Transcript Health Assessment and Phyical Exam by IVS

Health Assessment and Physical
Assessment
Ian Van V. Sumagaysay, RN, MAN
Clinical Instructor
Summer 2015
Definition of Health
• Individual definition of health.
• Health care provider or health care organization’s definition of health.
Physical Health Assessment
• Nursing history and physical examination
• Nurses use physical assessment skills to:
– Develop (obtain baseline data) and expand the data base
from which subsequent phases of the nursing process can
evolve
– To supplement, confirm, or refute data obtained in the
nursing history.
– Make clinical judgments about a clients changing health
status and management.
– Evaluate the effectiveness of nursing care.
– Enhance the nurse-patient relationship.
Physical Assessment
• Differentiate between variations of normal & abnormal assessment data
• Distinguish abnormal from normal findings in 3 major areas of
assessment:
– History
– Physical Exam
– Laboratory Data & Diagnostic Tests
–Integrated Physical Examination
• Example: the bath is a perfect time to incorporate assessment
skills
S - Subjective
• Symptoms that the patient reports
• What the patient feels
• The history
O - Objective
• Signs that can be observed by the examiner
• Physical examination findings
• Laboratory data & other diagnostic tests
A – Assessment/Action
• Interpretation & evaluation of data
• What action to take
P - Plan
• Therapeutic regimen
• Patient education
History
• Collect & interpret data related to the health history, chief complaint &
history of the present illness
• Comprehensive history: essential for establishing diagnosis (at least 80%
of the time)
Amount and frequency of Data
Collected
•
•
•
•
Complete
Episodic, problem centered or focused
Follow up
Emergency
• How often?
– Table 32-6 shows Recommended Preventive Screening schedules
Communication Skills
• Analyze communication methods for obtaining the health history
• Effective communication styles & interview techniques: important
elements for obtaining historical data & setting tone for therapeutic
relationships
Nursing Process in Health
Assessment
•
•
•
•
•
•
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
Prioritize
• First level priority
• Second level priority
• Third level priority
Medical vs. Nursing Diagnosis
• Medical- pertains to the etiology of the disease.
• Nursing- pertains to the impact of the disease on the individual or family;
the response to the disease.
Cultural Assessment
•
•
•
•
•
•
•
Culture
Subculture
Race
Ethnic Group
Minority Group
Customs & Rituals
Values & Cultural Norms
The Holistic Approach
• The clients culture must be taken in consideration when assessing and
planning.
– Example: fasting for religious reasons
• Where is the patient in their life cycle?
Health History Format
Biographical Data
• Name, age, gender, family/marital status, religion, ethnic group
• Date, address, occupation, HEALTH INSURANCE
• Referral source, informant (reliability) (document)
Chief Complaint
• Purpose of visit
• Brief, 1-2 symptoms & duration
• Pertinent
Present Illness (Problem): or
Current Health Status
• PI: Illness or focused history
• Initial wellness history
PI: Analysis of a Symptom
•
•
•
•
Onset
Characteristics
Course since onset
Pertinent negative information
PI: Analysis of a Symptom
• When:
Last well: Onset, duration & chronological sequence of
symptoms
• What: Quality, intensity, related symptoms
• Where: Location, range of symptoms
PI: Analysis of a Symptom
• How: Associated factors, communicable exposure
• Why: Possible solutions, treatment, (aggravating/alleviating factors)
Alternative Methods for Present
Illness: PI
PI: OLD CART
•
•
•
•
•
•
•
O - Onset
L - Location
D - Duration
C - Causative factors
A - Associations
R - Reactions to what has been tried
T - Treatment
Past Medical History
•
•
•
•
•
•
•
General health & strength
Major childhood & adult illnesses
Immunizations, dates & reactions
Surgery: dates, hospital, Dx, complications
Injuries
Disability
Medial-legal relationships
Past Medical History
•
•
•
•
Medications: current, past, Rx, OTC, herbs, alternative therapies
Allergies: medication, environment, food: must include “kind” of reaction
Transfusions: reactions, date & # of units
Emotional status: mood disorders, psychiatric attention
Family History
•
•
•
•
Family members with patient’s illness
Age of parents: age & cause of death
“Age & # of siblings: health status
History of heart disease, hypertension, cancer, TB, diabetes, asthma, STD’s,
kidney, thyroid disease, psychiatric illness
• Major genetic disorders & health problems
Family History
• Genogram to grandparents
Personal
&
Psychosocial
History
• Personal status: birthplace, socioeconomic group, general life satisfaction,
interests, sources of stress
• Habits:
diet, sleep, exercise, coffee, alcohol, drugs, tobacco
• Sexual History: satisfaction. Concerns
Personal & Psychosocial History
•
•
•
•
•
Home conditions: housing, economic conditions, safety
Occupation: work & conditions or hazards
Environment: Travel, milk & water supply
Military record: dates & geographic travel
Religious preference: concerns health care
Review of Systems: ROS
• Variations with age groups
• General: fever, chills, sweats, weight changes, weakness, fatigue,
heat/cold intolerance, bleeding, radiation
ROS: Skin, Hair, Nails
• Rashes, lumps, sores, itching, color or texture changes, bruising, abnormal
growths
ROS: Head
• Headaches, injury, dizziness, syncope, LOC, stroke
ROS: Eyes
• Vision/correction, blurring, diplopia, eye meds, trauma, redness, pain,
glaucoma, cataracts, surgery
ROS: Ears
• Hearing/loss, pain, discharge, infection, tinnitus, vertigo, dizziness
ROS: Nose
• Smell, obstruction, injury, epistaxis, discharge, colds, allergies, sinus pain
ROS: Mouth & Throat
• Hoarseness, sore throats, gum problems, tooth abscess, dental care, sore
tongue, taste
ROS: Neck
• Lumps, “swollen glands,” goiter, pain, stiffness
ROS: Respiratory
• Pain, dyspnea, SOB, cyanosis, wheezing, cough, sputum (color & quantity),
asthma, bronchitis, emphysema, pneumonia, TB/BCG, last CXR & results,
smoking
ROS: Cardiovascular
• Chest pain/distress, palpitations, SOB, dyspnea, orthopnea (pillows
needed), paroxsysmal nocturnal dyspnea, MI, rheumatic fever, murmur,
exercise tolerance, ECG or other cardiac tests, hypertension, edema, leg
pains/edema/coolness/hair loss, varicose veins, thrombosis ulcers
ROS: Gastrointestinal
• Appetite, digestion intolerance, heartburn, N & V, hematomesis, bowel
irregularity, stool appearance, flatulence/belching, hemorrhoids, jaundice,
ulcer, gallstones, abdominal enlargement, previous X-ray
ROS: Endocrine
• Thyroid enlargement/tenderness, heat/cold intolerance, unexplained
weight change, diabetes S/S, striae
ROS: Male Reproductive
• Puberty onset, erections, emissions, testicular pain or masses, hernias,
lesions/discharges, libido, sexual activity, contraception, infertility,
prostate, STDs, STE
ROS: Female Reproductive
• Menses: Menarche, regularity, duration & amount of flow, dysmenorrhea,
LMP, last Pap AND RESULTS, sexual activity, libido, contraception, fertility,
menopause, discharge, itching, sores, STDs
• Gravida/para: pregnancies, births, problems
ROS: Breast
• Pain, tenderness, discharge, lumps, galactorrhea,
mammogram AND RESULTS, SBE
ROS: Genitourinary
• Dysuria, pain, frequency, urgency, nocturia,
hematuria, stress incontinence, hernias, STIs
ROS: Musculoskeletal
• Joint stiffness, pain, motion restriction, weakness,
paresthesias, cramps, deformities, back problems
ROS: Hematologic
• Anemia, lymph swelling, bruising/petichiae, fatigue,
blood dyscrasia, transfusion, radiation
ROS: Neurologic
• CNS disease, syncope, blackouts, dizziness,
numbness, tingling, seizures, weakness/paralysis,
tremors, coordination, memory, cognition,
headaches, head injury
ROS: Psychiatric
• Depression, mood changes, difficulty concentrating,
nervousness, tension, suicidal thoughts, irritability,
sleep disturbances
Sources of Data
• Primary – Client
• Secondary – Family, support persons, health
professionals, laboratory reports and diagnostic
findings.
