Fundamental Nursing Skills and Concepts

1
Fundamental Nursing Skills and Concepts

• Chapter 12
• Page 185

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Purposes of Physical Assessment

• To evaluate the clients current physical
  condition
• To detect early signs of developing health
  problems
• To establish a baseline for future comparisons
• To evaluate the clients responses to medical and
  nursing interventions
• The overall goal of a physical assessment is to
  gather objective data about a client.
• Achieved on admission, at the beginning of each
  shift, and anytime there are changes in a clients
  condition.

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Four Basic Physical Assessment Techniques

• Inspection-----1
• Palpation------3
• Percussion----4
• Auscultation---2

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Techniques

• 1-INSPECTION-purposeful observation-most
  frequently used. Looking.
• 2-Auscultation-listening to body sounds. Heart,
  lung, abdominal sounds.
• 3-Palpation-lightly touching the body or
  applying pressure. Light palpation feel the
  surface of the skin, pulsation in pulse,
  vibration in the chest. Deep palpation,
  depressing 1 (2.5 cm) with forefingers of 1-2
  hands. Palpation provides information about
  size, shape, consistency and mobility of normal
  tissue and unusual masses, symmetry, temp.,
  moisture, tenderness, unusual vibrations.

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Techniques

• 4-Percussion-striking or tapping a part of the
  body. Least used method. Produces vibratory
  sounds. The quality of the sound aids in
  determining the location, size and density of
  underlying structures. Pg. 186 table 12.1
  percussion sounds

6
Physical Assessment Environment

• Easy access to a restroom
• A door or curtain that ensure privacy
• Adequate warmth for client comfort
• A padded, adjustable table or bed
• Sufficient room for moving to either side of the
  client
• Adequate lighting
• Facilities for handwashing
• A clean counter for placing examination equipment
• A lined receptacle for soiled articles

7
Equipment needed for physical assessment

• Gloves Assessment form
• Exam gown Pen
• Drapes
• Scale
• Stethoscope
• B/P cuff
• Thermometer
• Pen light
• Tongue blade

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The Nurse Gathers General Data pg.188

• Physical appearance in relation to clothing and
  hygiene- clean, well dressed, dressed
  appropriately for season, unclean, unshaven,
  dirty clothes.
• Level of consciousness-responsive, follows
  commands, lethargic.
• Body size-thin, flabby, heavy for height.

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The Nurse Gathers General Data pg.188

• Posture-stooped, erect.
• Gait-swaying, unsteady, slow, purposeful.
• Coordinated movement-weak, strong, overbalanced.
• Use of ambulatory aids-canes, walkers, wheel
  chairs or assistance of family.
• Mood- alert, listless, cheerful, talkative.
• Emotional tone-depressed, irritable, sad, lonely.
• The nurse observes and interacts with the client
  before the actual physical exam to gather this
  general information.

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Selecting a Approach for Data Collection

• Head-to-toe approach
• Body systems approach
• The nurse always drapes and positions the
  patient. Stay with the patient to make them feel
  comfortable and at ease. Always inform as to what
  is being done. Teach appropriately.

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Data collection

• Height , weight , vital signs , on every patient.

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Body Systems Approach

• Collecting data according to the functional
  systems of the body.
• Examination of structures in each system
  separately
• Organizes data collection according to the
  functional systems of the body. (ie. Skin, m/m,
  nails hair are included in the integementary
  system)

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Head-to-toe data collection

• Gathers data from top of the body working toward
  the feet.
• Prevents overlooking data, and reduces the number
  of body position changes.
• Generally takes less time.
• Six general areas

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Data Collection

• Head and Neck
• Chest
• Extremities
• Abdomen
• Genitalia
• Anus Rectum

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Head and neck

• Mental status assessment, level of pts. cognitive
  functioning, attention, concentration, memory,
  ability to think abstractly.
• Alert and oriented (chart it) usually that is all
  that is necessary.
• Unstable due to head injury, overdose, a more
  intense assessment is necessary.
• Head and neck are they symmetrical?

