Basic Physical Assessment Notes
Physical assessment is the systematic collection of objective data that are directly observed or are elicited through examination techniques, such as inspection, palpation, percussion, and auscultation. Subjective & Objective data Subjective data is the data the patient tells you Objective data is the data you collect during the assessment Inspection Performing deliberate, purposeful observations in a systematic manner Uses senses of smell, hearing, and sight
Looking for symmetry on both sides of body, lesions (tattoos, moles, pimples, and anything else not meant to be on skin), abnormalities, color, shape, moisture (diaphoresis, or lack of) Make sure you’re talking to the pt, letting them know what you’re looking at/for (not just blankly staring at them) Palpation Uses sense of touch Assesses temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs Temperature is assessed with the dorsal (back) side of your hand The palms of your hand are used to feel vibrations
Tips of your fingers are used to feel organs and other underlying structures Light palpation: apply light pressure with dominant hand, using circular motions to feel surface structure (only press ? in. ) Deep palpation: place non-dominant hand on top of dominant hand and apply pressure to feel deeper structures, like organs or masses (about 1-2in) Palmar surfaces of the examiner’s fingertips and finger pads are used for discriminatory sensation such as texture, vibration, presence of fluid, or size and consistency of a mass The dorsum (back of hand) is used to assess surface temp.
Percussion Act of striking one object against another to produce sound Assess location, shape, size, and density of organs and other underlying structures or tissues Tones (from softest to loud intensity): Flat: over bony prominences (thigh) Dull: over organs (liver) Resonance: normal lung Hyper-resonance: emphysematous lung, COPD Tympany: gastrointestinal, bowel sounds “Equal bilaterally” (sounds can’t be symmetric) Auscultation Listening with clean stethoscope to hear sounds within the body BP, heart, lung, and bowel sounds Four characteristics:
Pitch (high to low) Loudness (soft to loud) Quality (gurgling, swishing, etc) Duration (short, medium, long) Biographic Data Collected on admission & documented Identifies the patient Name, address, gender, marital status, race, occupation (more pg 46 TCNS) Reason for Seeking Care Focuses the assessment Use open ended question, “Tell me why you are here today” Document in pt’s own words History of Present Health Concern Explore the symptoms thoroughly (PQRST) Provocative or palliative What causes symptoms? What makes it better or worse?
What were you doing when you first noticed it? What triggers it? Quality or quantity: How does the symptom feel, look, or sound? How much are you experiencing right now? Is it so much that it prevents everyday activities? Region or radiation: Where is the symptom located? Does it spread? Severity: On a scale of 1-10 (1 being lowest) how bad is the symptom at its worst? Does it force you to stop what you’re doing? Does anything relieve it? Timing: When did the symptom begin? Did it occur suddenly or gradually? How often does it occur? Past Medical History
May provide insight into causes of the current symptom Includes past illnesses, chronic health problems and treatment, and previous surgeries or hospitalizations Are your immunizations up to date? Do you have any chronic illnesses or allergies? Describe any accidents, injuries, and surgeries you’ve had Family History Certain disorders have genetic links How old are the members of your family? If any members of your family are not living, what caused their death? Is there any history of this health problem you have in other family members?