Data Collection Method
• Observing
• Interviewing – direct, indirect
• Types of questions – open ended, close ended,
neutral, leading
• Stages of an interview: Opening, Body, Closing
Planning the Interview and
Setting
•
•
•
•
•
Time
Place
Seating Arrangement
Distance
Language
Concluding Questions
• “Is there anything else that you think would be
important for me to know?”
• Offer the opportunity for additions or corrections
• Clarification of understanding
Analysis of Data
• Identify abnormal findings
• Cluster findings into logical groups
• Localize findings anatomically
Consider Information Quality
• Reliability - how well an observation repeatedly give
the same result
• Validity - a close agreement between an observation
& the best possible measure of reality
• Sensitivity - the proportion of people with a
disease/condition who are positive for that disease
on a given test (true positive)
Consider Information Quality
• Specificity - the proportion of people without the
disease/condition who are negative on a given test
(true negative)
• Predictive Value of Test - the characteristic that is
most relevant to the clinical setting
Documentation of Data
• Permanent medical legal record of the patient’s
health status & treatment
• Record pertinent positive findings - abnormal
findings
• Record pertinent negative findings - normal findings,
or absence of abnormal findings
Measurements & Vital Signs
• Height
• Weight
• Circumferences: Head, Chest Abdomen,
Extremities
• Temperature, Pulse, Respiration, Blood Pressure
• Vision & Hearing Screening
Measurements & Vital Signs
•
•
•
•
•
Jugular Venous Distention
Body Mass Index
Skin fold thickness
Goniometer measurements of joint mobility
Waist to hip ratio
Preparing for the assessment
• Explain when, where and why the assessment will
take place
• Help the client prepare (empty bladder, change
clothes)
• Prepare the environment (lighting, temperature,
equipment, drapes, privacy
– See Table for equipment used during assessment
Positioning
• Positions used during nursing assessment, medical
examinations, and during diagnostic procedures:
–
–
–
–
–
–
Dorsal recumbent
Supine
Sims
Prone
Lithotomy
Genupectoral
• See Table 32-5 for client positions
Physical Examination
•
•
•
•
•
Inspection
Palpation
Percussion
Auscultation
Measurements
Inspection
•
•
•
•
•
Observe for wellness-illness condition
Identify degree of distress
Look before you touch
Provide comfortable, private conditions
Provide adequate direct & tangential lighting
Assessment Techniques
• Inspection - critical observation
– Take time to “observe” with eyes, ears, nose
– Use good lighting
– Look at color, shape, symmetry, position
– Odors from skin, breath, wound
– Develop and use nursing instincts
• Inspection is done alone and in combination with
other assessment techniques
Palpation
• Light palpation - gentle pressure, 1cm or 1/2 - 3/4
inches deep
• Deep palpation - may use bimanual methods, 4 cm
or 1 - 2 inches deep
• Palpate tender areas last
Palpation
• Sensitive areas of hand & fingers:
– Palmar area - discriminatory for touch
– Ulnar area - discriminatory for touch
– Dorsal area - discriminatory for temperature
Assessment Techniques
• Palpation - light and deep touch
– Back of hand to assess skin temperature
– Fingers to assess texture, moisture, areas of tenderness
– Assess size, shape, and consistency of lesions
– See Box which describes characteristics of masses
Percussion Sounds Heard
•
•
•
•
•
Tympany: Gastric Bubble
Hyperresonance: Lung disease
Resonance: Health Lung
Dullness: Liver
Flatness: Muscle
Auscultation
• Listening to sounds of lungs, heart, blood vessels & abdominal
viscera
• Ear
• Stethoscope
– Diaphragm is held firmly to skin, detects high frequency sounds
– Bell is held with light pressure, detects low frequency sounds
Measurements & Vital Signs
•
•
•
•
•
Height
Weight
Circumferences: Head, Chest Abdomen, Extremities
Temperature, Pulse, Respiration, Blood Pressure
Vision & Hearing Screening
Measurements & Vital Signs
•
•
•
•
•
Jugular Venous Distention
Body Mass Index
Skin fold thickness
Goniometer measurements of joint mobility
Waist to hip ratio
• CAGE questions:
1. Have you ever thought you should Cut down
2. Have you ever been Annoyed by criticism of your
drinking?
3. Have you ever felt Guilty about drinking?
4. Do you ever have an Eye-opener in the morning?
 YES to any of the above questions - need to
investigate further to see if there is a drinking
problem
Complete H&P - Objective
• History is subjective; Physical assessment is
objective
– 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
• Order of exam - head to toe in systematic order
• Order of techniques - IPPA (Inspection, Palpation,
Percussion, Auscultation)
• Be systematic, but be flexible based on patient’s
needs
– When might you change order of exam?
• In practice, you often will do “focused” PE examine only the pertinent parts
• PRIORITIZE (ABC’s, Maslow)
General Survey
• General appearance, gait, nutrition status (NOT to be confused with
nutrition history), state of dress, body build, obvious disability, speech
patterns, affect (mood), hygiene, body odor, posture, race, gender, height,
weight, vital signs
• Height up to age 2 is recumbent
– Add head circumference if child is less than 2 years old
Integumentary System
– Integument includes skin, hair, and nails
• Inspect: skin color and uniformity of color,
moisture, hair pattern, rashes, lesions, pallor,
edema
• Palpate: temperature, turgor, lesions, edema (Box
on lesions and on describing edema)
• Percussion and auscultation: rarely used on skin
Integumentary System
• Hair - texture, distribution, scalp, critters
• Nails - inspect and palpate
– 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
• Skin
– Terminology: pallor, cyanosis, edema, ecchymosis, macule, papule,
cyanosis, jaundice, types of edema, vitiligo, hirsutism, alopecia, turgor.
***know terminology, draw diagrams, take pictures
HEENT
• Head - inspection and palpation
– Size, shape, symmetry
• Eyes - inspection and palpation
– 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)
Eyes
• 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; (PERRLA)
– 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
Ears
• Inspection and palpation
– Inspect size, shape, position, discharge, lesions
– Palpate for tenderness, any lesions
• Review anatomy of ear and inner ear
• Gross hearing acuity: normal voice, whisper test,
Weber and Rinne
– Table 32-16
• Internal ear (behind tympanic membrane) –
otoscope can look through TM
Nose and Sinuses
• Inspection, palpation, percussion
• Inspect color of mucosa, presence of discharge
– There is a nasal speculum – most people don’t like it
– Assess for patency
• Palpate for tenderness
• Percuss for tenderness over frontal and maxillary
sinuses
– Table 32-17/ 32-23
Mouth and Throat
• Inspection, palpation, auscultation
• Inspect and palpate lips, tongue, oral cavity,
tonsils, pharynx (color, moisture), teeth, breath,
presence of exudate, erythema, lesions, palate
– 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)
• Oral health is strongly linked to overall health
Throat and Neck
• Inspect and palpate neck for trachea (should be at midline), thyroid,
lymph nodes.
• Auscultate carotids for bruits (bell)
– If bruit is heard, palpate for carotid thrill
– Palpate one side at a time
• Perform ROM on neck (active and passive)
Thorax and Lungs
• Changes in respiratory status can happen very slowly,
or very quickly, so respiratory status is assessed
carefully, and frequently
• See figure 32-35, p. 716 and figure 32-36 &37, p. 717
for chest landmarks - need to know angle of Louis,
how to count ribs, how to describe locations, what is
under the surface
– Landmarks are things felt or seen used to document
location of something
• Assess size and shape of thorax
– Anterior/posterior measurement should be less than the
transverse diameter.
– Look for deformities
– Barrel chest from asthma or COPD (AP>transverse
diameter)
• For efficiency, you usually assess posterior chest first
in the adult
– Pediatric clients, anterior exam more reliable.
