PhysicalPhysical AssessmentAssessment Dr.Dr. KarimaKarima ElshamyElshamy FacultyFaculty ofof NursingNursing MansouraMansoura UniversityUniversity EgyptEgypt PhysicalPhysical HealthHealth AssessmentAssessment NursingNursing historyhistory andand physicalphysical examinationexamination NursesNurses useuse physicalphysical assessmentassessment skillsskills to:to: – Develop (obtain baseline data) and expand the data base from which subsequent phases of the nursing process can evolve – To identify and manage a variety of patient problems (actual and potential) – Evaluate the effectiveness of nursing care – Enhance the nurse -patient relationship – Make clinical judgments ExceptExcept forfor thosethose occasionsoccasions whenwhen youyou seesee aa patientpatient specificallyspecifically toto conductconduct aa nursingnursing assessment,assessment, thethe assessmentassessment mustmust bebe integratedintegrated intointo routineroutine nursingnursing carecare

–– Example:Example: thethe bathbath isis aa perfectperfect timetime toto incorporateincorporate assessmentassessment skillsskills frameworkframework thatthat isis usedused forfor assessmentassessment SubjectiveSubjective datadata -- SSaidaid byby thethe clientclient –– (S)(S)

ObjectiveObjective datadata -- OObservedbserved byby thethe nursenurse –– (O)(O)

NursingNursing ProcessProcess –– SOAPIERSOAPIER PreparingPreparing forfor thethe assessmentassessment ExplainExplain when,when, wherewhere andand whywhy thethe assessmentassessment willwill taketake placeplace HelpHelp thethe clientclient prepareprepare (empty(empty bladder,bladder, changechange clothes)clothes) PreparePrepare thethe environmentenvironment (lighting,(lighting, temperature,temperature, equipment,equipment, drapes,drapes, privacyprivacy –– SeeSee TableTable 2828 --22 forfor equipmentequipment usedused duringduring assessmentassessment

PositioningPositioning PositionsPositions usedused duringduring nursingnursing assessment,assessment, medicalmedical examinations,examinations, andand duringduring diagnosticdiagnostic procedures:procedures: – Dorsal recumbent – Supine – Sims – Prone – Lithotomy – Genupectoral SeeSee TableTable 2828 --22 forfor clientclient positionspositions

AssessmentAssessment TechniquesTechniques InspectionInspection -- criticalcritical observationobservation –– TakeTake timetime toto ““observeobserve ”” withwith eyes,eyes, ears,ears, nosenose –– UseUse goodgood lightinglighting –– LookLook atat color,color, shape,shape, symmetry,symmetry, positionposition –– OdorsOdors fromfrom skin,skin, breath,breath, woundwound –– DevelopDevelop andand useuse nursingnursing instinctsinstincts InspectionInspection isis donedone alonealone andand inin combinationcombination withwith otherother assessmentassessment techniquestechniques