Lifestyle Patient’s lifestyle contributes to their overall health or wellbeing Do you smoke, drink, or do drugs? If so, for how long? Describe the foods you eat on a regular day Tell me about how well you sleep How much exercise do you get each day? Pg 50 TCNS has a brief overview of a head to toe physical assessment Taylor Health Assessment Comprehensive assessment Health history & complete physical exam when patient first enters a healthcare setting, with info providing a baseline for comparison of later assessments Ongoing partial assessment
Conducted at regular intervals (beginning of each home health visit or each hospital shift) during care of the patient Concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions Focused assessment Assesses a specific problem If a woman is having abdominal pain, the nurse asks about urinary and bowel problems, allergies, and a menstrual history during the health history and assesses vital signs and abdominal structures during physical assessment Emergency assessment
Rapid, focused assessment conducted to determine potentially fatal situations Assessing the airway, breathing, and circulation before beginning cardiopulmonary resuscitation Nursing health assessment differs from other types of assessments, in which it’s a holistic collection of info about factors that affect or are affected by one’s level of health Health assessment is an integral component of nursing care and is the foundation of the nursing process ~~~09/02/13~~~
Assessments are used to plan, implement, and evaluate teaching and care to promote an optimal level of health through interventions to prevent illness, restore health, and facilitate coping with disabilities or death Make sure patient is properly prepared for the assessment and all anxieties and questions are addressed Environment should be well lit, private, and quiet Make sure patient empties bladder Physical Assessment Systematic collection of objective info Head-to-toe sequence Equipment needed: Stethoscope Auscultate heart, lungs, abdomen
Ophthalmoscope Visualizes interior structures of eye For our class purposes, we will not be using this Otoscope Used to examine the ear canal & tympanic membrane Different attachments can also turn this into a nasal speculum to see into the nose Snellen Chart 11 lines of different-sized type, largest letters on top, smaller on bottom Percussion Hammer “Reflex hammer” Tests deep tendon reflexes Positioning Standing Pt stands erect Should not be used for pts who are weak, dizzy, or fall risk Assesses posture, balance, and gait Sitting Pt sits on chair, edge of bed/ examining table, or elevate the head in bed Allows for visualization of upper body & facilitates full lung expansion Assesses vital signs, head, neck, anterior/ posterior thorax, lungs, heart, breasts, and UE Supine Pt lays flat on back w/ legs extended and knees slightly flexed Assesses vital signs, head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulse Dorsal Recumbant Pt lies on back with legs separated, knees bent, feet flat on bed Assesses head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses Sims Position
Pt lies on either side with the lower arm below the body and the upper arm flexed at the shoulder and elbow Both knees are flexed, with the upper leg more acutely flexed Assesses rectum or vagina Prone Pt lies flat on the abdomen with head turned to one side Assesses hip joint and posterior thorax Lithotomy Pt is in dorsal recumbent position but with the buttocks at the edge of the table and the feet in stirrups Used to asses female genitalia and rectum Knee-chest Pt kneels, with body at a 90-degree angle to the hips, back straight Assesses anus and rectum Draping
Prevents unnecessary exposure, provides privacy, and keeps pt warm Expose only body parts being assessed to maintain the patient’s modesty and comfort Guidelines for Conducting a Physical Assessment Performing a General Survey First component of the physical assessment Appearance and behavior Inspect pt’s body build, posture, and gait Note proportion of height to weight Erect vs. slumped posture Uncoordinated or spontaneous movements may suggest neurologic problems Note signs of illness, such as: Changes in posture, skin color, and respirations Non-verbal communication of pain or distress Short attention span
Observe hygiene and grooming (cleanliness, body odors) Pt’s with inappropriate dress (wrong for season), worn or dirty clothing may be experiencing feelings of depression or have inadequate financial resources Assess cognitive processes (AOx3) Clues to mood and mental health are provided by speech, facial expressions, ability to relax, eye contact, and behavior Vital Signs See vital signs notes Height and weight Ratio of height to weight is an assessment of over all health and over-nutrition/ under-nutrition Shoes and heavy clothing should be taken off if measurements taken before pt undresses Assessing the Integument
Integument is comprised of the skin, nails, hair, and scalp Can give clues to local or systemic health problems History Rashes, lesions, changes in color, itching? Bruising or bleeding in skin? Allergies? Sun and sunburn history? More pg 571 Physical Assessment Examination gown used & pt in sitting position If pt has lesions of the skin or head lice, wear gloves Inspection Skin color should be relatively constant all over Minus more sun-exposed areas Changes in skin color include: Erythema Redness Facial area or other localized area Causes include blushing, alcohol, fever, injury trauma, or infection Cyanosis