• Intercostal spaces (ICS) are names according the rib
they lie beneath
– 4th rib lies superior to 4th ICS
– Posterior, you have to count spinous processes to name
ribs and ICSs
Lungs
• Inspect, Palpate, Percuss (normal note is resonance), Auscultate (normal is
clear and equal bilaterally)
– Auscultate using bilateral examination
• See Figure 32-40 pg. 719
• Assess and document respiratory rate, rhythm, and effort
Respiratory Terminology
•
•
•
•
•
•
•
Eupnea
Tachypnea
Bradypnea
Apnea
Hyperventilation
Hypoventilation
Dyspnea
Respiratory Warning Signs
•
•
•
•
•
Anxious expression
Suprasternal & intercostal retractions
Nasal flaring
Circumoral cyanosis
Hyperexpanded chest
– ALWAYS REMEMBER YOUR ABCs
Breath Sounds
• Auscultate using diaphragm, use a systematic approach, compare
each side to the other, document when and where sounds are heard
• Normal breath sounds: bronchovesicular, bronchial, and vesicular
– Abnormal breath sounds are called adventitious sounds
Breath Sounds
• Stridor - may be heard without stethoscope, shrill
harsh sound on inspiration d/t laryngeal
obstruction
• Wheeze - may be heard with or without
stethoscope (document which), high-pitched
squeaky musical sound; usually not changed by
coughing; Document if heard on inspiration,
expiration, or both; May clear with cough
– Noise is caused by air moving through narrowed or
partially obstructed airway
– Heard in asthma or FBA
Breath Sounds
• Crackles - heard only with stethoscope (formerly called rales): fine,
medium, coarse short crackling sounds (think hair); May clear with
cough
– Most commonly heard in bases; easier to hear on inspiration (but
occurs in both inspiration and expiration)
• Gurgles - heard
only with stethoscope (formerly called
rhonchi): Low pitched, coarse wheezy or whistling
sound - usually more pronounced during expiration
when air moves through thick secretions or
narrowed airways – sounds like a moan or snore;
best heard on expiration (but occur both in and out)
• Friction rub – Grating, creaking, or rubbing sound
heard on both inspiration and expiration; not
relieved by coughing; due to pleural inflammation
• Document breath sounds as clear, decreased or
absent, compare right to left, and describe type and
location of any adventitious sounds
– CTAB or BBS cl =
– NOT BS clear (BS could be bowel sounds . . .)
• Infants – respiratory rate is much faster, breath
sounds seem louder and harsher
– Babies belly breathe, so watch abdomen for counting
respirations rather than watching chest (up to about age 6
years)
• Elderly – Osteoporosis and postural changes can
decrease respiratory effort and function; cilia
decrease in number and function, so mucous is not
cleared as easily, putting elderly at increased risk for
respiratory infections
Breasts and Axillae
• Inspection and palpation
– 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
– 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
– Newborns – may have breast swelling and/or milky discharge
from nipples for up to 2 weeks
– Tanner Staging is a sexual maturity rating; female breast
development is one of the things rated (5 stages)
– Gynecomastia – enlargement of breast tissue in males; often occurs
during puberty, and often affects only one breast, or affects one more
so size is not symmetric
– Pregnant women – breasts enlarge as glandular tissue responds to
pregnancy hormones to prepare for breastfeeding
– Elderly – glandular tissue is replaced by fatty tissue, and elasticity of
connective tissue is lost after menopause, both contribute to breasts
becoming pendulous or flaccid
Heart
• See table 32-23 for History for Heart Assessment
• Pulse assessment and direct cardiac assessment
• Inspection and Palpation
Inspection
• Assessment of cardiac function is performed through
the anterior thorax.
• The base is the upper portion and the apex is the
bottom tip.
– The apex actually touches the anterior chest wall at the
fourth or fifth intercostal space just to the left of the
midclavicular line.
• This is know as the Apical impulse or point of maximal impulse
(PMI)
• An infants heart is more horizontal and has a larger diameter.
– The apex is at the third or fourth intercostal space just to the left of
the midclavicular line.
– By age 7 a child’s PMI is the same as an adult.
Cardiac Cycle
•
Understanding of the cardiac cycle
– RA to RV through the tricuspid valve
– RV through the pulmonary valve to the pulmonary artery
– Lungs to the LA
– LA through the mitral valve to the LV
– LV through the aortic valve to Aorta
– Aorta to the body
• The valves open and close as the pressures within the chambers change
• Two phases
– Systole: ventricles contract and eject blood from them
– Diastole: ventricles relax and blood fills the ventricles (and the
coronary arteries!)
