Adults
- may need special positioning related to mobility
- adapt examination to vision + hearing changes
- asses for change in physical ability
- assess for ability to perform activities of daily living (ADL)
- provide periods of rest as needed
SPICES
help to remember common problems of older adults that require nursing interventions and to focus your assessment as you perform a comprehensive physical examination S- sleep disorders P- problems with eating or feeding I- Incontinence C- Confusion E- Evidence of Falls S- Skin Breakdown
Basic Components of a General Survey
- Begins at first contact, overall impression of client, deviations of abnormal findings will lead to more focused assessments
- appearance/behavior
- grooming/hygiene
- body type/ posture
- mental state
- speech- slow, pressured, slurred
- vital signs
- height/weight