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Eyes

• Similar in size and distance from the center of
  the face.
• Iris- same color
• Sclera- white, yellow, orange?
• Corneas- clear
• Eyelashes-present, sparce, missing
• Drainage-present, no drainage

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Visual Acuity

• Ability to see far and near
• To assess far vision grossly, the nurse asks the
  client to cover one eye at a time and from a
  distance of approximately 20 feet the number of
  fingers the nurse raises.
• Snellen eye chart (tool for assessing far vision)
• Jaeger chart (visual assessment tool assessing
  near vision), small print.

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Eyes

• Pupil size-figure 12.9 top 191 is a pupil gauge
  in millimeters to assess pupil size.
• Pupil response is shown in fig. 12.10 (A)
• Nursing guidelines 12-2 pg. 191
• Visual acuity-ability to see far and near. Ask
  pt. Do you wear glasses, contact lenses, have a
  false eye (prothesis) or consider yourself blind?
• Assess gross vision-ask pt. to cover one eye at a
  time- from a distance of approximately 20 feet
  count the number of fingers the nurse raises.

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Eyes

• Snellen assesses far vision- cover 1 eye _at_ 20 .
  Ability to read smallest line of letters with and
  without corrective lenses. Then compare to norms.
• Jaegar- tests near vision
• Normal vision-ability to read printed letters
  seen by most people with out prescription lenses
  _at_ a distance of 20.
• 20/20 vision line read _at_ 20 as compared with
  norms.
• Where others can read the chart _at_ 200 recorded
  as 20/200.
• Written as a fraction, pt. sees at 20 feet what
  the norms see at 200 feet.

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Eyes

• Normal pupils are round and equal in size
• Consensual response-brisk, equal, and
  simultaneous constriction of both pupils when one
  eye and then the other is stimulated with light
• Accommodation-ability to constrict when looking
  at a near object and dilate when looking at an
  object in the distance. Fig. 12.10 (B) pg. 191
• PERRLA-pupils, equally, round, and react to light
  and accommodation. Normal findings.

21
Eyes

• Extraoccular movements-focus on and track the
  nurses finger. 6 positions, both eyes should
  move in a coordinated manner, smoothly. If no
  movement in one eye, may indicate cranial nerve
  damage. Irregular or uncoordinated movement, may
  be neurologic pathology.

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EARS

• Observe for appearance, size, shape, location.
• Move skin behind and in front and underlying
  cartilage.
• Check for tenderness
• Illuminate ear canal, visualize ear canal.
  Children pull down and back. Adults pull up
  and back.
• Cerumen yellowish, brown waxy secretion
  (normal).
• Does the pt. use a hearing aide device?
• Voice test or Weber or Rinne test used for
  hearing.
• pg. 192

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Hearing test

• Weber test using a tuning fork to assess bone
  conducted sound, strike and place on forehead.
  Ask is sound heard equally in both ears? If not
  bone conducted sound would be unequal indicating
  hearing loss in one ear.
• Rinne test using a tuning fork, strike the
  tuning fork and then place the stem first on
  mastoid area then to ear canal to determine a
  problem with ear structure. The client indicates
  when the sound stops. Assessment technique for
  comparing bone conduction of sound. Ears are
  tested separately.

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Hearing test

• Audiometry measurement of hearing acuity at
  various sound frequencies, to identify a persons
  range of hearing acuity.

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Hearing Acuity

• Ability to hear and discriminate sound
• Weber test (assessment technique for determining
  equality or disparity of bone conducted sound)
• Rinne test (assessment technique for comparing
  air versus bone conduction of sound)

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Nose

• Inspect while pt. is in a SNIFFING position.
• Septum midline?
• m/m moist, free of drainage, lesions, deviated
  septum, growths, fissures, flaring of nostrils?
• Document your findings.