AssessmentAssessment TechniquesTechniques PalpationPalpation -- lightlight andand deepdeep touchtouch –– BackBack ofof handhand toto assessassess skinskin temperaturetemperature –– FingersFingers toto assessassess texture,texture, moisture,moisture, areasareas ofof tendernesstenderness –– AssessAssess size,size, shape,shape, andand consistencyconsistency ofof lesionslesions –– SeeSee BoxBox 2828 --4,4, p.p. 529529 toto describedescribe characteristicscharacteristics ofof massesmasses AssessmentAssessment TechniquesTechniques PercussionPercussion -- soundssounds producedproduced byby strikingstriking bodybody surfacesurface –– ProducesProduces differentdifferent notesnotes dependingdepending onon underlyingunderlying massmass (dull,(dull, resonant,resonant, flat,flat, tympani)tympani) –– UsedUsed toto determinedetermine sizesize andand shapeshape ofof underlyingunderlying structuresstructures byby establishingestablishing theirtheir bordersborders andand indicatesindicates ifif tissuetissue isis airair --filled,filled, fluidfluid --filled,filled, oror solidsolid –– SeeSee tabletable 2828 --4,4, pagepage 530530 forfor percussionpercussion notesnotes AssessmentAssessment TechniquesTechniques AuscultationAuscultation -- listeninglistening toto soundssounds producedproduced byby thethe bodybody Direct auscultation – sounds are audible without stethoscope Indirect auscultation – uses stethoscope – Know how to use stethoscope properly (practice) – Fine -tune your ears to pick up subtle changes (practice) – Describe sound characteristics (frequency, pitch intensity, duration, quality) (practice) Flat diaphragm picks up high -pitched respiratory sounds best Bell picks up low pitched sounds such as heart murmurs Practice using BOTH diaphragms PRACTICEPRACTICE CompleteComplete HistoryHistory andand PhysicalPhysical NursingNursing historyhistory isis subjectivesubjective -- includesincludes thingsthings likelike biographicbiographic data,data, thethe chiefchief complaint,complaint, sourcesource ofof thethe data,data, historyhistory ofof presentpresent illness,illness, pastpast medicalmedical history,history, immunizationimmunization history,history, allergies,allergies, habitshabits ,, stressors,stressors, familyfamily historyhistory includingincluding genogram,genogram, patternspatterns ofof healthhealth care,care, andand aa reviewreview ofof thethe bodybody ’’ss systemssystems HistoryHistory ofof PresentPresent IllnessIllness HPIHPI isis aa chronologicalchronological storystory ofof whatwhat hashas beenbeen happeninghappening – Must get details of the problem, therefore must be systematic – OLFQQAAT (one system – there are others): onset, location, frequency, quality, quantity, aggravating factors, alleviating factors, associated symptoms, treatments tried (include all treatments - Rx, OTC, herbal, folk) – Lots of systems – find one that works, and use it UseUse whateverwhatever systemsystem worksworks forfor you,you, butbut useuse aa systemsystem painpain intensityintensity scales,scales, etcetc

–– Pain,Pain, quality/quantity,quality/quantity, radiation,radiation, setting,setting, timingtiming –– RateRate painpain fromfrom 11 toto 1010 –– UseUse ageage appropriateappropriate toolstools (faces)(faces)

CulturallyCulturally appropriateappropriate carecare ExamExam OrderOrder andand DocumentationDocumentation

DateDate andand identifyingidentifying datadata -- name,name, age,age, sex,sex, race,race, placeplace ofof birthbirth (if(if pertinent),pertinent), maritalmarital status,status, occupation,occupation, religionreligion SourceSource andand reliabilityreliability ofof historyhistory ChiefChief complaintcomplaint == reasonreason forfor visitvisit OrderOrder && DocumentationDocumentation FHFH -- ageage andand healthhealth ofof parentsparents andand siblingssiblings oror causecause ofof deathdeath (genogram);(genogram); HTN,HTN, DM,DM, CVD,CVD, Ca,Ca, HA,HA, arthritis,arthritis, addictionsaddictions ROSROS (subjective(subjective headhead --toto --toetoe review)review) – General - recent wt. change, fatigue, fever – Skin - rashes, lesions, changes, dryness, itching, color change, hair loss, change in hair or nails – Eyes - change in vision, floaters, glasses, HA, pain OrderOrder && DocumentationDocumentation

ROSROS – Ears - pain, loss of hearing, vertigo, ringing, discharge, infections – Nose and sinuses - frequent colds, congestion, HA, nosebleed – Mouth and throat - condition of teeth and gums, last dental visit, hoarseness, frequent sore throats – Neck - lumps, stiffness, goiter – Breasts - lumps, pain, discharge, BSE OrderOrder && DocumentationDocumentation

