5 Physical Assessment

A. Nursing Health History a. Biographic Data b. Chief Complaint c. History of Present Illness d. Past Health History of Illness e. FUNCTIONAL HEALTH PATTERNS (11 by Gordon) B. Physical Examination

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Best done when?

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Techniques:

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Head – toe (cephalo-caudal) examination

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Special Considerations: Positioning: a. Neck: nurse behind the client b. Thorax/Lungs: sitting position c. Abdomen:  Position  sequence of examination (technique and quadrants)

Skills of Physical Assessment Palpation: SENSITIVITY OF PARTS OF THE HAND

Hand Part Used

Type of Sensation Felt

Fingertips

Fine discriminations

Palmar / Ulnar surface

Vibratory sensations (e.g. thrills, fremitus)

Dorsal Surface

Temperature

Deep palpation

Light palpation

2 TYPES OF PALPATION: 1. Light palpation - 1 cm  dominant hand’s fingers parallel to skin

2.

surface  skin is slightly depressed;

Deep palpation – 4 cm

 done with one or two hands (bimanually)

a. deep bimanual b. deep palpation using one hand

Indirect percussion

Direct percussion

Skills of Physical Assessment 3. Percussion  sense of touch and hearing  tapping a part of body with fingertips to elicit

character and density of underlying tissue  determine whether underlying tissue a. AIR – FILLED b. FLUID FILLED C. SOLID

Skills of Physical Assessment 3. Percussion

Two types: a. Direct – to elicit tenderness or pain (differentiate) b. Indirect  Pleximeter: middle finger of non-dominant hand  Plexor: dominant hand * Plexor strikes the distal interphalengeal joint

Skills for Physical Assessment 4. Auscultation  process of listening to various sounds (breath, heart, bowel) produced within the body using stethoscope - stethoscope: bell and diaphragm: types of sounds

General Color: a. Normal: pinkish b. Pallor  Dark – skinned? Ashen gray  Brown – skinned? Yellowish brown tinge  Light skin? * Face, conjunctiva, nails

General Color: c. Jaundice – yellowish tinge  Evident where? * Sclera, mucous membranes, skin  Dark skinned: normal yellow pigmentation of sclera: Where to assess for jaundice? * Hard palate

General Color: d. Cyanotic – bluish tinge/discoloration  Best assess where? * Nail beds, lips, buccal mucosa 1. Central cyanosis  lips, buccal mucosa, tongue 2. Peripheral cyanosis  nails and skin of extremities

Skin Turgor:  fullness or elasticity  How:

* lifting and pinching the skin

a. Normal: Good: springs back to previous state b. Poor  For elderly:  For children:

 Scale

for describing edema: Grade 1+ : 2 mm Grade 2+ : 4 mm Grade 3+ : 6 mm Grade 4+ : 8 mm

* BRAWNY EDEMA

SKIN LESIONS: PRIMARY = APPEARS INITIALLY Macule – small flat Patch – bigger macule Papule – elevated Plaque – bigger papule Vesicle – with fluid Bulla– bigger vesicle Pustule – with pus Wheal – mosquito bites

SECONDARY : TRAUMATIZED PRIMARY LESION C = Crust U = Ulcer E = Erosion S = Scales

– dried blood, pus or serum – deep, irregular wearing away – wearing away of epidermis – shedding flakes

NAIL PLATE SHAPE : curvature and angle ▪ ▪

convex curvature angle between nail and nail bed: 160 degrees

b. Spoon – shaped nail: Koilonychia: (IDA)

NAIL PLATE SHAPE : curvature and angle c. Clubbing Early clubbing: flattened angle (180) Late Clubbing > 180

BLANCH TEST (CAPILLARY REFILL) a. Normal: b. Delayed return of pink

EYES AND VISION  Visual Acuity Tests: a. Distance Vision Test b. Near Vision Test  PERRLA  Pupil size

 Abnormalities:  Unequal pupil:  Dilated pupil?  Constricted pupil?

II. EYES AND VISION  Abnormalities: a. Myopia b. Hyperopia c. Presbyopia: loss of elasticity of lens d. Astigmatism: uneven curvature of cornea 

Tests for glaucoma: a. Tonometry – measures IOP: Normal: 8- 21 mmHg b. Perimetry – loss of peripheral vision c. Opthalmoscopy – cupping of the disc d. Gonioscopy – measures the angle to differentiate closed and open angle glaucoma

Question:  What

type of lens should be used to correct myopia?

 Type

of lens to be used to correct hyperopia?

EARS AND HEARING  To visualize ear canal: a. AdUlt b. ChilD  Tests: a. Rinne Test  Normal: AC is greater than BC  Conductive problems: BC > AC c. Schwabach Test

b. Weber test

 bone conduction by testing lateralization of sounds: N:

(-)

 Conductive

hearing loss, Bad ear hears better

 Sensorineural

hearing loss, Good ear hears better

 Interpretations:

BAD-CONDUCTION, GOOD-SENSATION

Mouth and Pharynx Question:

PART WHERE CENTRAL CYANOSIS IS BEST ASSESSED?

