Basic physical assessment head to toe assessment major body systems assessment
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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.

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Basic physical assessment head to toe assessment major body systems assessment
Basic Physical AssessmentHead-to-toe assessmentMajor body systems assessment


Purpose
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


Health history

Provides baseline subjective information

Guides and directs your physical assessment

Identifies

Strengths

Actual or potential health problems

Support system

Teaching needs

Discharge and referral needs

Use of effective communications skills

Family history

Life patterns

Sociocultural history

Spiritual health

Mental reactions

Emotional reactions

Health History


Physical assessment
PHYSICAL ASSESSMENT

  • Validates the patient’s complaints related to health

  • Assists in formulating nursing diagnoses and interventions

  • Monitors current health problems

  • Obtains baseline information for future assessments


Assessment techniques
Assessment techniques

  • Inspection …Always first!!!

  • Palpation

  • Percussion

  • Auscultation


Assessment techniques palpation

Temperature

Texture

Moisture

Organ size and location

Rigidity or spasticity

Crepitation, Vibration

Position

Size

Presence of lumps or masses

Tenderness, or pain

Assessment techniques Palpation


Assessment techniques percussion

Assess underlying structures for location, size, density of underlying organs.

Direct – sinus tenderness

Indirect- lung percussion

Blunt percussion- organ tenderness (CVA tenderness)

Assessment techniques Percussion


Assessment techniques percussion sounds
Assessment techniques Percussionsounds

  • Flatness – bone or muscle

  • Dullness – heart, liver, spleen

  • Resonance – air filled lungs (hollow)

  • Hyperresonance – emphysematous lung (hyperinflated)

  • Tympany – air-filled stomach (drumlike)


Assessment techniques auscultation
Assessment techniques Auscultation

  • Listening to sounds produced by the body:

    Heart

    Blood vessels

    Lungs

    Abdomen

  • Instrument: stethoscope

    • Diaphragm –high pitched sounds

    • Bell – low pitched sounds


Assessment techniques auscultation1

Avoid Interruptions

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

Assessment techniques Auscultation


Eyes perrla
Eyes - PERRLA

  • 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

    • PERRLA = Pupils equal, round, reactive to light, accommodation


Pupils
Pupils

  • Cloudy pupil: cataracts

  • Dilated pupil: glaucoma, trauma, neurologic disorder

  • Constricted pupil: drug use

  • Pinpoint pupil: opioid intoxication


Great vessels of the neck
Great vessels of the neck

  • Jugular veins

    • Empty unoxugenated blood directly into the superior vena cava, which empties into the right side of the heart

  • Carotid arteries

    • Reflects cardiac systole and is timed with S1, Palpate only one at a time

  • Carotid artery pulse – correlates with first heart sound


Assessment
Assessment

  • Position client supine

  • Then head elevated at 45 degrees

  • INSPECTION:

  • Lifts, heaves

  • PMI (assess location)


General reference lines
GeneralReference Lines

  • Sternal Line

  • Midclavicular Line

  • Apical /PMI – left 5 th iCS midclavicular line

  • Axillary Line


Heart auscultatory sites
Heart Auscultatory Sites

  • When auscultating sounds, place the stethoscpe over the four different site

  • All physicians take money- APTM

  • Aortic, Pulmonic, Trisuspic, Mitral

  • The sites are identified by the names of heart valves… but they are not located directly over the valves.

  • Rather, these sites are located along the pathway blood takes as it flows throught the heart’s chambers and valves.


Heart
Heart

  • 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


Cardiac cycle
Cardiac Cycle

  • 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

  • Diahragm of the stethoscpe – for highpitched sounds – heart sounds

  • Bell- for low pitched sounds – bruits, murmurs


Heart sounds
Heart Sounds

S1: Lub: mitral valve closure

S2: Dub: Aortic valve closure


Heart sounds s1 s2

S1:

Closure of mitral and tricuspid valves (M1 before T1)

Correlates with the carotid pulse

Can be split but not often

S2:

Closure of aortic and pulmonic valves

May have a split sound (A2 before P2)

Heart Sounds – S1 & S2


Heart sounds1
Heart Sounds

  • S1 loudest at the apex (tricuspid), this sound corresponds to the closure of M1& T1

  • May be split.

