Physical Assessment

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Physical Assessment

• Fundamentals of Nursing Practice.

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Patient History

• Sign-in Forms
• