Introduction to the Physical Assessment

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Introduction to the Physical Assessment

• Madeline Gervase
• MSN,CCRN,FNP,RN

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Assessment

• Systematic continuous collection, validation,
  and communication of client data
• Nursing process
• Initial and ongoing
• Medical vs Nursing
• Essential components

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Purposes of Assessment

• Obtain Baseline Date regarding functional
  abilities
• Supplement, confirm, or refute date obtained in
  nursing history
• Obtain data that helps establish nursing
  diagnoses and plan care
• Evaluate physiologic outcomes of health care and
  thus client progress
• Screen for presence of risk factors

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Types of Assessment

• Initial
• Focused
• Emergency
• Ongoing

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Types of Data

• Objective Data
• signs
• info perceived by the senses
• Ex T 101, moist skin
  
  

• Subjective Data
• symptoms
• info perceived only by affected person
• Ex feeling nervous, tired

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Characteristics of Data

• Complete
• Factual Accurate
• Relevant

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Problems r/t Data Collection

• Organization
• Omission
• Irrelevant or Duplicate Data
• Misinterpretation
• Too little data
• Documentation

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Why is a health history taken?

• Patterns of wellness/illness
• Physical Behavioral risk factors
• Deviations from norm
• Nurse as a resource

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Functional Health Patterns

• Health Perception/ Management
• Nutritional-Metabolic
• Elimination
• Activity-Exercise
• Sexuality-Reproduction
• Sleep-Rest

• Sensory-Perceptual
• Cognitive
• Role-Relationship
• Coping-Stress Tolerance
• Value-Belief

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Nursing Health History

• Chief Complaint
• Present Problem
• Usual health status
• Chronological story
• Impact on functioning
• Medications

• Past Medical History
• Family History
• Personal Social History
• Review of Systems or Functional Patterns

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Client Profile UK Clinical Setting

• Biographical Data
• Chief Complaint
• History of Present Illness
• Current Medications

• Current Treatments
• Past Illnesses or Past Hospitalizations
• Allergies

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General Survey Clinical Setting

• Age/Sex/Race
• Mental Status
• Behavior
• Mood
• Appearance
• Body Type
• Posture
• Body Mechanics

• Speech
• Use of language
• Thought Process
• Reliability as historian
• Height/Weight
• Vital Signs

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Explanation- Affect/Mood

• Affect observable behaviors which indicate the
  feelings or emotional status of the client.
• Mood term which refers to the clients
  emotional state as described by the client.

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Documentation Terms

• Affect
• Broad
• Restricted
• Blunted
• Flat
• Labile

• Mood
• Appropriate
• Inappropriate
• Depressed
• Anxiety
• Agitated
• Elated
• Manic
• Euphoric
• Euthymic (normal)
• irritable

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General Principles - History

• Explain purpose
• Communication techniques
• Utilization of data sources
• Document
• Avoid interruptions or tiring the client
• Consider clients developmental level

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Developmental Principles

• Pediatric
• Parent/child interactions
• Integrate child
• Respect adolescent, give choices

• Geriatric
• Do not stereotype
• Assess and accommodate
• sensory physical functioning

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Psychosocial Considerations - History

• Avoid stereotypes
• Healthcare beliefs
• Language differences
• Eye contact
• Non-judgmental
• Stressors/Coping Mechanisms

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Cultural Awareness Considerations

• Time Orientation
• Activity Orientation
• Human Nature Orientation
• Human-Nature Orientation
• Relational Orientation
• Seidel, 2003, pp. 43.

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History - Biographical Data

• Name
• Race
• Age
• Gender
• Marital status

• Birthplace, date
• Address
• Source of medical care
• Insurance coverage

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Past Health History

• Previous hosp. surgeries
• Allergies
• Illnesses Accidents
• Immunizations
• Medications
• Habits/Lifestyle
• ADLs

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Clients Family History

• Blood relatives
• Significant others
• Health history
• Family as resource
• Stressors in family

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Present Illness/Health Concerns

• Onset
• Duration
• Location, quality, and intensity
• Precipitating factors
• Relief factors
• Clients expectations
• Subjective and Objective data

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PQRST Characterize Symptoms

• Precipitating factors
• Quality
• Radiation
• Severity
• Temporal Factors

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OLD CARTS

• Onset
• Location
• Duration
• Character
• Aggravating factors
• Relieving factors
• Temporal factors
• Severity

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Reasons for Seeking Healthcare

• Chief complaint
• Why?
• Quotes
• Specify
• Clarify

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Resources

• Home and outside environment
• Community resources
• Financial
• Family significant others
• Consider Basic Human Needs

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Medical Diagnostic Data

• Medical vs Nursing Diagnosis
• Nursing Implications r/t Medical Diagnosis

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Contributions of Lab Data

• Verifies data
• Provides baseline information
• Evaluates outcomes
• Identifies problems missed in history and
  assessment

