1 Assessing Health: Physical Examination

2 Health Assessment: Performing a Physical ExaminationAn Overview

3 The Nursing Physical ExaminationPart of a general health assessment Used to gather data about the client Focuses on functional abilities and responses to illness/stressor

4 Purposes Establish baseline dataThe nurse performs a physical examination to: Establish baseline data Identify nursing diagnoses, collaborative problems, or wellness diagnoses Monitor the status of an identified problem Screen for health problems

5 Types of Physical ExaminationsComprehensive: Interview plus complete head-to-toe examination Focused: “Focused” on presenting problem Ongoing: Performed as needed to assess status Evaluates client outcomes

6 Organizing the ExaminationHead-to-toe Starts at the head Progresses “down” the body System-related data found throughout: Heart sounds - chest Pulses - periphery

7 Organizing the ExaminationBody systems Gathers system-related data all at once May be done in a predetermined order that mimics head-to-toe: Neurological Cardiovascular Respiratory Gastrointestinal

8 Preparing Yourself: What the Nurse NeedsTheoretical knowledge A & P, techniques Self-knowledge Skill and comfort level Willingness to seek help Knowledge about client situation Purpose of examination Client diagnosis

9 Preparing the EnvironmentPrivacy is key Draping Use of curtains Noise control TV/radio off Enable visualization Adequate lighting Flashlight if needed

10 Preparing the Client Develop rapport - OEWIPES Explain the procedurePromote client comfort: Develop rapport - OEWIPES Explain the procedure Respect cultural differences Use proper positioning

11 Positioning Sitting—used to take vital signsSupine—allows relaxation of abdominal muscles Dorsal recumbent—used for patients having difficulty maintaining supine position Sim’s—assessment of rectum or vagina Prone—assessment of hip joint and posterior thorax Lithotomy—assessment of female rectum and vagina; used for brief period only Knee-chest—assessment of the rectal area; used for brief period only Standing—assessment of posture, gait, and balance

12 Equipment Ophthalmoscope—visualizes the interior structures of the eyeOtoscope—examines the external ear canal and tympanic membrane Snellen’s chart—screens for distant vision Nasal speculum—visualizes the lower and middle turbinates of the nose Vaginal speculum—examines the vaginal canal and cervix Tuning fork—tests auditory function and vibratory perception Percussion hammer—tests deep tendon reflexes and determines tissue density

13 Physical Assessment SkillsFour major skills used: Inspection Palpation Percussion Auscultation

14 techniques Inspection—assess size, color, shape, position, and symmetry Palpation—assess temperature, turgor, texture, moisture, vibrations, and shape Percussion—assess location, shape, size, and density of tissues Auscultation—assess the four characteristics of sound, i.e., pitch, loudness, quality, and duration

15 Inspection Use of sight to gather dataUsed throughout physical examination Tools to enhance inspection Otoscope Ophthalmoscope Penlight Examples: Skin color, gait, general appearance, behavior

16 Palpation Use of touch to gather dataBegin with light pressure, moving to deep palpation Use caution with deep palpation Parts of the hands used: Fingertips: Tactile discrimination Dorsum: Temperature determination Palm: General area of pulsation Grasping (fingers and thumb): Mass evaluation Examples: Edema, moisture, anatomical landmarks, masses

17 Percussion Tapping on skin to elicit soundDirect Indirect Useful for assessing abdomen, lungs, underlying structures Examples: Distended bladder

18 Types of Sounds Heard When Using PercussionFlat — soft, e.g., thigh area Dull — medium, e.g., liver Resonance — loud, e.g., normal lung Hyper resonance — very loud, e.g., emphysematous lung Tympany — loud, e.g. puffed-out cheek

19 Using Hands to Produce Sound Waves During Percussion

20 Auscultation Use of hearing to gather assessment dataDirect auscultation: Listening without an instrument Indirect auscultation: Use of a stethoscope to listen Diaphragm - high-pitched sounds Bell – low-pitched sounds Examples: Heart sounds, lung sounds

21 Characteristics of Sound Heard When Using AuscultationPitch — ranging from high to low Loudness — ranging from soft to loud Quality — e.g., gurgling or swishing Duration — short, medium, or long

22 Abnormal Breath Sounds

23 Pattern Used for Palpation, Percussion, and Auscultation of the Chest

24 Age Modifications for the Physical ExaminationInfants: Parents hold Attend to safety Toddlers: Allow to explore and/or sit on parent’s lap Invasive procedure last Offer choices Use praise

25 Age Modifications for the Physical ExaminationPreschoolers: Use doll for demonstration Still may want parental contact Allow child to help with examination School-Aged Children: Show approval and develop rapport Allow independence Teach about workings of the body

