Physical Assessment

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Methodology

Inspection – visual examination, general state of health, apparent age, physique Palpation – touchy feely, maybe difficult at first due to cultural beliefs and biases, warmth, caring, understanding Percussion – gentle beating using both hands, detects fluids, air or mass. Auscultation – quality of sounds, intensity, duration of heart, lungs and intestines.

Sequence System

Flow

The Lungs

Inspection (respiration), palpation, percussion, auscultation

The Heart

Inspection (BP, P), palpation, auscultation

The Abs

Inspection, auscultation, percussion, palpation

The Musculoskeletal

Inspection, palpation, ROM, Strength testing, Deep tendon reflexes

History Vital Signs T ______ P ______ R ______ BP _____ Pain Assessment ______ O2 Saturation _________

Allergies Allergies 1. 2. 3.

PCN Shellfish Cat dander

Reaction Anaphylactic shock Hives Wheezing

Chronic Conditions Lung Problems ___________Stomach Problem_____________ Thyroid Problems _________Neurological Problems_________ Heart Problems __________Liver Problems _______________ Vision Problems __________Kidney Problems _____________ Arthritis _________________Diabetes ___________________ Chronic infection __________Treatment: __________________ Cancer (where/type) _______Treatment: _________________ Other Past Medical History or Surgeries:

Family History        

NSF Heart disease Hypertension Diabetes Stroke Seizures Kidney disease Liver disease

Medications Drug

Dose

Frequency

Altace

5 mg

BID

Lasix

20 mg

OD

Digoxin

0.125 mg

OD

Alupent

2 puffs

QID and prn SOB

Social History  

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Lives alone Lives with _________________ _________________ Stairs at home Yes ___ No___ Sleep pattern _______________

Immunization 

Immunizations current?  

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Yes ______ No ______

Last Tetanus toxoid? _______ Hepatitis A _______ Hepatitis B _______ Flu Vaccine ______

Smoking/Alcohol/Social Drug Nicotine Use: No  Yes – How much? _______ How Long? _____________  Instructed on “No Smoking” Policy? Yes No  Do you live in a smoking environment? Yes No Alcohol Use:  No  Yes – How much? _______How Long? _____________  Last Drink? ______________________________________ Social Drug Use:  No  Yes – Type?_______________ Frequency?__________ 

Disabilities/Impairment Impaired hearing 

Hearing Aid

Impaired vision 

Glasses

Cane or walking device ______________ Other: ______________ ______________

Dietary Habits Diet restriction: ________________ Special diet: ________________ Supplements: _________________

Systems Review

Other Assessments

Skin and Fall Assessment

Acuity Level

EENMT

Eyes:          

NSF Blurred Vision Yes __ No __ Double vision Yes __ No __ Inflammation Yes __ No __ Pain Yes __ No __ Color blind Yes __ No __ Itching Yes __ No __ Pupils abnormal Yes __ No __ Drainage -- Color ________Amount _________ Other __________________________________

Ears Ears:       

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NSF HOH (R) (L) Yes No Deaf Yes No Tinnitus Yes No Dizziness Yes No Drainage _______________ Sense of balance Yes No Pain Yes No Other __________________

Nose Nose:         

NSF Yes No Congestion Yes No Pain Yes No Sinus problems Yes No Nasal Flaring Yes No Alignment Yes No Nosebleeds – frequency _________________ Drainage – color ______amount ___________ Other ________________________________

Mouth Mouth:        

NSF Halitosis Yes No Pain Yes No Bleeding gums Yes No Lesions Yes No Sense of taste Yes No Dental Hygiene ____________ Last Dental Exam __________

Throat/Neck Throat/Neck:  

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NSF Sore throat Yes No Hoarseness Yes No Lumps No Swollen glands No Stiffness No

Yes Yes Yes

Rapid Assessment     

Quick Nursing Considerations: Patient safety VS – including O2 and Pain Universal precaution Anticipate needs Notify MD

PQRST Mnemonics History of present illness (HPI) - the chronological order of events of symptoms. 

