Chapter 13 Physical Assessment. OBJECTIVES. 1. List four purposes of a physical assessment. 2. Name four assessment techniques. 3. List at least five items needed when performing a basic physical assessment. 4. Discuss at least three criteria for an appropriate assessment environment.
OBJECTIVES • 1. List four purposes of a physical assessment. • 2. Name four assessment techniques. • 3. List at least five items needed when performing a basic physical assessment. • 4. Discuss at least three criteria for an appropriate assessment environment. • 5. Identify at least five assessments that can be obtained during the initial survey of clients. • 6. State two reasons for draping clients. • 7. Differentiate a head-to-toe and a body systems approach to physical assessment. • 8. List six ways in which the body may be divided for organizing data collection. • 9. Identify two self-examinations that nurses should teach their adult clients.
Question • Is the following statement true or false? The first step of the nursing process is planning.
Answer False. The first step of the nursing process is assessment.
Physical Assessment • First step of the nursing process Assessment: gathering information • Physical assessment: systematic examination of body structures One method for gathering health data
Physical Assessment Overall goal of the physical assessment is to gather objective data Nurses examine clients: • On admission • Briefly at the start of each shift • Any time a client’s condition changes
Overview of Physical Assessment • Purposes • To evaluate the client’s current physical condition • To detect early signs of health problems • To establish baseline for future comparisons • To evaluate client’s responses to medical and nursing interventions
Physical Assessment Four Basic Physical Assessment Techniques: -Inspection (purposeful observation) -Percussion (striking of tapping) -Palpation (lightly touching or applying pressure) -Auscultation (listening to body sounds)
Overview of Physical Assessment: Four Basic Physical Assessment Techniques • Inspection: purposeful observation The most frequently used assessment technique by nurses. • Examining particular body parts • Looking for specific normal and abnormal characteristics
Physical Assessment • Using special instruments to inspect parts of the body inaccessible to ordinary visual inspection techniques (usually with advance instruction)
Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) • Percussion (least used by nurses) • Striking or tapping the body with fingertips to produce vibratory sounds • Quality of sounds determines location, size, and density of underlying structures; variation in sound could mean possible pathologic change • Pain: possible disease process or tissue injury
Inspection and Percussion Table 13-1 Percussion Sounds p.228
Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) • Palpation • Light: touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand • Deep: depressing tissue approximately 1 in. with the forefingers of one or both hands
Physical Assessment Palpation provides the following information: • Size, shape, consistency, mobility of normal tissue and unusual masses • Symmetry/asymmetry of bilateral structures • Skin temperature and moisture • Tenderness • Unusual vibrations (Fistula: bruit & thrill)
Physical Assessment • Crepatius (subcutaneous emphysema): air trapped in subcutaneous tissues Can result from punctures of parts of the respiratory or GI systems such as in gunshot/stab wounds or chest tubes. Hallmark sign in increasing edema with “rice crispy” feeling and crackling when skin is palpated.
Figure 13-17 Palpation of thoracic excursion. In the posterior approach, the nurse places hands at the level of the 10th rib and observes for equal movement as the client inhales.
Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) • Auscultation (listening to body sounds) • Used for assessing the heart, lungs, and abdomen • Soft sounds, loud sounds • Nurses: practice auscultation repeatedly to gain proficiency; to ensure accuracy, eliminate or reduce environmental noise
Question • What is lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand called? a. Inspection b. Percussion c. Palpation d. Auscultation
Answer c. Palpation Palpation involves lightly applying pressure to the body using fingertips, back of the hand, or palm of the hand. Inspection is looking for specific normal and abnormal characteristics. Percussion is striking or tapping the body with fingertips to produce vibratory sounds. Auscultation is listening to the sounds of the heart, lungs, and abdomen with a stethoscope.