ROSROS – Respiratory - cough, sputum, wheezing, asthma, COPD, last PPD, last CXR, smoking history (can do here, or with “habits ”) – Cardiac - heart trouble, chest pain, SOB, murmur, h/o rheumatic fever, past EKG, FH of heart disease <50 yrs of age – GI - problems swallowing, heartburn, vomiting, bowel habits, pain, jaundice – Urinary - frequency, incontinence, pain, burning, hesitancy, nocturia, polyuria OrderOrder && DocumentationDocumentation ROSROS –– GenitaliaGenitalia -- lesions,lesions, discharge,discharge, sexualsexual orientation,orientation, sexualsexual function,function, menstrualmenstrual history,history, contraception,contraception, pregnancypregnancy history,history, TSETSE –– PeripheralPeripheral vascularvascular -- intermittentintermittent claudication,claudication, varicosevaricose veins,veins, bloodblood clotsclots –– MSMS -- musclemuscle oror jointjoint pain,pain, redness,redness, stiffness,stiffness, warmth,warmth, swelling,swelling, familyfamily historyhistory –– NeuroNeuro -- fainting,fainting, blackouts,blackouts, seizures,seizures, weaknessweakness OrderOrder && DocumentationDocumentation ROSROS –– EndocrineEndocrine -- sweats,sweats, skinskin change,change, heatheat oror coldcold intolerance,intolerance, excessiveexcessive thirstthirst (polydipsia),(polydipsia), excessiveexcessive urinationurination (polyuria),(polyuria), weightweight change,change, menstrualmenstrual changeschanges –– PsychiatricPsychiatric -- mentalmental illness,illness, thoughtsthoughts ofof harmingharming selfself oror othersothers AllAll ofof ROSROS isis subjectivesubjective;; PEPE isis objectiveobjective CompleteComplete H&PH&P -- ObjectiveObjective HistoryHistory isis subjective;subjective; PhysicalPhysical assessmentassessment isis objectiveobjective – Objective portion of exam begins with the general survey ; Each body system reviewed in text has nursing history at the beginning of the procedure for the objective exam – In actual practice, you get most of the history before ever touching the client, but there are usually additional history questions to ask during the exam OrderOrder ofof examexam -- headhead toto toetoe inin systematicsystematic orderorder OrderOrder ofof techniquestechniques -- IPPAIPPA (Inspection,(Inspection, Palpation,Palpation, Percussion,Percussion, Auscultation)Auscultation) BeBe systematic,systematic, butbut bebe flexibleflexible basedbased onon patientpatient ’’ss needsneeds – When might you change order of exam? InIn practice,practice, youyou oftenoften willwill dodo ““focusedfocused ”” PEPE -- examineexamine onlyonly thethe pertinentpertinent partsparts PRIORITIZEPRIORITIZE (ABC(ABC’’s,s, Maslow)Maslow) GeneralGeneral SurveySurvey

GeneralGeneral appearance,appearance, gait,gait, nutritionnutrition statusstatus (NOT(NOT toto bebe confusedconfused withwith nutritionnutrition historyhistory ),), statestate ofof dress,dress, bodybody build,build, obviousobvious disability,disability, speechspeech patterns,patterns, affectaffect (mood),(mood), hygiene,hygiene, bodybody odor,odor, posture,posture, race,race, gender,gender, height,height, weight,weight, vitalvital signssigns