Bluish Exposed areas, particularly the ears, lips, inside of mouth, hands/ feet, nail beds Causes include cold environment, cardiac or respirator disease (decreased oxygen) Jaundice Yellowish Overall skin areas, mucous membranes, and sclera Liver disease (increase in bilirubin levels) Pallor Paleness (or ashen grey/ yellow tinge in darker people) Exposed areas, particularly the face and lips, conjunctivae, and mucous membranes Anemia (decreased hemoglobin) or shock (decreased blood volume) Inspecting skin vascularity and lesions Skin is inspected for vascularity bleeding, or bruising
Anything on the skin is considered a lesion Moles, freckles, tattoos, birthmarks, piercings, scars, sores Ecchymosis (bruising) is a collection of blood in sub-q tissues causing a purplish discoloration Petechiae is a small hemorrhagic spots caused by capillary bleeding Moles ABCDE- asymmetric, border, color, diameter, elevation/ exudate Lesions are areas of diseased or injured tissue Table 25-6 pg 573 (don’t need to know specifics) Inspecting nails Shape, angle, texture, color Somewhat convex, follow natural curve of finger Nail and it’s base should be 160° Nail abnormalities pg 576
Capillary refill Should be immediate- 3 seconds If pt has artificial nails or nail polish use the pad of their finger instead Inspecting hair and scalp Hair should be found everywhere but palms/ soles, and parts of genitalia Assess for color, texture, distribution Decreased oxygenation of peripheral tissues may cause loss of hair Excessive hair growth may occur in persons with hormonal disorders Separate the hair to inspect the scalp for color, dryness, scaliness, lumps, lesions, or lice Feel for lumps and bumps; if felt, are they tender? Palpation Skin is normally warm and dry
In a dehydrated pt, the texture is dry, loose, and wrinkled while the mucous membranes are cracked and dry Turgor- fullness or elasticity of the skin Usually assessed on the sternum or under the clavicle by lifting a fold of skin with the thumb and first finger Normal: when the fold returns to usual shape when released Skin fold returns slowly on a dehydrated pt However this may be normal in older patients Edema- excess fluid in tissues that is characterized by swelling, with taut & shiny skin over the edematous area Area is palpated with 2 fingers and measurement of indentation (in mm) is taken Scale of 0 to +4, starting at +1 for 2 mm
If it is deep, it is called pitting edema Can be result of over hydration, heart/ kidney failure, trauma, or PVD Assessing the Head and Neck Includes skull, face, eyes, ears, nose and sinuses, mouth and pharynx, trachea, thyroid gland, and lymph nodes History Changes in vision/ hearing with age? Glasses/ hearing aids? Allergies? Disturbances in vision/ hearing? History of chronic illnesses such as hypertension, diabetes, or thyroid disease? Head trauma? More pg 577 Physical Assessment Inspection Inspect the head for size and shape Normal cephalic, round Symmetry
Gentle curve with prominences at the frontal and parietal bones Inspect face for color, symmetry, distribution of facial hair, edema (around eyes), and involuntary facial movements Note any abnormalities (drooping, tremors) Eyes External structures Eyes, eyebrows, eyelids, eyelashes, lacrimal glands, pupils, and iris inspected for position and alignment Pupils are normally black, equal in size, round, and smooth Assess for reaction to light and accommodation and for convergence PERRLA Pupils equal, round, reactive to light accommodation Eyes aligned in sockets or protruding/ sunken
Eyelids/lashes Look for any exudates (drainage), color, puffy, sties, redness, eyelashes curl outward Two different colored eyes = asymmetric Any round body part you document like a clock Ears Midline, symmetric, no lesions, piercings, tenderness Tympanic membrane intact, pearly gray, and light reflex present Neck Check for bruit in 3 places along carotid artery on both sides Trachea midline, no lumps or bumps, no lesions ROM of neck Chin to chest, look up, look right & left, ear to shoulder both sides Muscle strength Put hand on face and have them do ROM moves while resisting them
Assessing the Thorax & Lungs Lungs, rib cage, cartilage, & intercostal muscles If pt is smoker, plan of care should include ways to stop smoking Health history Trauma to ribs or lung surgery? Number of pillows used when sleeping? Chest pain with deep breathing? Persistent cough? Allergies? Exposure to chemicals, asbestos, or smoke? More pg 586 Taylor Physical Assessment Requires a stethoscope and tape measurer Pt is sitting Thorax Inspection Color should be even and consistent with pt’s face No lesions
Shape/ contour should have a downward equal slope at rib cage Chest should be symmetric, with the transverse diameter greater than the anteroposterior diameter If it is greater, its considered barrel-chested Should be 2:1 Palpation Detects areas of sensitivity, chest expansion during respirations, and vibrations (fremitus) Use palmar surface of hands to palpate the thoracic landmarks in a sequential pattern for temp, moisture, muscular development, and any tenderness or masses To check chest expansion, place both hands on the middle of back w/ the fingers about level with T9 and thumbs midline to body (along spinal column).
