Transcript Physical Assessment - University of Kentucky

Physical Assessment
N
U
R
S
I
N
G
8
6
9
Purpose
N
U
R
S
I
N
G
8
6
9
•Gather baseline data
•Supplement, confirm, or refute data in nursing hx
•Confirm and identify nursing diagnosis
•Make clinical judgments about changing status
•Evaluate the physiological outcomes of care
Data
N
U
R
S
I
N
G
8
6
9
•Subjective
•Objective
Subjective Data
N
U
R
S
I
N
G
8
6
9
•What client or family tells you
• Symptoms
• “I’m in pain”
• “I feel anxious”
• “There is a stabbing pain in my chest”
Objective Data
N
U
R
S
I
N
G
8
6
9
•Information gained through the nurses’ senses
•Signs or observations
•B/P 120/70
•Lung sounds clear in all lobes bilaterally
•Pt grimaces with pain and guards abdomen
•Abdomen soft, tender, nondistended
Health History
N
U
R
S
I
N
G
8
6
9
•Provides baseline subjective information
•Family history
•Life patterns
•Sociocultural history
•Spiritual health
•Mental reactions
•Emotional reactions
Skills
N
U
R
S
I
N
G
8
6
9
•Inspection
•Palpation
•Percussion
•Auscultation
•Olfaction
Inspection
N
U
R
S
I
N
G
8
6
9
•Process of observation
•Good lighting
•Position and expose body parts for optimal viewing
•Inspect for size, shape, color, symmetry, & position
Palpation
N
U
R
S
I
N
G
8
6
9
•Patient should be relaxed and positioned comfortably
•Tender areas palpated last
•Warm hands, gentle touch, short fingernails
•Apply pressure slowly, gently, and deliberately
•Light palpation precedes deep palpation
•Assess softness/rigidity, masses, temperature, size
•Vital arteries NOT palpated in manner that obstructs
flow
Percussion
N
U
R
S
I
N
G
8
6
9
•Tapping to evaluate size, borders, and consistency of
body organs and discover fluid in body cavities
•Helps verify abnormalities reported from x-ray
•Character of sound depends on density of underlying
tissue
•Abnormal sounds suggest mass, air, or fluid in organ or
body cavity
•Direct method
•Indirect method
Ausculation
N
U
R
S
I
N
G
8
6
9
•Sounds produced by body
•Quiet environment
•Good stethoscope
•Stethoscope placed next to skin
•Diaphragm used for high-pitched sounds
•Bell used for low pitched sounds
Listen….
N
U
R
S
I
N
G
8
6
9
1. Frequency/pitch: # vibrations per second
2. Loudness: soft, medium, loud
3. Quality: types: gurgling, blowing
4. Duration: short, medium, long
Olfaction
N
U
R
S
I
N
G
8
6
9
•Be familiar with nature and source of body odors
•Foul odors can help detect infections
Sytematic Approach
N
U
R
S
I
N
G
8
6
9
•Head-to-toe assessment
•Major body systems assessment
Head-to-toe
N
U
R
S
I
N
G
8
6
9
•Begins at head and progresses down to the toes
•Most comprehensive
•Used to obtain baseline information to identify changes
in patient status
Major body systems
N
U
R
S
I
N
G
8
6
9
•Focuses on one system at a time
•Cardiac: heart sounds, pulses, capillary refill, B/P
•Respiratory: breath sounds, rate and depth, skin color
Stethoscope
N
U
R
S
I
N
G
8
6
9
Head-to-toe
N
U
R
S
I
N
G
8
6
9
•Neuro status
•Mucous membranes and skin
•Cardiac assessment
•Respiratory assessment
•Abdominal assessment
•Upper and lower extremities
•Accessories such as IV line, catheters, & dressings
General Appearance
N
U
R
S
I
N
G
8
6
9
•Assess during initial contact with client
•Look for signs of distress
•Body type
•Posture
•Hygiene
•Dress
•Mood
•Speech
•Signs of abuse
Consciousness Level
N
U
R
S
I
N
G
8
6
9
•Assessed by talking with client
•How difficult is it to get the client to respond?