Cardiac cycle: EKG
• See figure 32-44 for correlations to EKG
•
Client is in the supine position to begin
– Sitting, supine, left lateral recumbent
• Figure 32-47
• Heart sounds can change with respiratory changes
– Always do your heart assessment before your respiratory assessment
• Look for pulsations and thrills along the chest wall.
Figure 32-45 Anatomical Sites for
Cardiac Function
Auscultation
• The first heart sound, or the S1 (lub) is the closure of the tricuspid and
mitral valves.
• The second heart sound, or the S2(dub) is the closure of the aortic and
pulmonary valves.
Auscultation
•
When the heart rhythm is irregular compare your apical and radial pulse
rate simultaneously.
– If the radial pulse is slower than the apical pulse it is called a pulse
deficit.
• Report the pulse deficit to the physician immediately.!
Additional Heart Sounds
• S3- ventricular gallop
– Occurs just after S2
– Ken-tuck-y
– Stiff or dilated ventricle
• Hypertension or heart failure
• Can be normal in persons <30yrs old
• S4- atrial gallop
– Occurs just before S1
– Ten-es-see
– Heart failure
*** extra heart sounds best heard with the client lying on the left
side and the stethoscope at the apical site
Murmurs
• Sustained swishing or blowing sounds heard at the beginning, middle, or
end of systolic or diastolic phase.
– Caused by increased blood flow though an abnormal structure of a
damaged structure.
– Between S1 and S2 it is called a systolic murmur.
– Between S2 and the next S1 it is a diastolic murmur.
Murmur
• Thrill- continuous palpable sensation
• Intensity
• Grade 1-5
1- barely audible
2- audible but faint
3- loud, with or without thrust or thrill
4- loud, with thrust or thrill
5- very loud, with thrill, audible without stethoscope
• Pitch
– Low, medium, high
• Low pitched murmurs heard best with bell
• High pitched murmurs heard best with diaphragm
• Quality
– Crescendo murmur- starts softly and builds
– Decrescendo murmurs- starts loud and softens
Murmurs are hard! They take time and a lot of experience!!
Vascular
• Assessment includes measurement of blood pressure and thorough
assessment of the integrity of the peripheral vascular system.
• Usually examination is done during assessment of other body systems.
– Ex: femoral pulse palpation after abdominal exam
Blood Pressure
• Readings may vary between limbs
– Tend to be higher in the right side
– Systolic readings >15 points suggests atherosclerosis or aortic disease.
– Always record the highest reading
• In pediatrics 4 extremity BP readings are often done.
Carotid Arteries
• Inspect for obvious pulsations.
• Palpation of the pulse
– Normal is localized and strong not diffuse.
– Both arteries should be equal in pulse rate, rhythm, and strength.
• Auscultation is important
– Especially in the middle aged adult and older
• A blowing sound is called a Bruit
Jugular Veins
• Examination of the right internal jugular vein is best.
– Reflects the pressure of the right atrium.
– The higher the column the higher the RA pressure is.
• Can suggest right sided heart failure
– Supine with head elevated 30-45 degrees
– Measure the pressure by measuring the vertical distance
between the angle of Louis and the highest level of the
visible point of the pulsations.
– See 32-52 and 32-53
Peripheral Arteries and Veins
• Assessment of the adequacy of blood flow to the extremities
– Pulses
– Condition of skin and nails
Pulses
• Use distal pads of the second and third finger,
compare each side.
• Apply firm pressure but do not occlude.
• Assess for elasticity of the vessel wall, strength, and
equality.
– It should spring back once pressure is released.
– Strength is a measurement of the force.
• 0-4+
–
–
–
–
–
0= absent
1+= diminished, barely palpable
2+= easily palpable, normal
3+= full pulse, increased
4+= strong, bounding, cannot obliterate
• Pulses
– Radial
– Ulnar
– Brachial
– Femoral
– Popliteal
– Posterior tibial
– Dorsalis pedis
Lymphatic System
• Palpation of the superficial inguinal nodes
• Figure 32-65
• Vocabulary
Musculoskeletal
• Assessment of range of motion, muscle strength, tone and joint and
muscle condition.
• Uses inspection and palpation.
• Position as indicated for individual joint/muscle assessment.
Inspection
• Gait
• Posture
– Common posture abnormalities.
