Introduction To Physical Assessment

Introduction to the Physical Assessment Madeline Gervase MSN,CCRN,FNP,RN

Assessment  Systematic

& continuous collection, validation, and communication of client data  Nursing process  Initial and ongoing  Medical vs Nursing  Essential components

Purposes of Assessment Obtain Baseline Date regarding functional abilities  Supplement, confirm, or refute date obtained in nursing history  Obtain data that helps establish nursing diagnoses and plan care  Evaluate physiologic outcomes of health care and thus client progress  Screen for presence of risk factors 

Types of Assessment Initial  Focused  Emergency  Ongoing 

Types of Data  Objective

Data

“signs”  info perceived by the senses 



Ex: T 101, moist skin

 Subjective

Data

“symptoms”  info perceived only by affected person  Ex: feeling nervous, tired 

Characteristics of Data  Complete  Factual

& Accurate

 Relevant

Problems r/t Data Collection  Organization  Omission  Irrelevant

or Duplicate Data  Misinterpretatio n  Too little data  Documentation

Why is a health history taken? Patterns of wellness/illness  Physical & Behavioral risk factors  Deviations from norm  Nurse as a resource 

Functional Health Patterns 

   

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Health Perception/ Management Nutritional-Metabolic Elimination Activity-Exercise SexualityReproduction Sleep-Rest

   

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Sensory-Perceptual Cognitive Role-Relationship Coping-Stress Tolerance Value-Belief

Nursing Health History  

Chief Complaint Present Problem    

Usual health status Chronological story Impact on functioning Medications

  

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Past Medical History Family History Personal & Social History Review of Systems or Functional Patterns

Client Profile – UK Clinical Setting   

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Biographical Data Chief Complaint History of Present Illness Current Medications

 



Current Treatments Past Illnesses or Past Hospitalizations Allergies

General Survey – Clinical Setting        

Age/Sex/Race Mental Status Behavior Mood Appearance Body Type Posture Body Mechanics



Speech   

 

Use of language Thought Process Reliability as historian

Height/Weight Vital Signs

Explanation- Affect/Mood 

Affect – observable behaviors which indicate the feelings or emotional status of the client.



Mood – term which refers to the client’s emotional state as described by the client.

Documentation Terms 

Affect     

Broad Restricted Blunted Flat Labile



Mood          

Appropriate Inappropriate Depressed Anxiety Agitated Elated Manic Euphoric Euthymic (normal) irritable

General Principles - History  Explain

purpose  Communication techniques  Utilization of data sources  Document  Avoid interruptions or tiring the client  Consider client’s developmental level

Developmental Principles  Pediatric

Parent/child interactions  Integrate child  Respect adolescent, give choices 

 Geriatric

Do not stereotype  Assess and accommodate: 

 sensory

&

physical functioning

Psychosocial Considerations - History  Avoid

stereotypes  Healthcare beliefs  Language differences  Eye contact  Non-judgmental  Stressors/Coping Mechanisms

Cultural Awareness Considerations Time Orientation  Activity Orientation  Human Nature Orientation  Human-Nature Orientation  Relational Orientation 



Seidel, 2003, pp. 43.

History - Biographical Data Name  Race  Age  Gender  Marital status 

Birthplace, date  Address  Source of medical care  Insurance coverage 

Past Health History  Previous hosp. & surgeries  Allergies  Illnesses & Accidents  Immunizations  Medications  Habits/Lifestyle  ADLs

Client’s Family History 

Blood relatives



Significant others



Health history



Family as resource

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Stressors in family

Present Illness/Health Concerns Onset  Duration  Location, quality, and intensity  Precipitating factors  Relief factors  Client’s expectations  Subjective and Objective data 

PQRST – Characterize Symptoms     

Precipitating factors Quality Radiation Severity Temporal Factors

OLD CARTS –        

Onset Location Duration Character Aggravating factors Relieving factors Temporal factors Severity

Reasons for Seeking Healthcare  Chief

complaint

 Why?  Quotes  Specify  Clarify

Resources  Home

and outside environment  Community resources  Financial  Family & significant others  Consider Basic Human Needs

Medical Diagnostic Data  Medical

vs

Nursing Diagnosis  Nursing Implications r/t Medical Diagnosis

Contributions of Lab Data Verifies data  Provides baseline information  Evaluates outcomes  Identifies problems missed in history and assessment 