Have pt take a deep breath. Thumbs should follow expansion symmetrically Percussion Percuss in a similar fashion as the picture below and listen to over the lung tissue (should sound resonant) Auscultation Ask pt to breathe slow and deep through the mouth Don’t have the pt hyperventilate (and get dizzy)! If pt has COPD or emphysema, the bases of lungs may be diminished Use this sequential pattern to listen to breath sounds on the posterior and anterior thorax (go down to 3, skip 4, do 5): Normally, breath sounds result from free movement of air in and out of the bronchial tree.
Note pitch, duration, & intensity of the sounds Bronchial sounds are heard over the trachea and are high pitched, harsh, hollow sounding Inspiration < Expiration Bronchovesicular sounds are heard over the mainstem bronchus and are moderate “blowing” sounds, Inspiration = Expiration (sounds similar during insp. & exp. ) Vesicular breath sounds are heard best over the base of the lungs and are soft, low pitched, Inspiration > Expiration Crackles are fine crackling sound as air moves through wet secretions, most often heard on inspiration (can be course crackling if heard around bronchioles, bronchi, or trachea)
Assessing the Cardiovascular and Peripheral Vascular System Heart and extremities Health history Chest pain, palpitations, or dizziness? Swelling an ankles and feet? Number of pillows used to sleep? Type and amount of pills? Heart defect, rheumatic fever, or chest/ heart surgery? More pg 589 Taylor Physical Assessment Pt can be sitting or in a supine position with head elevated to 30° An adequately lit & quiet room necessary Peripheral vascular assessments may be combined with assessment of other body areas Inspection Observe for pulsations around the area of the heart
There shouldn’t be any unless pt just exerted themselves Exception is apical impulse around 5th intercostal space Neck vein distension can indicate heart disease Palpation Use palmar surface of hand with fingers held together Use a systematic manner: aortic, pulmonic, Erb’s Point, tricuspid, and mitral areas Note size, duration, force, and location in relationship to the midclavicular line Normal: No pulsation palpable over aortic & pulmonic areas but a palpable apical impulse Auscultation Ask patient to breathe normally Use systematic method to listen to heart sounds ?
APE To Man (aortic, pulmonic, erb’s, tricuspid, mitral) Go over once with diaphragm and then when you get to the mitral area, take the apical pulse for 1 full minute Then go back over the heart with bell Anything outside of the usual “lubb-dubb” is abnormal Dubb heard in aortic & pulmonic Lubb heard in tricuspid & mitral Lubb & dubb should be heard equally over Erb’s Listen to the descending aorta for a bruit Assessing the Abdomen Contains stomach, SI, LI, spleen, kidneys, urinary bladder, and female reproductive organs Health History Abdominal pain? Indigestion, nausea/ vomiting, constipation/ diarrhea?