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Smelling Acuity

• Ability to smell and identify odors
• Have the client occlude one nostril and close his
  or her eyes
• Place substances with strong odors beneath the
  patent nostril for identification

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Physical Assessment

• Tongue midline, any lesions, ulcerations, dry,
  note color. Top pg. 194 assessing taste. Note
  odor(halitosis), m/m pink ,moist , intact.
• Teeth missing, in good repair, mal-positioned,
  dentures?
• Smiles lips look same symmetrical?
• Facial skin smooth, unbroken, uniform, color,
  warm, resilient

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Cont.

• Alterations in integrity
• Wound-a break in the skin
• Ulcer-an open crater-like area
• Abrasion-area rubbed away by friction
• Laceration-torn, jagged wound
• Fissure-crack in the skin, especially in or near
  m/m
• Scar-mark left by the healing of a wound or
  lesion
• Table 12-4 pg. 195 common skin lesions

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Physical assessment

• Hair-color, texture, distribution of scalp hair,
  eye brows, eye lashes. Any nits? Debris? Lesions?
• Scalp-palpate scalp for contour. Smooth, intact,
  lesion free scalp. Assess _at_ random by separating
  and looking.
• Neck-bend head forward, back, side to side.
  Rotate 180
• Trachea-center of neck
• Carotid arteries-visible and palpated easily.
• Lymph nodes-lightly palpate
• Thyroid gland-assess for enlargement

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Physical assessment

• Chest spine-check for turgor (resiliency of the
  skin), elasticity quality and the pressure
  exerted on it by fluid with in the tissue. Pinch
  skin on chest sternum area. Should return to
  original shape within few seconds. This is
  measured in seconds. Prolonged tenting indicates
  dehydration.
• Chest shape and movement-assessing chest
  excursion page 196. about tenth rib area thumbs
  together. Have patient breathe and note how much
  thumbs move apart. 1 2 normally. Pg. 196 fig
  12.17
• Top 196- shows chest sizes and shapes.

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Physical assessment

• Pg. 196, fig.12.18- shows variations in spinal
  curves
• A-appears midline-normal
• B-Scoliosis-pronounced lateral curvature of the
  spine
• C-Lordosis- natural lumbar curve is exaggerated
• D-Kyphosis- increased curve in the thoracic area

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Physical assessment

• Breasts- teach to examine breasts on routine
  basis. Monthly breast exam about one week after
  menstrural period or on specific date
  post-menopausal is suggested.
• Study 12.1 page 197 on own, so you will be able
  to teach to your clients. Also table 12.5, pg.
  198 Breast examination guidelines , will be of
  help.

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Physical assessment

• Heart Sounds-2 normal heart sounds, S? and S? .
• S? Lub is louder at the apex or mitral area.
• S? Dub can be heard here also but louder over
  aortic area.
• A tiny slurring or splitting sound lubba-dub or
  lub-dubba may indicate the valves do not always
  close at the same time.
• Abnormal heart sounds, S? and S?.

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Cont.

• S? - normal in children, not in adults. May sound
  like lub-dub-dub or ken-tuck-y.
• S? - heard before S? and may sound like
  lub-lub-dub or ten-ne-ssee.
• Murmurs, clicks, rubs are abnormal heart sounds,
  need to be reported and further investigated.

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Normal Lung Sounds

• Tracheal sounds are loud and coarse. Heard
  equally in length during inspiration and
  expiration and are separated by a brief pause.
• Bronchial sounds are heard over the upper part of
  the sternum. Harsh and loud. Shorter on
  inspiration than expiration with a pause between
  them.

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Normal Lung Sounds

• Bronchovesicular sounds are heard on either side
  of the central chest or back. Medium-range sounds
  of equal length during inspiration and
  expiration, with no noticeable pause.
• Vesicular sounds are located in the periphery of
  all the lung fields. Soft, rustling quality is
  longer on inspiration than expiration, with no
  pause between.