Count (CBC)  Analysis

of peripheral venous blood specimen  Main components: RBC = red blood cell count (erythrocytes)  WBC = white blood cell count (leukocytes)  Hgb = hemoglobin  Hct = hematocrit 

Test: Urinalysis (UA) Analysis of a urine specimen  Screens for: 

  

urinary infection renal disease diabetes mellitus

Urinalysis  Main

components

pH4.6 - 8.0  Proteinup to 10mg/100ml  Specific gravity-1.003 - 1.030  Glucosenegative  Ketonesnegative  Bloodup to 2 RBCs 

Test: Electrolytes (lytes, e-) Inorganic substances in the body that conduct electrical current  Usage: 



Assess fluid balance

Electrolytes  Main

Components:

Na+  K+  Cl Ca P  Mg 

sodium potassium chloride calcium phosphate magnesium

Test: Chest X-Ray (CXR, PA Chest, PA & LAT Chest) Radiographic exam of the thorax  Visualizes respiratory & cardiac function  Identifies & follows progression/ remission of dx process 

Test: Arterial Blood Gas (ABG) 



Assesses the adequacy of ventilation and oxygenation via arterial blood Use: measures respiratory and metabolic (renal) disturbances

Arterial Blood Gases  Main

Components: pH  PaCO2  PaO2  HCO3  SaO2 

General Nursing Implications  Assess

client’s readiness to learn  Explain procedure to client  Assist client in dealing with the test  Provide privacy  Prepare client for test  Universal precautions  Send specimens promptly

Specific Nursing Implications  Electrolytes:

Note diet, food and fluid intake  Note s/s that could affect fluid balance (N/V/D) 

 Chest

X-Ray:

Transport  Remove metal objects  Stand clear 

Specific Nursing Implications  Arterial

Gases

Blood

Anticoagulants?  Time drawn  Check site for bleeding  Pressure  Sample on ICE  STAT to lab 

Physical Assessment: Pediatric Principles  Assess:  



coping ability previous knowledge readiness

Encourage questions  Explain at developmental level 

Physical Assessment: Pediatric Principles Use concrete terms  Small amounts of info at a time  Simple & clear explanations  Only offer choices that are available  Honest praise/rewards 

Physical Assessment Methods  Inspection  Palpation  Auscultation  Percussion

Equipment Stethoscope  Pen light  Blood Pressure Cuff  Thermometer  Watch with second hand 

Inspection  Assessment

process during which the nurse observes the client

Inspection 

Initial contact and ongoing  Use olfaction, touch  General appearance, body language  Systematic unhurried approach  Expose part, respect privacy  Examine: color, size, shape, position, symmetry (compare like areas)  Know “normals”  Observe “normals/abnormals”

Palpation  The

use of the hands and the sense of touch to gather data

Palpation 

Detects texture, shape, temp, movement, pain, moisture  Short fingernails, warm hands  Gentle approach  Light palpation first, if pain - STOP!  Palpate tender areas last  Three types:  Light palpation (1/2 inch)  Deep palpation (1 inch)  Bimanual deep palpation (2 hands)

Auscultation  The

act of listening to sounds within the body to evaluate the condition of body organs  (stethoscope)

Auscultation  Stethoscope: bell for low pitch sounds (cardiac sounds)  Diaphragm for high pitch sounds (bowel, breath, normal cardiac) 

4

characteristics of sounds

Frequency/pitch: # vibrations per second  Loudness: soft, medium, loud  Quality: types; gurgling, blowing  Duration: short, medium, long (specify) 

Auscultation  Quiet

environment  Know landmarks  Know “normals”  PRACTICE! PRACTICE! PRACTICE!  Requires concentration, practice, and application of knowledge

Percussion  Tapping

of various body organs and structures to produce vibration and sound.

Documentation - Purpose      

Communication Quality Assurance Legal Reimbursement Research Planning Client Care

   

Education Statistics Accrediting/Licensure Historical Document

Principles of Documentation       

Timing Confidentiality Permanence Signature Accuracy Sequence Appropriateness

    

Completeness Standard Terminology Brevity Legibility Legal Awareness

Learning Outcomes The student will be able to: 1. 2. 3. 4. 5.

State the purposes of the physical exam. Name the necessary equipment need to perform a physical exam. Describe the four basic techniques used in physical examination. Describe guidelines for preparing a client and the environment for a physical examination. What are the components of a general survey?