  • S2 loudest at the base (aortic),

  • Physiologic S2 splitting- heard best at pulmonic area during peak inspiration

  • S2 splitting – when the pulmonic valve closes later than the aortic valve – normal during inspiration

  • Fixed split – ASHD – no variation with insp.


Extra heart sounds s3
Extra Heart Sounds- S3…

  • a low-pitch vibration in early diastole immediately after S2

  • Rapid ventricular filling: ventricular gallop May be a cardinal sign of CHF in adults

  • May be normal in children, and patients with high cardiac output (athletes)

  • Pathological in adults: CHF, HTN, CAD

  • S1 -- S2-S3

  • Sounds like: Ken--tuc-ky


Extra heart sounds s4
Extra Heart Sounds- S4…

  • Soft, low-pitched sound in late diastole immediately before S1

  • Atria contract and eject blood into resistant ventricles (slow ventricular contraction): atrial gallop

  • May be physiological in infants and small children

  • Common in HTN pts

  • S4-S1 — S2

  • Sounds like Ten-nes--see


Heart sounds2
Heart Sounds

  • Normal (Lub-dub, Lub-dub)

  • S1 Lub (Closure of AV Valves at start of systole)

  • S2 Dub – (Closure of pulmonic and aortic valves upon end diastole)

  • 3rd Heart Sound – Middle 3rd of diastole

  • 4th Heart Sound – Atrial


S1 systole s2 diastole s1 systole s2
S1 Systole S2 Diastole S1 Systole S2

S4

S3

S4

M

T

A

P

M

T

A

P


Peripheral pulses
Peripheral Pulses Diastole S1 Systole S2

  • 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 pulses1

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

Peripheral Pulses


Grading
Grading pulse site without occluding pulse

  • 0 = Absent, not palpable

  • 1+- Diminished, barely palpable

  • 2+- Easily palpable, normal pulse

  • 3+ - Full pulse, increased

  • 4+ - Strong, bounding, cannot be obliterated


Lower extremities
Lower Extremities pulse site without occluding pulse

  • Pedal pulses

  • Foot strength bilaterally

  • Homan’s Sign

  • Capillary refill (see next slide)

  • Edema

  • Pain


Capillary refill
Capillary Refill pulse site without occluding pulse

  • 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


Assessing for edema

Depress pulse site without occluding pulse

pretibial area & medial malleolus for 5 seconds

Grade pitting edema

1+ to 4+

Assessing for Edema


Lungs anatomy and landmarks
Lungs – Anatomy and Landmarks pulse site without occluding pulse

  • Lungs are paired but not symmetrical (see next slide)

  • right lung = 3 lobes RUL, RML, RLL

  • left lung=2 lobes LUL , LLL

  • Lung border locations:

  • Apices – 1 inch above the clavicles

  • Bases – located at the level of the 6th rib (T10)

  • Lateral chest – extend from the apex of the axilla to the 7th or 8th rib.


Lungs
Lungs pulse site without occluding pulse

  • Inspection

  • Color, Size and shape of chest, any deformities or lesions

  • Resp. rate and depth

  • Pattern of respiration – regular rhythm

  • Abnormal patterns

    • Hyperventilation-fast rate and deep breathing

    • Tachypnea >28 vs. bradypnea <10

    • Stertorous -“death rattle” –seen in comatose patient


Lungs1
Lungs pulse site without occluding pulse

  • Inspection

    • Check size, shape, symmetry

      • Altered shape ex., COPD, barrel chest

      • Altered symmetry ex., kyphosis (hunchback), scoliosis (S)

      • Altered breathing ex., rib fractures, pneumothorax

      • Altered color ex., hypoxia

      • Retractions from airway obstruction, respiratory distress

      • Scars from lung surgery, trauma


Looking at related structures
Looking at related structures pulse site without occluding pulse

  • Skin: cyanosis, pallor

  • Nails: Clubbing

    • Spongy nail matrix and nail angle of greater than 160 degrees

    • Associated with congenital heart disease


Ap diameter anterior posterior diameter
AP Diameter pulse site without occluding pulseAnterior Posterior Diameter

  • The diameter of the chest from front to back should half the width of the chest.

  • AP-Transverse/Lateral diameter= 1:2;

  • Transverse/Lateral should twice as wide as front to back

  • Barrel chest – emphesyma pts (alveoli lost its eleasticity so lung tissue does not recoil back to normal

  • COPD / Emphysema classically produces the "Barrel Chest Deformity" Lungs are overinflated, and pushing the chest wall out

  • Pectus carinatum(Pigeon chest)– sternum protrudes out beyond the front of the abdomen– may be related to Rickkets

  • Pectus excavatum(funnel chest)– sternum pushed in; depressed on all or part of the sternum


Normal breath sounds
Normal Breath Sounds pulse site without occluding pulse

  • Bronchial over trachea

  • Bronchiovescular over main bronchi

  • Vesicular over lesser bronchi, bronchioles, and lobes


Continuous sounds pulse site without occluding pulse

Wheezes

Rhonchi

Discontinuous sounds

Crackles (Rales)

Fine

Course

*Atelectic crackles

Pleural friction rub

Adventitious/AbnormalBreath SoundsNote whether the sound occur during inhalation or exhalation, or both.


Wheeze rhonchi continuous sound
Wheeze & Rhonchi pulse site without occluding pulseContinuous Sound

Wheeze

  • high-pitched musical sounds heard first when a patient exhales

  • Partial blockage in airflow

  • Severe blockage – wheezes also heard when patient inhales

  • Asthma, CHF, or foreign body obstruction, tumors

    Rhonchi

  • low pitched – snoring, rattling sound

    heard primarily when the pt exhales

  • may also be heard on inhalation

  • disappears with coughing

  • Uncleared secretions, bronchitis, pneumonia,


Crackles discontinuous sound
Crackles pulse site without occluding pulseDiscontinuous Sound

  • Crackles(Rales) -Caused by collapsed or fluid-filled alveoli popping open.

  • FINECrackles–

    • usually heard in the lung bases;

    • CHF, Pneumonia, restrictive diseases – pulm fibrosis, asbestosis, atelectasis (early CHF)

  • COURSE Crackles

    • during inhalation and may be present in exhalation

    • Sounds like bubbling or gurgling as air moves through secretions in the larger airways

    • COPD, pulm edema


Crackles discontinuous sound1
Crackles pulse site without occluding pulseDiscontinuous Sound

  • Crackles(Rales) -Caused by collapsed or fluid-filled alveoli poppingopen.

  • Atelectic crackles

    • common in elderly, disappears after several deep breaths

  • Pleural friction rub – pericarditis

    • fluid in the pericardial space due to inflamed pleura

    • pain on deep inspiration.


Pulmonary edema
Pulmonary Edema pulse site without occluding pulse

  • Accumulation of fluid in the air sacks (aveoli) of the lungs


Abnormal breath sounds
Abnormal Breath Sounds pulse site without occluding pulse

  • Diminishedbreath sounds

    • Obese, muscular chest wall

    • poor inspiratory effort

    • pleural effusion

  • Absent breath sounds

    • Missing lung/lobe

    • airway obstruction, pneumothorax


Lungs palpation
Lungs - Palpation pulse site without occluding pulse

  • Crepitus– SQ air pockets = abnormal

    • Indicates subcutaneous air in the chest

    • Feels like puffed rice cereal crackling under the skin and indicates air is leaking from the airways or lungs due to chest tube or open wound

  • Tactile fremitus – increased fluid accumulation = abnormal

  • A palpable vibration that is caused by the transmission of air through the broncho pulmunary system

    • Decreased fremitus – over areas where pleural fluid collects (effusion, and pneumothorax, atelectasis, emphysema)

    • Increased fremitus – abnormally seen in areas in which alveoli are filled with fluid and exudate, occurs with consolidation of lung tissue (pneumonia). You will feel more vibration.