26 Age Modifications for the Physical ExaminationAdolescents: Provide privacy Concerned that they are “normal” Use examination to teach healthy lifestyle Screen for suicide risk Young/ Middle Adults: Modify in presence of acute or chronic illness

27 Age Modifications for the Physical ExaminationOlder Adults: May need special positioning related to mobility Adapt examination to vision and hearing changes Assess for change in physical ability Assess for ability to perform activities of daily living Provide periods of rest as needed

28 Basic Components of a Comprehensive Examination: The General SurveyBegins at first contact Overall impression of client Deviations lead to focused assessments Appearance/behavior Grooming/hygiene Body type/posture Mental state Speech Vital signs Height/weight

29 Mental Status - Emotional and cognitive functions – inferred through behaviorsConsciousness Language Mood & affect Orientation Attention Memory Abstract reasoning Thought process Thought content Perceptions

30 Appearance Posture & Position Body movement Dress Grooming & Hygiene

31 Behavior Facial expression Speech Mood/affect

32 Cognitive function Orientation Attention span Memory - Recent & RemotePerson Place Time Attention span Memory - Recent & Remote Judgment

33 Thought Processes & PerceptionsLogical Goal directed Coherent Relevant Thought content Consistent & logical Perceptions Screen for suicidal thoughts

34 Whole person, general status, any obvious physical characteristicsGeneral Survey Whole person, general status, any obvious physical characteristics

35 Physical appearence Age Sexual development Level of consciousnessAlert, oriented, responds appropriately Skin color Facial features - symmetry

36 Body structure Stature Nutrition Symmetry Posture PositionBody build, contour Physical deformities

37 Mobility Gait Range of motion

38 Behavior Facial expression Mood & affect Speech Dress Personal hygiene

39 Measurements Height Weight Vital signsSkinfold thickness – estimates body fat Infant/child – head circumference Birth & every visit until age two Yearly from two-six years of age

40 Skin Color Temperature Moisture Texture Thickness Mobility & turgoranterior chest under clavicle Vascularity or bruising Tatoos Lesions Color, elevation, pattern/shape, size, location, exudate? Edema Pitting Edema scale 1+ (mild)- 4+(very deep)

41 Shapes of lesions (pg.51-54)Iris or target – resemble eye Linear – scratch, line, streak, stripe Polycyclic – annular that grow together Zosteriform – linear lesions along nerve route Annular – circular (ring worm) Confluent – run together (urticaria) Discrete – remain separate Grouped – clusters (contact dermatis) Gyrate – twisted, coiled, snakelike

42 Primary skin lesions Macule (patch) flat, color change, circumscribedPapule (plaque) solid, elevated circumscribed Nodule ( tumor) solid, elevated, hard or soft Wheal (urticaria -hives) superficial, raised, transient, erythematous, slightly irregular shape

43 Primary skin lesions Vesicle (bulla) elevated cavity containing clear fluid Pustule - turbid(pus) filled cavity, circumscribed and elevated Cyst – encapsulated, fluid-filled cavity in dermis or subcutaneous layers

44 Secondary skin lesionsCrust-thicken dried-out exudate Scale- compact, desiccated flakes, dry/greasy, silvery/white Fissure- linear crack with abrupt edges dry/moist

45 Secondary skin lesionsErosion-moist, superficial, scooped-out , shallow depression – no scar Ulcer deeper, irregularly shaped, may bleed – leaves scar Excoriation, abrasion, superficial sometimes crusted

46 Secondary skin lesionsScar - Collagen formation after tissue lost heals Atrophic- depressed r/t thinning epidermis Lichenification-thicken skin produces tightly packed papule Keloid- hypertropic scar- skin is elevated r/t excessive scar tissue

47 Hair Nails Color Texture Lesions Shape & contour Consistency ColorClubbing (heart & lung disease) Spoon (iron deficiency) Consistency Smooth, regular, brittle, splitting, thickness Color Capillary refill

48 Abnormal findings Pallor CyanosisAnemia, arterial insufficiency, albinism, vitiligo Cyanosis Chronic heart & lung disease Exposure to cold, anxiety

49 Abnormal findings Erythema JaundiceHyperemia – inflammation, fever, alcohol intake, blushing Polycythemia - >RBCs, capillary stasis CO poisoning Venous stasis- decreased blood flow Jaundice > bilirubin r/t liver inflammation, hemolytic disease Carotenemia r/t eating food high in carotene Uremia r/t renel failure

50 Abnormal findings Brown-tan Addison’s disease – cortisone defiencyCafé-au-lait spots - > melanin pigment

51 Basic Assessments: Skin, HeadIntegumentary: Skin characteristics Color Temperature Moisture Texture Turgor Lesions Hair Nails