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Provocative - Palliative factors – what makes a symptom worse or better. Quality – description of the symptom Region – which part of the body is affected Severity – what is the intensity of the symptom; using a scale of 0-10 (10 worst)

Neurological Assessment

Tools The following tools will be used during the neurological exam: 

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Reflex hammer (tomahawk model) Penlight Tongue blade Safety pin Cotton swab Ophthalmoscope Eye chart Tuning fork Dermatome chart

 NSF  Cooperative

Yes No

 Memory Changes

Yes No

 Dizziness

Yes No

 Headaches

Yes No

 Oriented to: Person __ Place __ Time __  Deviation: ________________Pupils Size: __________________  PEARLA

Yes No

 Reaction: Brisk __ Sluggish __ No Response __  LOC: Alert __ Confused __ Sedated __ Somnolent __ Comatose Agitated __ Other ___  Speech: Clear __ Slurred __ Aphasic __ Dysphasia __ None  Grips: ________Foot pushes: _________Gag reflex: ___________

Neuro Documentation

Rapid Assessment Stroke • Cardiac • Comfort • Pulmona • ECG, cardiac ry monitor • Safety • O2 2LPM, Pulse Ox • Lab works – CBC, Coags

Rapid Assessment

Changes • Neuro • Cardiac in Mental • Safety Status

• Safety • Lab works – CBC, lytes, U/A • Following MD order – sitter or restraints • ECG, Cardiac monitor • O2 at 2LPM, Pulse Ox • Accucheck

Rapid Assessment • • Safety Seizure Neuro • Safety

• Airway • Lab works – CBC, lytes, urine toxicology, ETOH level • CT Brain • Accucheck • Pulse Ox • Meds – Ativan 2mg IV • NPO

Cardiac Assessment

The Heart Chambers and Major Vessels http://www.nucleusinc.com/animatio n2.php

 Patient

Positions and Special Techniques for Auscultation

 Position

 Use

 supine

 general auscultation and most heart sounds

sitting up and leaning  forward and holding  exhalation

 aortic stenosis, aortic regurgitation, pericardial  rubs

 left lateral decubitus

 S3, S4, mitral stenosis (using bell of  stethoscope)

 Vasalva manoeuver

 increases intensity of mitral valve prolapse and  hypertrophic cardiomyopathy, decreases intensity  of aortic stenosis

 squatting and standing

 increases intensity of aortic stenosis, decreases  intensity of outflow obstruction in hypertrophic  cardiomyopathy

1) LV area: apex of the heart at 4th or 5th intercostal space (ICS) along MCL 2) RV area: 3rd to 5th ICS along the left sternal border (LSB) 3) pulmonic area: 2nd ICS along the LSB 4) aortic area: 2nd ICS along the right sternal border (RSB)

Murmurs When you encounter a murmur while auscultating, it is important to evaluate the following characteristics: 1. 2. 3.

4.

5.

systolic vs. diastolic duration pitch: high, medium, low quality: harsh, rumbling, blowing intensity: eg crescendo, decrescendo,

Distal Pulses

Using a Doppler

Internal Pacemaker

External (Temp) Pacemaker

ECG Animations

Lead Placement -http://nobelprize.org/medicine/educational/e 6Second Strips -http://www.skillstat.com/ECG_Sim_demo.htm Cardiac Sounds – http://www.med.ucla.edu/wilkes/Systolic.h tm

INTERNATIONAL CODES DESCRIBING PACEMAKERS AND IMPLANTED DEVICES

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Cardiovascular NSF Cardiac Rate: Regular Irregular Irregularly irregular Chest Discomfort Yes No – Where:_______ Intensity (1 -10) _______ Onset _______________ Duration_____________Resolution ____________ Radial Pulse (R)/(L) Yes No Pedal Pulse (R)/(L) Yes No JVD (R)/(L) Edema – Location __________Pitting __ Non-pitting __ Pacemaker – Date Inserted ________________ Type _____________Where: __________________ Murmur: Yes No

Cardiac Documentation

Rapid Assessment

Chest Pain

• Cardiac • Comfort • Pulmonar • Lab works – y CBC, CPK with • Pain Iso. Troponin • Stat ECG • O2 at 2LPM, Pulse Ox • Meds – ASA, NTG, MSO4

Rapid Assessment Atrial Fib or A Flutt er

• Cardia • Stat ECG • Cardiac c monitor • Meds • BR