Food allergies/ lactose intolerance? Appetite and usual food/ fluid intake? Bowel and bladder elimination patterns? Gastrointestional disorders? For females, menstrual history? More pg 595 Taylor Physical Assessment Pt should void bladder Place pt in supine position with head slightly elevated (by pillow or bed) Make sure pt is warm and comfortable in order to prevent contraction of abdominal muscles, which makes palpation difficult Divide abdomen into 4 quadrants to easily document areas specifically Inspection Color should be even all over Umbilicus should be centered
Abdomen should be symmetric without visible peristalsis Look for any scars, stretch marks, or masses Auscultation Using the diaphragm, sequentially (clockwise) listen to the bowel sounds in each quadrant (should be heard every 5-32 seconds) In order to consider bowel sounds “absent”, nurse must listen to each quadrant for at least 2 minutes Percussion Useful in assessing a full bladder or changes in abdominal contents Percuss in all 4 quadrants to identify fluid, masses, or air (should hear tympany, unless over a full bladder then it should be dull) Palpation
Use pads of fingers with a light, gentle dipping motion Watch pt’s face for nonverbal signs of pain Palpate each quadrant lightly the first time around (feel surface structure) and then over once more a little firmer (feel internal organs) To palpate the liver Place your left hand under patient’s back at the level of 11-12 ribs With fingers pointed to head, ask pt to inhale and press up and in Liver should feel firm and smooth and may be mildly tender Assessing Lower Extremities Check for edema/ swelling (legs look shiny and taut)
Scars from surgeries/ injuries, veracose veins/ spider veins, sun spots Health History Phyiscial Assessment Palpation Palpate peripheral pulses (grade all bilaterally) Femoral, popliteal, posterior tibial, dorsalis pedis Assessing Urinary Bladder & Elimination Physical assessment Normally positioned below the symphysis pubis and cannot be palpated or percussed when empty When the bladder is full and distended however it rises to just below the umbilicus Note any swelling and palpate for tenderness Urine Color (depending on hydration) should be a pale yellow to amber Odor should be a slight aromatic
Turbidity- urine should be clear pH- usually 6, but can range from 4. 6-8 depending on diet and meds Specific gravity- 1. 015-1. 025 Assessing Female Genitalia NOT PART OF VALIDATION, BUT WRITTEN TESTS External female genitalia consists of the mons pubis, labia, clitoris, vaginal orifice, and urethral opening Health History Menstrual history Sexual history Pain with intercourse # of pregnancies History of STI’s Use of contraceptives More pg 598 Physical Assessment Male Dr. ’s may have a female present in the room for pt comfort Ask pt to empty bladder before examination Inspection
Color, size of labia, and vaginal opening Lesions/ discharge/ smell/ infected hair follicles Mucous membranes are dark pink and moist Skin should be smooth without lesions or swelling May be small amount of clear or whitish discharge Vaginal opening should be midline Palpation Only palpate if you really notice something wrong Use firm palpation Palpate labia for masses Palpate the Bartholin’s glands (located slightly below the left and right of the opening of the vagina) for swelling, pain, & discharge Bartholin cyst- a hard lesion that feels like a cyst (smooth, round)
Assessing Male Genitalia NOT PART OF VALIDATION, BUT WRITTEN TESTS Male genitalia includes the penis, testicles, epididymis, scrotum, prostate, and seminal vesicles Health History Frequency of rectal exams Frequency of testicular self-exams Use of contraceptives History of STI’s More pg 599 Physical Assessment Pt may be standing or supine; gloves used Inspection Size, placement, contour, appearance of the skin, redness, edema, and discharge Uncircumcised pt’s: retract foreskin to inspect the glans penis Use back of hand to lift penis to see the scrotum
Assess scrotum for symmetry It is not unusual for the left testicle to lie lower than the right Both testes should be similar bilaterally Note any swelling Any lesions Hair should be diamond shaped Palpation If pt were to get an erection, you state that this is a normal reflex and continue to (quickly) finish your assessment Scrotum and testes should be free of masses and non-tender Assessing the Rectum and Anus NOT PART OF VALIDATION, BUT WRITTEN TESTS Health History Bowel patterns, including constipation, diarrhea, or pain History of blood or mucous in the stool
