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.
Guides and directs your physical assessment
Actual or potential health problems
Discharge and referral needs
Use of effective communications skills
Emotional reactionsHealth History
Organ size and location
Rigidity or spasticity
Presence of lumps or masses
Tenderness, or painAssessment techniques Palpation
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
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 toeAssessment techniques Auscultation
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)Heart Sounds – S1 & 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
Documentation of PulsesPeripheral Pulses
Depress pulse site without occluding pulse
pretibial area & medial malleolus for 5 seconds
Grade pitting edema
1+ to 4+Assessing for Edema
Continuous sounds pulse site without occluding pulse
Pleural friction rubAdventitious/AbnormalBreath SoundsNote whether the sound occur during inhalation or exhalation, or both.
heard primarily when the pt exhales
Epigastric, umbilical, suprapubic
Inspect pulse site without occluding pulse
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 abdomenDifferent Sequence of Assessment
-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
Light Palpation pulse site without occluding pulse
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 organsPalpation