Basic Physical Assessment Head-to-toe assessment Major body systems assessment. Purpose. 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.
Provides baseline subjective information
Guides and directs your physical assessment
Actual or potential health problems
Discharge and referral needs
Use of effective communications skills
Organ size and location
Rigidity or spasticity
Presence of lumps or masses
Tenderness, or pain
Assess underlying structures for location, size, density of underlying organs.
Direct – sinus tenderness
Indirect- lung percussion
Blunt percussion-organ tenderness (CVA tenderness)
Start with a general inspection first
Proceed for specific observation of the system
Expose only the part being examined
Examine the unaffected area or parts first
Examine external parts first, then internal
Compare one side to the other side
Proceed from head to toe
S1: Lub: mitral valve closure
S2: Dub: Aortic valve closure
Closure of mitral and tricuspid valves (M1 before T1)
Correlates with the carotid pulse
Can be split but not often
Closure of aortic and pulmonic valves
May have a split sound (A2 before P2)
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
Documentation of Pulses
pretibial area & medial malleolus for 5 seconds
Grade pitting edema
1+ to 4+
Pleural friction rub
heard primarily when the pt exhales
Epigastric, umbilical, suprapubic
Have patient empty bladder
Position patient supine with knees slightly flexed
Note the abdominal shape and contour.
The abdomen should be flat to rounded in people of average weight.
A protruding abdomen may be due to obesity, pregnancy, ascites, or abdominal distention.
A slender person may have a slightly concave abdomen
-Density of abdominal contents
-Screen for abnormal fluid or masses
Tympany – predominantly over the abdomen – gas-filled
Dull over organs in the abdominal cavity (liver, spleen)
CVA tenderness Costovertebral AngleCVA tenderness – positive in pyelonephritis
TENDERNESS, MASSES, RIGIDITY
Deep palpation - depress 5-8 cm; that’s about 2-3 inches.
In obese, patient, put one hand over the other and push down.
Palpate the entire abd on a clockwise direction and not any: Tenderness; Masses; Enlarged organs