HeightHeight upup toto ageage 22 isis recumbentrecumbent – Add head circumference if child is less than 2 years old IntegumentaryIntegumentary SystemSystem Integument includes skin, hair, and nails – Inspect:Inspect: skinskin colorcolor andand uniformityuniformity ofof color,color, moisture,moisture, hairhair pattern,pattern, rashes,rashes, lesions,lesions, pallor,pallor, edemaedema Palpate:Palpate: temperature,temperature, turgor,turgor, lesions,lesions, edemaedema PercussionPercussion andand auscultation:auscultation: rarelyrarely usedused onon skinskin Terminology:Terminology: pallor,pallor, cyanosis,cyanosis, edema,edema, ecchymosis,ecchymosis, macule,macule, papule,papule, cyanosis,cyanosis, jaundice,jaundice, typestypes ofof edema,edema, vitiligo,vitiligo, hirsutism,hirsutism, alopecia,alopecia, etc.etc. IntegumentaryIntegumentary SystemSystem HairHair -- texture,texture, distribution,distribution, scalp,scalp, critterscritters NailsNails -- inspectinspect andand palpatepalpate – Why palpate? – Cyanosis - is it true or d/t cold? – Blanch test (aka capillary refill or CFT): delayed return of color indicates poor arterial circulation – Clubbing - loss of normal angle between nail and nail bed d/t chronic oxygen deprivation SkinSkin –– knowknow terminology,terminology, drawdraw diagrams,diagrams, taketake picturespictures HEENTHEENT HeadHead -- inspectioninspection andand palpationpalpation – Size, shape, symmetry EyesEyes -- inspectioninspection andand palpationpalpation – Inspect and palpate lids, lashes, inspect eye position and symmetry and position, symmetry and size of pupils – Visual acuity with Snellen chart 20/20 - first number (numerator) is distance from chart Second number is distance at which a normal eye could have read that line (OU, OD, OS) Always record if tested cc (with correction) EyesEyes Visual acuity (Snellen for distance, Rosenbaum for near vision) Visual fields - assess peripheral vision EOMs - checks 6 ocular movements; tests CN 3, 4, and 6 Pupil response to light and accommodation; Pupils constrict o light, and also to accommodate for near vision (dilate for dimness and distance) Direct and consensual pupil response Corneal light reflex - checks eye alignment Fundoscopic exam - ophthalmoscope Terminology - myopia, presbyopia, ptosis, etc EarsEars InspectionInspection andand palpationpalpation – Inspect size, shape, position, discharge, lesions – Palpate for tenderness, any lesions ReviewReview anatomyanatomy ofof earear andand innerinner earear GrossGross hearinghearing acuity:acuity: normalnormal voice,voice, whisperwhisper test,test, WeberWeber andand RinneRinne InternalInternal earear (behind(behind tympanictympanic membrane)membrane) –– otoscopeotoscope cancan looklook throughthrough TMTM

NoseNose andand SinusesSinuses Inspection,Inspection, palpation,palpation, percussionpercussion InspectInspect colorcolor ofof mucosa,mucosa, presencepresence ofof dischargedischarge – There is a nasal speculum – most people don ’t like it – Assess for patency PalpatePalpate forfor tendernesstenderness PercussPercuss forfor tendernesstenderness overover frontalfrontal andand maxillarymaxillary sinusessinuses (Procedure(Procedure 2828 --8)8) MouthMouth andand ThroatThroat

Inspection,Inspection, palpation,palpation, auscultationauscultation InspectInspect andand palpatepalpate lips,lips, tongue,tongue, oraloral cavity,cavity, tonsils,tonsils, pharynxpharynx (color,(color, moisture),moisture), teeth,teeth, breath,breath, presencepresence ofof exudate,exudate, erythema,erythema, lesions,lesions, palatepalate – Read differences in oral exam for elderly clients – Enlarged tonsils are graded Grade 1 – wnl Grade 2 – tonsils b/w pillars and uvula Grade 3 – tonsils touching uvula Grade 4 – tonsils touching each other (kissing tonsils)

ThroatThroat andand NeckNeck

InspectInspect andand palpatepalpate neckneck forfor tracheatrachea (should(should bebe atat midline),midline), thyroid,thyroid, lymphlymph nodesnodes AuscultateAuscultate carotidscarotids forfor bruitsbruits (bell)(bell) –– IfIf bruitbruit isis heard,heard, palpatepalpate forfor carotidcarotid thrillthrill –– PalpatePalpate oneone sideside atat aa timetime PerformPerform ROMROM onon neckneck (active(active andand passive)passive)

AssessAssess sizesize andand shapeshape ofof thoraxthorax – Look for deformities (Fig. 28 -52, p. 574) – Barrel chest from asthma or COPD PresencePresence ofof supernumerysupernumery nipplesnipples ForFor efficiency,efficiency, youyou usuallyusually assessassess posteriorposterior chestchest firstfirst IntercostalIntercostal spacesspaces (ICS)(ICS) areare namesnames accordingaccording thethe ribrib theythey lielie beneathbeneath – 4th rib lies superior to 4th ICS – Posterior, you have to count spinous processes to name ribs and ICSs

LungsLungs

Inspect,Inspect, Palpate,Palpate, PercussPercuss (normal(normal notenote isis resonance),resonance), AuscultateAuscultate (normal(normal isis clearclear andand equalequal bilaterally)bilaterally) –– AuscultateAuscultate usingusing diagramdiagram