• Kyphosis
• Lordosis
• Scoliosis
• Assess extremities
–
–
–
–
Overall size
Gross deformity
Bony enlargements
Symmetry
Palpation
• Palpate all bones, joints and surrounding muscles.
• Note for:
– Tenderness
– Heat
– Edema
– Resistance to pressure
** there should be no discomfort and muscles should be firm
Range of Motion
• Active and passive motion of all muscle groups
• See figure 32-84
• Insert 32-34
Abdomen
• Assessment of the lower GI tract, liver, spleen,
uterus, ovaries, kidneys and bladder.
• Use inspection, auscultation, percussion and
palpation (in that order!!)
• Landmarks are important!
– Xiphoid process marks the upper boundary of the
abdominal region.
– Symphysis pubis marks the lower boundary.
– Divide the abdomen into four quadrants
32-37
Inspection
• Note posture
– Note any guarding or splinting
• Inspect for abnormal movements such as pulsations or heaves.
• Inspect:
– Skin
– Umbilicus
– Contour and symmetry
– Masses
Auscultation
• Bowel sounds
– Normally soft, gurgling sounds that occur irregularly 5-35
times a minute lasting ½ second to several seconds.
– It takes 5 minutes of continuous listening before it can be
called absent bowel sounds.
• Hyperactive
• Hypoactive
• Borborygmi
– Hyperactive, growling sounds
• Presence of vascular sounds or bruits can be
indicative of an aneurysm or stenotic vessel.
– Report to physician immediately!!
Percussion
• Takes practice!!!
• Percuss for organs and masses
– Dull is heard over a solid organ
– Liver size
Palpation
• Systemic palpation over each quadrant to assess for muscular resistance,
distention, tenderness, and superficial organs or masses.
• Observe patients response.
• Light and then deep palpation in all four quadrants.
Female and Male Genitalia
Read information in book.
Remember that for many this is an embarrassing
topic, but so important!!
Neurological System
• Complex and time consuming!
• Many functions
– Initiation and coordination of movement
– Sensory stimuli
– Motor
– Speech
– Memory
– Organization of thought processes
Structure and Function
Central Nervous System (CNS)
• Cerebral cortex
– Frontal lobe
•
•
•
•
•
•
Personality
Behavior
Emotions
Intellectual Function
Ability to write words
Speech Motor (Broca’s area)
– Parietal lobe
• Primary center for sensation
• Ability to recognize body parts
• Left versus right
– Occipital lobe
• Primary visual reception center
• Understanding of written material
- Temporal Lobe
• Primary auditory reception center
• Understanding of written material
• Wernicke’s area
• Basal ganglia
– Control autonomic associated movements
• The arm swing alternating with the legs during
walking
• Thalamus
– Main relay station
• Synapses form
• Pain threshold
• Hypothalamus
– Center for:
• temperature control
• Sleep
• Pituitary regulation
• HR
• BP
• Emotional regulation
• Autonomic nervous system activity
• Cerebellum
– Coordinates and smoothes movement
• Voluntary movements, equilibrium and muscle tone
• Brainstem
• Midbrain
– Visual reflexes
• Pons
– connects
• Medulla
– Quality of respirations and heart rate
– Swallowing, hiccoughing, gag and cough reflexes
• Spinal cord
• Highway
Structure and Function, cont.
Pathways of the CNS
• Crossed representation
• Sensory pathways
– Spinothalamic tract
• Pain
• Temperature
• Crude touch
– Posterior (dorsal) column
• Sensations of position
• Vibration
• And fine touch
• 32-40
Structure and Function, cont.
Peripheral Nervous System
• Carries messages to the CNS from sensory
receptors and from the CNS to muscles and
glands
–
–
–
–
Cranial nerves
Spinal nerves
Autonomic nervous system
Reflex arc
• Cranial Nerves
• Spinal Nerves
– “Mixed” nerves (both sensory and motor fibers)
– 31 pairs
• 8 cervical
• 12 thoracic
• 5 lumbar
• 1 coccygeal
Autonomic Nervous System
• Governs the glands, cardiac muscle, and the smooth
muscles of the digestive, respiratory and skin.