•Alert and oriented x 3
•Oriented to person, place, and time
Pupillary Response
N
U
R
S
I
N
G
8
6
9
•Shine light through pupil onto retina
•Cranial nerve III stimulated
•Observe for pupillary constriction
•Observe for accomodation
•Pupils: black, round, regular, equal in size, 3-7 mm
Pupils
N
U
R
S
I
N
G
8
6
9
•Cloudy pupil: cataracts
•Dilated pupil: glaucoma, trauma, neurologic disorder
•Constricted pupil: drug use
•Pinpoint pupil: opioid intoxication
PERRLA
N
U
R
S
I
N
G
8
6
9
Pupils equal, round, reactive to light, accommodation
Mucous Membranes
N
U
R
S
I
N
G
8
6
9
•Inside lower lip
•Inside cheek
•Nares
•Conjunctiva
•Look at : color, hydration, texture, lesions
•Normal : red, smooth, moist, without lesions
Peripheral Pulses
N
U
R
S
I
N
G
8
6
9
•Apply firm pressure with pads of index and middle
finger on pulse site without occluding pulse
•Measure strength of pulse and equality
•Assess carotid, radial, and pedal
•Also assess brachial, posterior tibial, and dorsalis pedis
PERIPHERAL PULSES
PERIPHERAL PULSES
Grading
N
U
R
S
I
N
G
8
6
9
•0 – Absent, not palpable
•1+- Diminished, barely palpable
•2+- Easily palpable, normal pulse
•3+ - Full pulse, increased
•4+ - Strong, bounding, cannot be obliterated
Capillary refill
N
U
R
S
I
N
G
N
8
6
9
•Should test fingers and toes
•Press down on nail to compress capillaries
•Color goes white, then release
•Color should return briskly; < 3 seconds
•Document “sluggish” if > 3 seconds
Heart
N
U
R
S
I
N
G
8
6
9
•Review: heart is in the center of the chest, behind and to
left of the sternum
•Base is at top, apex is the bottom tip
•Apex touches anterior chest wall at 5th intercostal space
medial to left midclavicular line
•Heart pumps blood through 4 chambers
•Events on left side occurs just before those on right
•Valves open and close, pressures within rise and fall and
chambers contract as blood flows though each chamber
HEART
Cardiac Cycle
N
U
R
S
I
N
G
8
6
9
•Systole: ventricles contract and eject blood from left
ventricle into aorta and from right ventricle into
pulmonary system
•Diastole: ventricles relax and atria contract to move
blood into ventricles and fill coronary arteries
Heart Sounds
N
U
R
S
I
N
G
8
6
9
S1: Lub: mitral valve closure
S2: Dub: Aortic valve closure
APE to Man: Aortic, pulmonic, Erb’s Point, Tricuspid,
Mitral
HEART
Lung Sounds
N
U
R
S
I
N
G
N
U
R
8
6
9
•Apex and bases opposite from heart: apex at top, bases at
bottom
•Right lung has 3 lobes, left has two
•Angle of Louis where 2nd rib articulates with sternum
•2nd intercostal space is below 2nd rib and is starting point
on right
•Use diaphragm of stethoscope
•Inspiration and expiration = one breath
•Listen to both in each area
•Go from apex to bases comparing side to side
LUNGS
Respiratory Rate
N
U
R
S
I
N
G
8
6
9
•Measure respiratory rate without client’s awareness
•After checking radial pulse, keep hand at pulse site and
begin counting respirations
•Observe depth of respirations
•Documentation for normal: lungs sounds clear and equal
in all lobes bilaterally
Skin
N
U
R
S
I
N
G
8
6
9
•Color
•Turgor
•Assess for breakdown
Abdomen
N
U
R
S
I
N
G
8
6
9
•Sounds, masses, tenderness
•Divide into four quadrants: RUQ, RLQ, LUQ, LLQ
•Inspect then auscultate
•Bowel sounds: absent, hypoactive, hyperactive
•Listen continuously for 5 minutes to determine absence
•Palpate and/or percuss after listening
•Abdomen should be soft, non-tender, non-distended
ABDOMEN
ABDOMEN
Lower Extremities
N
U
R
S
I
N
G
8
6
9
•Pedal pulses
•Foot strength bilaterally
•Homan’s Sign
•Capillary refill
•Edema
•Pain
EDEMA
Vital Signs
N
U
R
S
I
N
G
8
6
9
•Temperature
•Pulse
•Respirations
•Blood Pressure
Temperature Sites
N
U
R
S
I
N
G
8
6
9
•Oral
•Rectal (one degree higher than oral)
•Axillary (one degree lower than oral)
•Tympanic
•Esophageal
•Pulmonary artery
•Urinary bladder
Factors
N
U
R
S
I
N
G
8
6
9
•Age
•Exercise
•Hormone level
•Circadian rhythm
•Stress
•Environment
•Temperature alteration
Blood Pressure
N
U
R
S
I
N
G
8
6
9
•Lateral force on walls of artery by pulsing blood under
pressure from heart
•Maximum pressure with ejection is systolic
•Minimum pressure with ventricular relaxation is
diastolic
•Measured in mm Hg
•Normal Adult: 110-140/60-90
Factors affecting B/P
N
U
R
S
I
N
G
8
6
9
•Age – B/P increases with age
•Stress
•Race – increased in African-Americans
•Medications
•Diurnal Variation
•Gender
Orthostatic Hypotension
N
U
R
S
I
N
G
8
6
9
•Decrease in blood pressure when changing from lateral
to upright position
•Can be caused by dehydration, anemia, prolonged
bedrest, vasodilation from B/P medications
•Record B/P and pulse with client lying, sitting, and
standing. Obtain readings 1-3 minutes after position
change.