THORAX AND LUNGS APL ratio Percussion: Normal:

a. b.  

Resonant

Dullness:

with solid tissue (PNEUMONIA) or fluid (Pleural effusion)

Hyperresonance: 

hyper-inflated lungs (asthma, emphysema)

Thorax and Lungs Chest deformities: 1. Pigeon chest : pectus carinatum 

Narrow, transverse diameter, increased AP and protruding sternum

2. Funnel chest : pectus excavatum 

Sternum depressed, narrow AP diameter,

Thorax and Lungs Chest deformities: 3. Barrel chest : 

APL is 1:1

4. Kyphosis 

Excessive convex curvature

5. Scoliosis

NORMAL BREATH SOUNDS: a. Bronchial  air passing thru trachea  in front of trachea.  1:2 ratio (inspiration: expiration)

NORMAL BREATH SOUNDS: b. Bronchovesicular  air moving thru larger bronchi  between scapulae, 2nd ICS.  1:1 ratio  

NORMAL BREATH SOUNDS: c. Vesicular  air moving through smaller bronchioles and alveoli  peripheral, base of lungs  5:2 ratio

ADVENTITIOUS BREATH SOUNDS: 1. CRACKLES – RALES: R = Roll hair A = Air pass mucus L = Low lungs E = Exaged by inspiration S = Styles: fine, med, course

ADVENTITIOUS BREATH SOUNDS: 2. FRICTION RUB  rubbing, inflamed pleural surfaces.  grating sound  lower anterior chest  audible: both inspiration and expiration.

ADVENTITIOUS BREATH SOUNDS: 3. GURGLES  air thru narrowed spaces  coarse, with snoring quality  predominate: bronchi and trachea.  best heard on expiration.

ADVENTITIOUS BREATH SOUNDS: 4. WHEEZE  air thru constricted bronchus  high pitched, squeaky musical sound.  over all lung fields  best heard on expiration.

JUGULAR VEIN:  semi-fowler’s: 30-45° during assessment.  veins not visible: normal  veins distended: possible right sided heart disease.  Measure JV highest distention from angle of Louis  until 4cm only.  above 4cm: vein distention.

a.

Point of Maximal Impulse

a.

Semilunar and Attrioventricular (AV) valves P: 2nd ICS left sternal border A: 2nd ICS right sternal border M: 5th ICS left MCL T: 5th ICS left sternal border

BREAST a. Upper outer quadrant 

common site of breast cancer

b. BSE 5-7 after the first menstruation day MONTHLY c. 20-40 y/o: Clinical breast exam yearly D. Mammography at 40 yearly

a. Sequence: By quadrant: RLQ, RUQ, LUQ, LLQ

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b. Position: c. Bowel Sounds:    

Normoactive Hypoactive Hyperactive Absent:

Abdominal Test: Shifting Dullness

1. 2. 3. 4. 5. 6.

COMPONENTS OF NEUROLOGICAL ASSESSMENT Mental Status Level of Consciousness Reflexes Motor Functions Sensory Functions Cranial Nerves

I. Mental Status:  Reveals cerebral function (intellectual and affective)  Major areas of assessment: a. Language b. Orientation c. Memory d. Attention span e. Calculation

Language Aphasia – inability to express oneself by speech, writing or comprehend spoken or written language due to disease of cerebral cortex Two Categories: 1. Sensory or receptive aphasia 2. Motor or expressive aphasia A.

Sensory/receptive aphasia - loss of ability to comprehend written or spoken words Two types: a. Auditory aphasia – unable to understand symbolic content associated with sounds b. Visual aphasia – unable to understand printed or written figures 1.

2. Motor/ expressive aphasia - loss of power to express oneself by writing, making signs or speaking How to assess language deficits:  Point to common objects and name them  Read some words and match printed and written words with pictures  Respond to verbal/written commands

Speech Patterns: - pace, clarity, spontaneity Abnormalities: a. Perseveration - repeating the same response as different questions are asked b. Paraphasia - speech appropriately expressed but contains incorrect words

B. Orientation – 3 spheres C. Memory Listen for lapses of memory If problems are present: Three categories of memory: 1. Immediate recall N: can repeat series of 5 – 8 digits in sequence and 4 – 6 digits in reverse order

C. Memory 2. Recent memory - Ask to recall the events of the day - Recall information given early in the interview - Provide 3 facts to recall (color, object, address), then ask later

C. Memory 3. Remote memory - Previous illness or surgery (years ago), birthday, anniversary D. Attention Span - Tests the ability to concentrate (alphabet, count backward from 100)

E. Calculation - Serial seven or serial three test N: can complete serial seven in 90 seconds with 3 or less errors

II. Level of Consciousness  Conscious, L O S C  Glasgow Coma Scale (GCS) a. Eye opening 4 b. Verbal response 5 c. Motor response 6 Perfect score: 15 (fully alert and oriented) * Score of 7 or less- comatose