Family history of polyps, colon or rectal cancer, or prostate cancer History of hemorrhoids Frequency of DREs History of anal intercourse Physical Assessment Lubricant, gloves, and good lighting necessary Pt may be in sims, knee-chest, lithotomy or standing and leaning over the examination table Inspection Increased pigmentation and some hair growth normal Note any lesions or hemorrhoids (document like a clock) Fissure- cracking (may be painful) Palpation Sphincter tone at the anus should be firm and mucosal lining smooth Males
Prostate gland can be assessed through the anterior rectal wall Normally smooth, firm, & about 1? in. in size Females Cervix could be felt as a small, round mass when palpating the anterior rectal wall Assessing the Musculoskeletal System Primary structures include bones, muscles, cartilage, ligaments, tendons, and joints Provides info about posture, gait, bone size/ structure, joint ROM, and muscle strength Normally, the joints are bilaterally equal in size, shape, and color; free of swelling, pain nodules, or crepitus, and can move through full ROM Health History
History of trauma, arthritis, or neurologic disorder History of pain or swelling in the muscles and/ or joints Frequency and type of usual exercise Dietary intake of calcium Any surgery on muscles or joints? History of smoking & alcohol intake? Physical Assessment Standing, sitting, & supine Can be integrated into assessment of other body systems See TCNS for guide to ROM and muscle tone tests (or T pg 602) Inspection of muscles Observe bilaterally (should be symmetric) Palpation of muscles Palpate for tenderness No atrophy, tremors, or flaccidity Palpating bones Normal contour and prominence and bilateral symmetry
No enlargements or asymmetry Inspecting the joints Full ROM includes flexion, extension, hyperextension, abduction, adduction, supination, & pronation Palpate joints for pain, swelling, nodules, and crepitis Inspecting spinal curves Have pt standing Inspect spine from the back and from the side Normally has concave curves at the cervical and lumbar spine and convex curves at thoracic and sacrococcygeal spine Kyphosis- increased thoracic spinal curve; more often seen in older adults Lordosis- exaggerated lumbar curve; more often seen in pregnancy or obesity Scoliosis- lateral curvatureof the spine with increased convexity on the side that is curved Assessing the Neurologic System Includes cerebral function, cranial nerve function, cerebellar function, motor and sensory function, and reflexes Pt should be AOx3, have full sensory function, and all muscle groups bilaterally strong Health History History of numbness, tingling, or tremors History of seizures, headaches, dizziness, or trauma to head or spine History of infections to the brain History of stroke Changes in vision, hearing, taste, or smell More pg 605 Physical Assessment
Cerebral function is evaluated throughout the health history interview and the physical assessment Assess pt’s mental status, memory, emotional status, cognitive abilities, and behavior Cerebellar function is evaluated by fine motor skills, coordination, and balance Sensory system is assessed by having the patient identify various sensory stimuli, and evaluate the reflexes by contraction of specific muscles Pt should be sitting Assessing mental status Includes level of awareness, level of consciousness, behavior and appearance, memory, abstract reasoning, and language Assess overall appearance
Clean, neat, erect posture Short & long term memory recall To assess awareness, ask person what today’s date is, their name/ age, name of the city their in, etc. Assessing level of consciousness Awake and alert Fully awake, AOx3, responds to all stimuli, including verbal commands Lethargic Appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying their name Stuporous Unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely
to be appropriate; responds to painful stimuli with purposeful movements Comatose Cannot be aroused, even with use of painful stimuli; may have some reflex activity (if none, pt is in a deep coma) Assessing memory Short term Ask pt to repeat series of numbers forward or back Start with 3 digits, and gradually increase until the patient doesn’t respond correctly Most adults can repeat a series of 5-8 numbers forward and 4-6 backward Long term Ask them when their birthday is or wedding anniversary Assessing abstract reasoning
Ask the pt to explain a proverb such as “the early bird gets the worm” If intellectual ability is impaired, they may give a literal explanation to the phrase Assessing Motor and Sensory Function Inspection of balance and gait Have patient walk heel to toe across room Observe posture, balance, and arm/ leg movements Posture should be erect with a slight swaying in the standing position Gait should be even with simultaneous arm movements Assessing motor function and coordination Have pt rapidly touch each finger with thumb and tap foot on floor Assessing sensory perception