52 Basic Assessments: Skin, HeadEyes External eye Sclera Pupils PERRLA-pupils round, react to light,& accomemdating Visual acuity Vision examinations Acuity, distance, near, color, visual fields Internal structures Head: Skull and Face Size Shape Facial features

53 Basic Assessments: Ears, Nose, MouthHead: Ears/hearing External ear Inner ear Tympanic membrane Hearing Weber’s test Rinne’s test Balance Romberg’s test Nose Smell Mouth Lips Buccal mucosa Teeth Hard and soft palates

54 Basic Assessments: Neck, BreastsMusculature Trachea Thyroid gland Cervical lymph nodes Breasts: Size Shape Nipple characteristics Tissue Include axillae

55 Basic Assessments: LungsChest and Lungs: Describe size and shape of chest Relate findings to landmarks Breath Sounds: (pg 122 J) Bronchial Bronchovesicular Vesicular Adventitious Diminished or misplaced Abnormal vocal sounds

56 Basic Assessments: Heart, VesselsCardiovascular–Heart: Inspection PMI-point of maximal impulse located at 5th ICS Heaves/Lifts Palpation Thrill Heart sounds Location: Aortic, Pulmonic, Tricuspid, Mitral Components: S1, S2, S3, S4 Murmurs

57 Basic Assessments: Heart, VesselsCardiovascular–Vessels: Central vessels Carotid arteries Palpate pulsation * Special precautions Auscultate for bruit (whooshing sound caused by turbulent blood flow) Jugular veins Peripheral vessels Blood pressure Peripheral pulses Signs of inadequate oxygenation Varicosities

58 Variations in Arterial PulsesAbsent 0 Weak “thready” 1+ Hard to palpate, may fade in and out, easily obliterated by pressure R/t >cardiac output, PAD, aortic valve stenosis

59 Variations in Arterial PulsesNormal 2+ Bounding 3+ Full – easily palpable, pounds under fingertips r/t hyperkinetic states(exercise, anxiety) anemia, hyperthyroidism Corrigan’s - >normal force, then collapses suddenly r/t Aortic valve regurgitation

60 Variations in Arterial PulsesPulses bigeminus – rhythm is coupled with every other beat comes early or normal beat followed by premature beat r/t PVC or PAC Pulse alternans - regular rhythm but force varies r/t CHF

61 Basic Assessments: AbdomenDifferent order for assessment skills Inspect Auscultate Percuss Palpate

62 Order of assessment Abdomen Inspection Auscultation – four quadrantsIncreased, normal, decreased, absent Listen for several minutes in each quadrant High pitched tinkling or rushes indicates bowel obstruction Do before percussion/palpation so presence or absence of bowel sound and pain is not altered Percussion Palpation Light -tenderness, muscle tone & surface characteristics Deep-tenderness, masses, and aortic pulsation Abdomen should be soft, relaxed and free from tenderness

63 Characteristics of Masses Determined by PalpationShape Size Consistency Surface Mobility Tenderness Pulsatile

64 Basic Assessments: Bones, Muscles, JointsJoint mobility: Color change Deformity Crepitus Coordination: Finger-thumb opposition Movement Balance: Romberg’s test Body shape/symmetry: Posture Gait Spinal curvature-normal, kyphosis, lordosis, list, scoliosis (pg. 191 J) Muscle strength: Range of motion Resistance

65 Basic Assessments: NeurologicalStaff nurse Uses Focused Neuro Assessment: Cerebral Functioning: Level of consciousness Arousal - response to stimuli Orientation - time, place, person Mental status/cognitive function Behavior, appearance, response to stimuli, speech, memory, communication, judgment Cranial nerve assessment

66 Basic Assessments: NeurologicalReflexes: Automatic responses Responses on a graded scale 0 No response 1+ diminished 2+ average 3+Brisk 4 + hyperactive with Clonus (short jerking motion) Example: deep tendon reflexes Motor/Cerebellar Function: Movement/coordination Tone Posture Equilibrium Proprioception (body postion)

67 Basic Assessments: NeurologicalSensory Function: Light touch Light pain Temperature Vibration Position Sense Stereognosis –recognise solid objects Graphesthesia -recognize #, outlines and symbols Two-point discrimination Point localization Extinction

68 Genitourinary AssessmentMale: Includes reproductive information External genitalia: penis, urethral opening, scrotum, lymph nodes, pubic hair Examine for the presence of a hernia Female: Female external genitalia: labia, clitoris, urethral opening, vaginal orifice, pubic hair, lymph nodes

69 Genitourinary AssessmentOther: Kidneys [CVA (costovertebral angle) tenderness] Bladder (palpation of the abdomen) NP/MD responsible for anus, rectum, prostate examination NP/MD responsible for pelvic examination

70 Purposes of DocumentationIdentify actual and potential health problems Make nursing diagnoses Plan appropriate care Evaluate patient’s responses to treatment