Overview of Physical Assessment • Equipment: Items needed for a basic physical assessment (Box 13-1 p.229) Gloves Examination gown Scale Cloth/paper drapes Pen light Tongue blade
Overview of Physical Assessment (cont’d) • Environment • Special examination room or at bedside • Easy access to a restroom; a door or curtain to ensure privacy • Adequate warmth • Lined receptacle for soiled articles • Adequate lighting
Overview of Physical Assessment (cont’d) • Environment (cont’d) • Padded, adjustable table or bed • Sufficient room for movement around client • Facilities for hand hygiene • Clean counter or surface for placing examination equipment
Performing a Physical Assessment: Basic Activities During a Physical Assessment • Gather general data during first contact with client. Using a systematic approach. By observing and interacting with the client before the actual physical examination, the nurse notes the following: •Physical appearance with regard to clothing and hygiene •Level of consciousness
Basic Activities During a Physical Assessment • Body size (weight is more reliable) • Posture • Gait / coordinated movement of lack of it • Use of ambulatory aids • Mood and emotional tone • Preliminary data • Vital signs, weight (zero the scale), height, documentation
Performing a Physical Assessment: Basic Activities • Drape and position the client • Ensure that client is covered with a drape (sheet of soft cloth or paper). Done more for client modesty. • Begin examination with the client standing or sitting
Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) • Select a systematic approach for collecting data Head-to-toe approach: Three Advantages • Prevents overlooking some aspect of data collection • Reduces the number of position changes required of the client
Basic Activities During a Physical Assessment (cont’d) • Generally takes less time because the nurse is not constantly moving around the client in what may appear to be a haphazard manner
Basic Activities During a Physical Assessment (cont’d) Body systems approach: assessing client according to the functional systems of the body. Integumentary system: • Skin, mucous membranes, nails, hair Cardiovascular system • Peripheral pulses, heart sounds, BP
Body Systems Approach During a Physical Assessment Advantages: • Findings tend to be clustered, making problems more easily identifiable Disadvantages: • Nurse examines the same areas of the body several times before completing assessment • Frequent position changes during examination may tire the client
Data Collection: 6 General Areas for Data Collection Head and Neck Chest and Spine Abdomen Extremities Genitalia Anus and Rectum
6 General Areas for Data Collection • Head and neck • Mental status assessment (alert and oriented) • Eyes: accommodation; Snellen eye chart (far vision); Jaeger chart (near visual acuity); extraocular movements • Ears: cerumen; Weber test; Rinne test; audiometry • Nose: abnormalities; smelling acuity (not usually checked unless impairment is supected)
Pupil Size Assessment Guide P.E.R.R.L.A. Means Pupils are Equal, Round, Reactive to Light and Accommodation. (Accommodation: the ability of the eyes to focus on objects that are close up and far away); constrict when close; dilate when far away
Pupil Size Assessment Guide An eye exam is done to check how a client’s nervous system is functioning, especially after a head injury or during serious illness. Abnormal findings would include: • Not of equal size • Not round (misshapen) • No changes when light is shined • No change when looking at something is close or far away
Figure 13-11 A: Testing pupil response to light. B: Testing accommodation. C: Assessing extraocular movements.
Weber Test Quick screening test for hearing. Nurse strikes the tuning fork on the palm, then places the vibrating stem in the center of the client’s head.
Rinne Test Usually done in conjunction with the Weber test: Test is done for air conduction vs. bone conduction of sound Nurse strikes tuning fork and places the vibrating stem on the client’s mastoid area.
Figure 13-12 Technique for straightening the ear canal of an adult and child
Question • When preparing a client for the Rinne Test, which of the following equipment should the nurse keep ready? a. Stethoscope b. Tuning fork c. Snellen chart d. Jaeger chart
Answer b. Tuning fork A tuning fork is required to conduct the Rinne test to determine hearing impairment. A stethoscope is used to listen to lung, heart, and abdominal sounds. A Snellen chart and a Jaeger chart are tools for assessing far and near vision respectively.
Data Collection: Six General Areas for Data Collection (cont’d) • Head and neck (cont’d) • Mouth and oral mucous membrane • Normal oral mucous membranes are pink, intact and moist • The lips should look the same when client smiles, purses lips, shows teeth (stroke clients will not) • Teeth, dentures
Data Collection: Six General Areas for Data Collection (cont’d) • Unusual breath odors What should the nurse suspect if client has a “fruity” odor? • Assessment of taste: Rarely done by nurses.
Data Collection: Six General Areas for Data Collection (cont’d) • Facial skin: assessment of the skin begins with the head & continues throughout the body when examining those areas Normal skin should be: Smooth Unbroken Uniform of color consistent with ethnicity or race Warm and resilient
Data Collection: Six General Areas for Data Collection (cont’d) Alterations in skin integrity: • Wound: break in the skin • Ulcer: open, crater-like area • Abrasion: area that has been rubbed away by friction • Laceration: a torn, jagged wound