Objective data
Objective Data pulse site without occluding pulse

  • Respiratory

    • Rate: 18 resp/min

    • Depth: deep, even, shallow

    • Effort: labored, unlabored

  • Breath Sounds

    • Describe: clear, rhonchi, inspiratory/expiratory wheezes, crackles

    • Location: all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat.

    • Cough: present/not present

      • Describe: productive, moist, nonproductive

    • Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.


Interventions
Interventions pulse site without occluding pulse

  • Position, Turn, Cough, Deep breathe

  • O2 Method: nc, venti mask, rebreathing mask

    • Flow rate: 2L/min; 3l/min

    • Humidity: yes/no

  • Pulse Oximeter: continuous, spot monitoring

  • Incentive Spirometer: in use, n/a

    • Time used: 10 am, 11 am, 1 pm, 3 pm

    • Volume: 500 cc, 500 cc, 600 cc, 800 cc

  • Oropharyngeal Suctioning: Describe- moderate amount thick tan secretions

  • Med List: Albuterol inhaler, Prednisone, Theophylline


Abdomen
Abdomen pulse site without occluding pulse

  • 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


Abdomen1
Abdomen pulse site without occluding pulse

  • RUQ – liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of colon, ascending /transverse colon, right kidney

  • LUQ – stomach, spleen, body of pancreas, left kidney, splenic flexure of colon, transverse/descending colon

  • RLQ – cecum, appendix, right ovary, tube, ureter, and spermatic cord

  • Midline – aorta, uterus, bladder

    Epigastric, umbilical, suprapubic


Different sequence of assessment

Inspect pulse site without occluding pulse

Auscultate

Percuss

Palpate

Procedure:

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

Different Sequence of Assessment


Abdomen inspection
Abdomen - Inspection pulse site without occluding pulse

  • Lesions – benign, scars from sx or trauma, striae, etc.

  • Distention - can be from fluid, air, mass, or obstruction

  • Pulsations - or movement of abdominal wall from peristalsis, pulsations and respiratory movement

    • Peristalsis usually can’t be seen. If seen, slight wavelike motions.

    • Visible rippling waves may indicate bowel obstruction -reported immediately.

    • In thin pts, abdominal aortic pulsations may be seen in the epigastric area.

    • Marked pulsations may indicate HTN, Aortic insuff, AAA, or other condition causing widening pulse pressure (see next slide)


Aneurysm
Aneurysm pulse site without occluding pulse

  • Note vascular sounds – presence of bruits over aorta, renal, iliac, femoral

  • Normally no bruits noted

  • Abdominal aortic aneurysm – surg emerg.-tx immed to prevent hemorrhage, shock, and death

  • If you see bounding pulsation on abd wall, feel for pulsations, and measure (greater than 6 cm- most likely aneurysm) report.


Auscultation of bowel sounds
Auscultation of Bowel Sounds pulse site without occluding pulse

  • Absent

    • no BS for 5 min

  • Hypoactive

    • less than 5/min

  • Active

    • 5-30 per min

  • Hyperactive

    • > 30 /min


Abdomen procedure
Abdomen - procedure pulse site without occluding pulse

  • BOWEL SOUNDS

  • VENOUS HUMS

  • RENAL BRUITS

  • INGUINAL BRUITS

  • Use diaphragm of stethoscope lightly on skin to prevent stimulating bowel sounds

  • Start in RLQ (BS often present here) then proceed all four quadrants

  • Listen for 3-5 minutes

  • Note character and frequency of BS


Bowel sounds
Bowel Sounds pulse site without occluding pulse

  • Normal BS are high-pitched, gurgling noises caused be air mixing with fluid during peristalsis. The noises vary in frequency and pitch, and intensity. They are loudest before meal times. Normal BS – 5-30 per minute

  • Borborygmus, or stomach growling – are the loud, gurgling, splashing bowel sound heard over the large intesting as gas passes through it.