• Two areas
– Sympathetic
– Parasympathetic
• Reflex Arc
– A response below the level of consciousness
• Helps control and permit quick reaction
• Maintain balance and appropriate muscle tone
• 32-88
• Equipment needed
–
–
–
–
–
–
–
Penlight
Tongue blade
Cotton swab
Cotton ball
Tuning fork (128 Hz or 256 Hz)
Percussion hammer
Occasionally need: familiar aromatic substance
Objective Data
The Physical Exam cont..
• Test Cranial Nerves II thru XII
• CN I Olfactory
Sensory
Smell—coffee, cloves, peppermint
• CN II Optic
Sensory
Visual acuity—Snellen chart
Test for visual fields
Examine with ophthalmoscope
• CN IIIOculomotor
Motor
Move eye up, down and peripherally
Test for accommodation
Pupillary constriction
Observe for ptosis of upper eyelid
• CN IV
Trochlear
Motor
Inferior lateral movement of
the eye
• CN V
Trigeminal
Sensory
Corneal reflex
Sensation of skin of the face using a
wisp of cotton
(eyebrow, cheeks and chin)
Motor
Chewing, biting, lateral jaw
movements (move jaw side to side)
• CN VIAbducens
Motor
Inferior lateral eye movements
• CN VII Facial
Sensory
Taste—anterior 2/3 of tongue
sweet—sugar; salt
sour—vinegar
bitter—quinine
Motor
Movement of forehead and mouth
Raise eyebrows, show teeth, smile
and puff out cheeks
• CN VIII Acoustic
Sensory
Hearing, balance, Weber and Rinne tests
Otoscope
• CN IX Glosso-pharyngeal
Motor
Swallowing and phonation
Sensory
Taste—posterior 1/3 of tongue
See CN VII
• CN X
Vagus
Sensory
Sensations of posterior 1/3 of tongue,
throat exam
Motor
Gag reflex
Swallowing and phonation
• CN XI
Spinal
Motor
Shoulder movement, shoulder
shrug, head rotation—
push against examiner’s
hand
• CN XII Hypoglossal
Motor
Tongue movement—protrude
tongue, push tongue into
the cheek
Objective Data—
The Physical Exam, cont.
Motor System—Inspect and Palpate
• Muscles
– Size
– Strength
– Tone
– Involuntary movements
• Cerebellar function
– Balance tests
•
•
•
•
Gait
Tandem walking
Romberg test
Shallow knee bend
– Coordination and skilled movements
•
•
•
•
Rapid alternating movements (RAM)
Finger-to-finger test
Finger-to-nose test
Heel-to-shin test
Objective Data—
The Physical Exam, cont.
Sensory System
• Person is alert,
cooperative, and
comfortable
• Guidelines for sensory
testing
• Spinothalamic tract
– Pain
– Temperature
– Light touch
• Posterior column tract
– Vibration
– Position (kinesthesia)
– Tactile discrimination
(fine touch)
• Stereognosis
• Graphesthesia
• Two-point discrimination
• Extinction
• Point location
Objective Data—
The Physical Exam, cont.
• Test the stretch or deep tendon reflexes
–
–
–
–
–
–
–
–
Technique
Grading
Reinforcement
Biceps reflex
Triceps reflex
Brachioradialis reflex
Quadriceps reflex
Achilles reflex (“ankle jerk”)
• Clonus
(DTR’s)
• 32-41
Neurologic Re-check
• Level of consciousness
– Person
– Place
– Time
• Motor function
• Pupillary response
• Vital signs
Glasgow coma scale (GCS)
Glascow Coma Scale
 Measures clinical ability of patient to
open eyes, verbalize appropriately and
move willingly
– Used To:
 Evaluate neurological status after initial injury
and throughout recovery
 Estimate neurological outcome
Glascow Coma Scale Rating
 GCS <7 = Severe head injury/Coma
 GCS 8-13 = Moderate head injury
 GCS 13-15 = Mild head injury
Abnormal Findings
Abnormalities in Muscle
Movement
•
•
•
•
•
Paralysis
Fasciculations
Tic
Myoclonus
Tremor
•
•
•
•
Rest tremor
Intention tremor
Chorea
Athetosis
After the Exam
•
•
•
•
Assist with dressing
Documentation
Follow up information
EDUCATION!!
• Questions???