Physical Assessment Part 1 Flashcards
Types of Nursing Assessment
- Admission Assessment (all the details)
- Shift Assessment (from day to day)
- Focused Assessment (on one specific area of the patient)
Organization of Nursing Assessment
- head-to-toe
- systems
- concepts
chose which works best for you!
Why do we assess patients?
- assess functional ability, nursing history
- establish nursing diagnoses and plan of care
- to assess progress and outcomes
- make clinical judgments
- identify areas for teaching
- communicate the client’s health status
How do we assess patients?
- types: subjective (symptoms), objective (signs)
- sources: client, records, family and other health care providers
- collection: observation, interviewing, examining, reading
What is your most important tool?
your senses: smell, taste, hearing, touch, and sight
Tools to use during assessment
- non-sterile gloves
- stethoscope
- pen light
- pen & paper
- bandage scissors
- 2X2 gauze
- tongue blade
- Doppler
- conducting gel
- alcohol pads
- V/S equipment
- safety pin or needle
- tape measure
Stethoscopes
- ear piece should fit snuggly in ear
- tubing should be between 12-18 inches
- chest piece should fit size of patient
Diaphragm
- detects high-pitched sounds like breath sounds, normal heart sounds, bowel sounds
- press firmly against skin
Bell
- detects low pitched sounds like abnormal heart sounds
- lay lightly on skin
Doppler
- ultrasonic stethoscopes that detect blood flow rather than amplify sound
- need transmission gel on skin
Inspection
- visual observation to determine health status
- throughout entire physical
- size, shape, color, symmetry, position, abnormality
Palpation
- determine: position, size, fluid, mass, movement, compressibility, pain, vibration, temperature
- use: palmer surface of fingers and pads, ulnar surface of hand and fingers, dorsal surface of hands
- always have warm and clean hands, fingernails should be short
- palpate tender areas last (do the easy things first)
- chat while palpating and watch
- wear gloves if necessary
- use two hands when palpating light (1cm) then deep (4cm)
Auscultation
- listen for sounds produced by body
- should be done in quiet place
- place stethoscope on bare skin
- target and isolate each sound
- identify all the characteristics of each sound
Duration (Auscultation Descriptive Terms)
long, short, continuous, interrupted
Pitch (Auscultation Descriptive Terms)
high or low
Intensity (Auscultation Descriptive Terms)
loudness
Quality (Auscultation Descriptive Terms)
subjective description (whistling, gurgling, snapping, etc)
Location (Auscultation Descriptive Terms)
right or left, 4 abdominal quadrants, anterior or posterior chest wall, etc
Physical Assessment Guidelines
- use a systematic approach
- review chart and get report
- approach one side of patient always looking at patient
- assess the environment and equipment
- check vitals first
- assess systems at greatest risk
- compare both sides
- look under gown
- record quickly and concisely
- most invasive and painful last
- cultural considerations
General Survey
- Paint a picture
- sex/race/age
- body type
- admitting diagnosis
- medical history
- posture/gait/mobility
- hygiene
- speech
- orientation
General Survey (Environment)
- position of bed and overhead table
- equipment
- sharps and gloves
- linen condition
- presence of family, spiritual needs
Anxiety
- level
- behavior
- learning needs
- cognitive function
- support
- family/lifestyle
- spirituality
Normal Vital signs
- Temp oral: 35.8-37.3
- Pulse 60-100; average 80
- Respiration 12-20
- BP less than 120/80
Pain
Medication: when was it given, how much, how effective, level of consciousness, vitals
- Pattern: onset, duration, associated activity/event/time/med/what makes better/worse
- Area:where
- Intensity: mild, moderate, severe, scale
- Nature: quality, characteristics
Head
-position, size, shape, contour, symmetry
Vision
- farsighted/nearsighted
- appearance: symmetry, eyes, lids, brows, sclera, lenses
- glasses? contacts?
Ears
- assistive devices
- drainage
- can hear normal speaking tones
Nose
- inspect nares
- nasal discharge, injuries, surgery, patency
Mouth and Throat
- dentition
- dentures
- tongue, mucous membranes, uvula
Cognition
- complex set of mental activities through which individuals acquire, process, store, retrieve, and apply information
- nervous system function
Accomodation
pupils should constrict when looking at the nearer object and dilate when looking at the far object
PERRLA
pupils are equal, round and reactive to light and accommodation
Skin
- color
- temp
- moisture
- turgor
- incisions, lesions, pressure ulcers
- IVs
- numbness, tingling, itching
- scars, tattoos, piercings
- hair and nails
- edema