III. REFLEXES - Automatic response of the body to stimulus - Not voluntary learned or conscious - Deep tendon reflex (DTR) is activated when tendon is stimulated (tapped) and its associated muscle contracts - Reflex response varies among individuals and by age

Equipment: reflex hammer Scale for Grading Reflex Responses 0: No reflex response +1: minimal activity (hypoactive) +2: normal response +3: more active than normal +4: maximum activity (hyperactive) 

REFLEXES: 1. Biceps Reflex - tests the spinal cord C5 & C6 2. Triceps Reflex - spinal cord C7 and C8 - triceps tendon 1-2 in above elbow

REFLEXES 3. Brachioradialis reflex - spinal cord C3 and C6 - tap directly on the radius (1-2 in) above the wrist or the styloid process (bony prominence on the thumb side of the wrist)

REFLEXES 4. Patellar reflex - spinal cord L2, L3, L4 5. Achilles reflex - spinal cord level S1 and S2 - dorsiflex the ankle 6. Plantar (Babinski) reflex

CEREBELLAR FUNCTION a. Posture and gait b. Smooth and coordinated movements c. Equilibrium

Cerebellar disorders: Ataxia  lack of muscle coordination  tremors  disturbance of equilibrium, timing of movements and gait

MOTOR FUNCTION Gross Motor and Balance Tests a. Gait b. Romberg test c. Standing on one foot with eyes closed (5 seconds) d. Heel to toe walking

MOTOR FUNCTION Fine Motor Tests for Upper Extremities a. Finger to Nose Test b. Alternating Supination and Pronation of Hands on Knees c. Finger to Nose and nurse’s finger ( 18 in) d. Finger to thumb

V. SENSORY FUNCTION  include touch, pain, temperature, position and tactile discrimination  face, arms, legs, hands, feet are tested

Three types of tactile discrimination: a. One and two point discrimination  ability to sense whether one or two areas of skin are being stimulated by pressure b. Stereognosis  act of recognizing objects by touching and manipulating them c. Extinction  failure to perceive touch on one side of the body when two symmetrical areas of the body touched simultaneously AGNOSIA - Inability to recognize objects by use of senses

CN I: CN II: CN III: CN IV: CN V: CN VI: CN VII: CN VIII: CN IX: CN X: CN XI: CN XII:

THE CRANIAL NERVES Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear/Acoustic Glossopharyngeal Vagus Spinal Accessory Hypoglossal

The intervention that should be included in the assessment of a patient’s orientation would be: A. asking the patient to state the time of day       B. inquiring if the patient remembers the nurse’s name       C. ascertaining if the patient can follow simple directions       D. determining if the patient follows movement with the eyes

Which of the following indicates a normal finding on percussion of the lungs? 1. 2. 3. 4.

Tympany over the right upper lobe Resonance over the left upper lobe Hyperresonance over the left lower lobe Dullness above the left 10th intercostal space

Tympany would be heard over the stomach (air filled). 2. Correct. Resonance is a normal sound over the lung. 3. Hyperresonance is never a normal finding 4. Dullness would be heard below (not above) the 10th intercostal space. 1.

1. 2. 3. 4.

After auscultating the abdomen, the nurse should report which of the following to the primary care provider? Bruit over the aorta Absence of bowel sounds for 60 seconds Continuous bowel sounds over the ileocecal valve A completely irregular pattern of bowel sounds

1.

2.

3.

4.

Correct. A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified. In order for absence of bowel sounds to be considered abnormal, they must be silent for 3 to 5 minutes. Continuous bowel sounds are normally heard over the ileocecal valve following meals. Bowel sounds are more commonly irregular than they are regular.

1. 2. 3. 4.

If unable to locate the client’s popliteal pulse during a routine examination, the nurse should perform which of the following next? Check for a pedal pulse. Check for a femoral pulse. Take the client’s blood pressure on that thigh. Ask another nurse to try to locate the pulse.

1.

2. 3. 4.

Correct. If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point. Taking a thigh BP requires locating the popliteal pulse. Since the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate.

1. 2. 3. 4.

Which of the following is an expected finding during assessment of the older adult? Facial hair becomes finer and softer. Decreased peripheral, color, and night vision. Increased sensitivity to odors. Respiratory rate and rhythm are irregular at rest.

1. 2. 3. 4.

Facial hair is likely to become coarser, not finer. Correct. Visual acuity often lessens with age. The sense of smell becomes less, rather than more acute. The respiratory rate and rhythm is regular at rest. However, both may change quickly with activity and be slow to return to the resting level.

1. 2. 3. 4.

If the client reports loss of short-term memory, the nurse would assess this using which one of the following? Have the client repeat a series of three numbers, increasing to eight if possible. Have the client describe his or her childhood illnesses. Ask the client to describe how he or she arrived at this location. Ask the client to count backwards from 100 subtracting seven each time.

1. 2. 3. 4.

Recalling a series of numbers tests immediate recall. Recalling childhood events tests remote (long-term) memory. Correct. Recent memory includes events of the current day. Subtracting backwards from 100 tests attention span and calculation skills.