Physical Assessment- Exam 3 Flashcards
Purpose of physical assessment?
Gather baseline data about the clients health
Supplement, confirm, or refute previous data
Make clinical judgments
Evaluate psychological outcomes of care 
Types of data
Subjective and objective
Sources of data
Primary and secondary
Laboratory diagnostic test
ABGS, CBC, sputum
Radiologic studies diagnostic test
Chest x-ray
CT
V/Q scan
PET scan
Diagnostic tests
Skin test
Pulmonary function test
Endoscopy examinations
Interview and the stages
Orientation phase
Working phase
Termination phase
Types of physical assessment
Comprehensive
Focused
System specific
Ongoing
Elements of assessment
History
Baseline history
Problem based history
Assessment
Interview
Physical assessment
Planning
Based on assessment data
Process and the physical assessment
Assessment
> interview
> physical assessment
Nursing diagnosis
Planning
>based on assessment data
Evaluation
> establishes nursing accountability
Techniques for assessment
All senses except for taste
Inspection
Palpation
Percussion
Auscultation
Olfaction
Inspection of the patient (Visual)
Good lighting
Expose all of part to be examined, drape, or cover parts, not being examined for privacy
Use additional lighting/devices for some areas of body eyes, ears throat
During inspection, observe for
Color
Shape/symmetry
Movement
Position
Palpitation
Bimanual/manual technique
Dorsum of hand - assess body temp
Palm or ulnar surface of hand
Palmer surface of finger/finger pads
Light palpation
1 cm or 1/2 depth
Deep palpation
4cm or 2 in depth
Palpate to assess
Texture
Resistance
Resilience
Mobility
Temperature
Thickness
Shape
Moisture
Percussion- direct
Apply directly to body
Percussion- indirect
 Applied through another surface
Auscultation (auditory)
 Frequency
Loudness
Quality
Duration
Auscultation- frequency
Number of oscillations per second generated by a vibrating object
Auscultation- loudness
Amplitude of a sound wave
Auscultation- quality
Descriptive
Auscultation- duration
Length of time that sound last
What part of the stethoscope is best for low pitch sounds
Ex: vascular and some heart sound
Bell
What part of the stethoscope is best for high pitch sounds
Example: bowel and some abnormal lung sound
Diaphragm
Olfactory -sense of smell
Used to detect abnormal versus normal
Examples
Alcohol on breath
Foul smelling odor from wound
sweet, smelling odor from mouth
Preparing for the assessment
Gather all necessary equipment
Introduce yourself
Explain procedure
Use gloves if necessary
Wash hands before and after any contact with patient
Clean stethoscope, head in blood pressure cuffs between patients
Make patient comfortable and allow for privacy and confidentiality
What general survey do we start with before we start assessment
Race/gender
Age
Body type
Posture
Signs of distress
Substance abuse
Speech
Movement/gait
Hygiene/grooming
Dress
Affect/mood
Patient abuse
Signs of abuse
Inconsistency between injury and statement
Bruises, lacerations, burns, bites
X-ray show fractures in various stages of healing
Behavior, issues, insomnia, anxiety, isolation
- most common in dependent lobes; right and left lung bases
- fine crackles: are high pitched fine, short, interrupted cracking sounds
- medium crackles: are lower, moister sounds heard during middle of inspiration; not cleared with cough
- coarse crackles: are loud, bubbly sounds heard during inspirations or expiration, not cleared by coughing
Crackles
Primarily heard over trachea and bronchi, if loud enough, able to heard over most lung fields
Cause: muscular spasm, fluid or mucus in large airways, new growth or external pressure causing turbulence
Loud low pitched rumbling, coarse sounds are heard either during inspiration or expiration, sometimes cleared by coughing
Rhonchi
- heard all over lung fields
- high velocity airflow through severely narrowed or obstructed airway
- high pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration, usually louder on expiration
Wheezes
- heard over anterior lateral lung field (if pt is sitting up)
- inflamed pleura; partial pleura, rubbing against visceral pleura
- dry rubbing or grating quality is heard during inspiration or expiration, does not clear with coughing; heard loudest over lower lateral anterior surface
Pleural friction rub