AssessAssess andand documentdocument respiratoryrespiratory rate,rate, rhythm,rhythm, andand efforteffort RespiratoryRespiratory TerminologyTerminology EupneaEupnea TachypneaTachypnea BradypneaBradypnea ApneaApnea HyperventilationHyperventilation HypoventilationHypoventilation DyspneaDyspnea RespiratoryRespiratory WarningWarning SignsSigns

AnxiousAnxious expressionexpression SuprasternalSuprasternal && intercostalintercostal retractionsretractions NasalNasal flaringflaring CircumoralCircumoral cyanosiscyanosis HyperexpandedHyperexpanded chestchest –– ALWAYSALWAYS REMEMBERREMEMBER YOURYOUR ABCsABCs BreathBreath SoundsSounds

AuscultateAuscultate usingusing diaphragm,diaphragm, useuse aa systematicsystematic approach,approach, comparecompare eacheach sideside toto thethe otherother ,, documentdocument whenwhen andand wherewhere soundssounds areare heardheard NormalNormal breathbreath sounds:sounds: bronchovesicular,bronchovesicular, bronchial,bronchial, andand vesicularvesicular –– AbnormalAbnormal breathbreath soundssounds areare calledcalled adventitiousadventitious soundssounds

BreathBreath SoundsSounds StridorStridor -- maymay bebe heardheard withoutwithout stethoscope,stethoscope, shrillshrill harshharsh soundsound onon inspirationinspiration d/td/t laryngeallaryngeal obstructionobstruction WheezeWheeze -- maymay bebe heardheard withwith oror withoutwithout stethoscopestethoscope (document(document which),which), highhigh --pitchedpitched squeakysqueaky musicalmusical sound;sound; usuallyusually notnot changedchanged byby coughing;coughing; DocumentDocument ifif heardheard onon inspiration,inspiration, expiration,expiration, oror both;both; MayMay clearclear withwith coughcough – Noise is caused by air moving through narrowed or partially obstructed airway – Heard in asthma or FBA BreathBreath SoundsSounds CracklesCrackles -- heardheard onlyonly withwith stethoscopestethoscope (formerly(formerly calledcalled rales):rales): fine,fine, medium,medium, coarsecoarse shortshort cracklingcrackling soundssounds (think(think hair);hair); MayMay clearclear withwith coughcough

– Most commonly heard in bases; easier to hear on inspiration (but occurs in both inspiration and expiration) BreathBreath SoundsSounds GurglesGurgles -- heardheard only only with with stethoscope stethoscope (formerly(formerly called called rhonchi): rhonchi): Low Low pitched, pitched, coarsecoarse wheezy wheezy or or whistling whistling sound sound -- usuallyusually more more pronounced pronounced during during expirationexpiration whenwhen airair movesmoves throughthrough thickthick secretionssecretions or or narrowed narrowed airways airways –– soundssounds like like a a moan moan or or snore; snore; best best heardheard on on expiration expiration (but (but occur occur both both in in andand out)out) FrictionFriction rubrub –– Grating,Grating, creaking,creaking, oror rubbingrubbing soundsound heardheard onon bothboth inspirationinspiration andand expiration;expiration; notnot relievedrelieved byby coughing;coughing; duedue toto pleuralpleural inflammationinflammation

DocumentDocument breathbreath soundssounds asas clear,clear, decreaseddecreased oror absent,absent, comparecompare rightright toto left,left, andand describedescribe typetype andand locationlocation ofof anyany adventitiousadventitious soundssounds –– CTABCTAB oror BBSBBS clcl ++ == –– NOTNOT BSBS clearclear (BS(BS couldcould bebe bowelbowel soundssounds .).) BreastsBreasts andand AxillaeAxillae

InspectionInspection andand palpationpalpation – Instruct female clients to perform BSE q month – Men have some glandular tissue beneath nipple; women have glandular tissue throughout breast and into axilla Largest portion of glandular tissue in women in in upper outer quadrant See breast health guidelines – Inspect for symmetry, contour (shape), look for any areas of hyperpigmentation, retraction or dimpling, edema – Palpate breasts, areolae, nipples and axillary lymph nodes in both men and women Be sure to include tail of Spence

AnyAny Questions?Questions?