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Physical assessment

• Abnormal lung sounds or adventitious sounds are
• Crackles-(rales), intermittent, high pitched
  popping sounds. Crispy rice cereal distant areas
  during inspiration.
• Gurgles-(rhonci), low pitched continuous bubbling
  sounds, predominant during expiration.
• Wheezes-whistling or squeaking sounds, through
  narrowed passages, inspiration and expiration.
• Rubs-grating, leathery sounds. Heard by 2 dry
  pleural surfaces moving over each other.

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The nurse

• Should assess the characteristics of any cough.
• Should assess the appearance of raised sputum.
• Should always use the auscultation sequence and
  guidelines on page 198b -199.

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Extremities

• Nurse notes-alignment, mobility, strength,
  compares size, temp., nail characteristics,
  checks capillary refill, peripheral pulses,
  checks for edema, skin sensations, deep tendon
  reflexes with a hammer.
• Muscle strength- grasp - squeeze release nurses
  fingers. As nurse pushes and pulls on forearm
  and upper arm patient is to give resistance.
  Lower extremities have pt. push and pull foot
  against resisting hand. Top pg.200
• Finger and toe nails- shape and thickness may
  indicate chronic cardiopulmonary disease process
  or a fungus. Fig.12.24, diamond shaped space is a
  normal finding.

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Extremities

• Capillary refill time- amount of time it takes
  blood to resume flowing in the base of the nail
  beds after being compressed and released.
  Normally 3 seconds.
• Edema-excessive amount of fluid with in tissue.
  Pts. with liver, kidney and cardiovascular
  dysfunction are prone to develop edema. Pg. 201
  box 12-2 good chart to know. The nurse presses
  finger into tissue over a bone to assess for
  edema. Indention remains pitting edema.

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Extremities

• Quantify severity by using the chart, 1, 2, 3,
  4, 5 Brawny edema
• Skin sensation-use light touch-sharp, dull, soft,
  cold, and warm objects to touch the skin in
  various places to assess patients sensation.

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Abdomen

• Abdomen- 4 quadrants- always inspect,
  auscultate, palpate, and percuss.
• Can alter bowel sounds and change findings, done
  in any other manner.
• Bowel sounds-are assessed on admission and one
  time per shift.
• Abdominal girth- assessed over widest part of
  abdomen, same place every day. Page 202 fig 12.26
  shows measuring abdominal girth. An indelible pen
  mark may need to be placed to insure the same
  place is being assessed daily.

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Bowel Sounds

• Wavelike contractions of the large and small
  intestines that move fluid and intestinal
  contents toward the rectum produce bowel sounds.
  Clicks and gurgles are heard with stethoscope.
• Occur 5-34 times per minute. More frequently
  heard post a meal.
• Hyperactive-frequent
• Hypoactive-occur after long periods of silence
• Absent-no bowel sounds for 2-5 minutes
• More frequent after the person eats.

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Genitalia

• In most cases the genitalia is only inspected.
• Nurse of the same gender as the patient present.
• Don gloves, inspect skin, distribution and
  characteristics of hair. Presence of lice. Any
  fissures, ulcerations, bruising, drainage, foul
  odor, trauma? The physician may do internal exam
  of female with a speculum.
• Men- the prostate gland is palpated during a
  rectal exam. Observe for circumcision and scrotum
  size. Any drainage, foul odor, fissures? Teach
  men testicular self exam page 203.

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Anus and rectum

• Position patient on their side with knees bent.
  Buttocks is separated with a gloved hand to
  visualize the external orifice, (fig. 12.28).
• Should be intact, moist and hairless.
• External hemorrhoids (saccular protrusions filled
  with blood) may be observed.
• Rectal fissures (cracks) if constipation is
  chronic.
• Trauma maybe present due to anal intercourse.

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Nursing Diagnoses

• Ineffective health maintenance
• Ineffective therapeutic regimen management
• Deficient knowledge
• Noncompliance
• Health-seeking behaviors