  • Hyperactive BS - > 30 /min – loud, high pitch, tinkling that occur frequently – may occur with diarrhea, constipation, and laxative use

  • Hypoactive < 5 per min; - occur infrequently – assoc. with bowel obstruction, ileus, peritonitis, and indicate diminished peristalsis. (paralytic ileus, use of narc meds can decrease peristalsis)

  • Absent, no BS for 5 minutes.

  • Be sure to allow enough time for listing in each quadrant before you decide that bowel sounds are absent. If NGT to suction, turn off suction as to not obscure or mimic sounds


Percussion
Percussion pulse site without occluding pulse

·To assess

-Density of abdominal contents

-Locate organs

-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


Abdomen palpate
Abdomen - Palpate pulse site without occluding pulse

  • Palpate all four quadrants:

  • To check for muscle resistance or rigidity; masses, fluid, tenderness.

    • To palpate, put finger of one hand close together and make gentle rotating movements as you depress ½ inch (1.3 cm) Light palpation – depress 1 cm:Relaxation; Tenderness; Masses

  •    Palpate areas of pain and tenderness last

  • Normal: the abd should be soft and nontender. As you palpate, note any

  • Abnormal findings: tenderness, masses, and rigidity


Palpation

Light Palpation pulse site without occluding pulse

TENDERNESS, MASSES, RIGIDITY

Deep Palpation

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

Palpation


Normally palpable structures
Normally Palpable Structures pulse site without occluding pulse

  • Know what is underneath so you can determine what can be expected from normal to abnormal

    • Ex. suprapubic distention, full bladder or tumor?

    • Sigmoid colon, stool can be palpated there

  • Liver – should not be able to palpate liver way below the rib = enlarged


Rebound tenderness
Rebound Tenderness pulse site without occluding pulse

  • Use when found abdominal pain or tenderness

  • Hold hand at 90 deg angle & push slowly & deeply

  • Lift hand quickly

  • Norm. response is no pain on release of pressure

  • Perform at end


Abdomen summary
ABDOMEN (summary) pulse site without occluding pulse

  • INSPECT-SKIN, PULSATION

  • AUSCULTATE FOR BOWEL SOUNDS IN 4 QUADRANTS FOR 2-5 MIN & DETERMINE IF AUDIBLE, ABSENT, HYPOACTIVE, HYPERACTIVE

  • PERCUSS FOR TYMPANY & LIVER DULLNESS

  • PALPATE LIGHTLY FOR TENDERNESS, MASSES, RIGIDITY


References
References pulse site without occluding pulse

  • ASSESSMENT OF HEAD & NECKhttp://e-courses.cerritos.edu/rsantiago/My%20Webs/ASSESSMENT%20OF%20HEAD%20&%20NECK_SP%2004.ppt

  • Health History and Physical Assessment http://e-courses.cerritos.edu/rsantiago/My%20Webs/PowerPoint%20Presentations.htm

  • Physical Assessment http://webteach.mc.uky.edu/nursing/nur869/webquests/lab1/Presentationphysical%20assessment.ppt


References1
References pulse site without occluding pulse

  • Rachel S. Natividad, RN,MSN: Assessment of the Abdomen http://e-courses.cerritos.edu/rsantiago/My%20Webs/ASSESSMENT%20OF%20THE%20ABDOMEN%20N212_n251%20SP04.ppt

  • Rachel S. Natividad, RN,MSN: Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system http://e-courses.cerritos.edu/rsantiago/My%20Webs/Cardiovascular%20Assessment%20_N212_N251%20SP04.ppt

  • Rachel S. Natividad, RN, MSN:The Respiratory System, Thorax and Lungs

  • http://e-courses.cerritos.edu/rsantiago/My%20Webs/Resp%20Assess%20N212_251%20SP04.ppt


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