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Test Complete Blood Count(CBC)

• Analysis of peripheral venous blood specimen
• Main components
• RBC red blood cell count (erythrocytes)
• WBC white blood cell count (leukocytes)
• Hgb hemoglobin
• Hct hematocrit

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Test Urinalysis (UA)

• Analysis of a urine specimen
• Screens for
• urinary infection
• renal disease
• diabetes mellitus

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Urinalysis

• Main components
• pH- 4.6 - 8.0
• Protein- up to 10mg/100ml
• Specific gravity- 1.003 - 1.030
• Glucose- negative
• Ketones- negative
• Blood- up to 2 RBCs

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Test Electrolytes (lytes, e-)

• Inorganic substances in the body that conduct
  electrical current
• Usage
• Assess fluid balance

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Electrolytes

• Main Components
• Na sodium
• K potassium
• Cl- chloride
• Ca calcium
• P phosphate
• Mg magnesium

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Test Chest X-Ray (CXR, PA Chest, PA LAT Chest)

• Radiographic exam of the thorax
• Visualizes respiratory cardiac function
• Identifies follows progression/ remission of dx
  process

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Test Arterial Blood Gas (ABG)

• Assesses the adequacy of ventilation and
  oxygenation via arterial blood
• Use measures respiratory and metabolic (renal)
  disturbances

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Arterial Blood Gases

• Main Components
• pH
• PaCO2
• PaO2
• HCO3
• SaO2

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General Nursing Implications

• Assess clients readiness to learn
• Explain procedure to client
• Assist client in dealing with the test
• Provide privacy
• Prepare client for test
• Universal precautions
• Send specimens promptly

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Specific Nursing Implications

• Electrolytes
• Note diet, food and fluid intake
• Note s/s that could affect fluid balance (N/V/D)
• Chest X-Ray
• Transport
• Remove metal objects
• Stand clear

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Specific Nursing Implications

• Arterial Blood Gases
• Anticoagulants?
• Time drawn
• Check site for bleeding
• Pressure
• Sample on ICE
• STAT to lab

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Physical AssessmentPediatric Principles

• Assess
• coping ability
• previous knowledge
• readiness
• Encourage questions
• Explain at developmental level

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Physical AssessmentPediatric Principles

• Use concrete terms
• Small amounts of info at a time
• Simple clear explanations
• Only offer choices that are available
• Honest praise/rewards

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Physical Assessment Methods

• Inspection
• Palpation
• Auscultation
• Percussion

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Equipment

• Stethoscope
• Pen light
• Blood Pressure Cuff
• Thermometer
• Watch with second hand

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Inspection

• Assessment process during which the nurse
  observes the client

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Inspection

• Initial contact and ongoing
• Use olfaction, touch
• General appearance, body language
• Systematic unhurried approach
• Expose part, respect privacy
• Examine color, size, shape, position, symmetry
  (compare like areas)
• Know normals
• Observe normals/abnormals

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Palpation

• The use of the hands and the sense of touch to
  gather data

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Palpation

• Detects texture, shape, temp, movement, pain,
  moisture
• Short fingernails, warm hands
• Gentle approach
• Light palpation first, if pain - STOP!
• Palpate tender areas last
• Three types
• Light palpation (1/2 inch)
• Deep palpation (1 inch)
• Bimanual deep palpation (2 hands)

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Auscultation

• The act of listening to sounds within the body to
  evaluate the condition of body organs
• (stethoscope)

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Auscultation

• Stethoscope
• bell for low pitch sounds (cardiac sounds)
• Diaphragm for high pitch sounds (bowel, breath,
  normal cardiac)
• 4 characteristics of sounds
• Frequency/pitch vibrations per second
• Loudness soft, medium, loud
• Quality types gurgling, blowing
• Duration short, medium, long (specify)

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Auscultation

• Quiet environment
• Know landmarks
• Know normals
• PRACTICE! PRACTICE! PRACTICE!
• Requires concentration, practice, and application
  of knowledge

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Percussion

• Tapping of various body organs and structures to
  produce vibration and sound.

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Documentation - Purpose

• Communication
• Quality Assurance
• Legal
• Reimbursement
• Research
• Planning Client Care

• Education
• Statistics
• Accrediting/Licensure
• Historical Document

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Principles of Documentation

• Timing
• Confidentiality
• Permanence
• Signature
• Accuracy
• Sequence
• Appropriateness

• Completeness
• Standard Terminology
• Brevity
• Legibility
• Legal Awareness

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Learning OutcomesThe student will
be able to

• State the purposes of the physical exam.
• Name the necessary equipment need to perform a
  physical exam.
• Describe the four basic techniques used in
  physical examination.
• Describe guidelines for preparing a client and
  the environment for a physical examination.
• What are the components of a general survey?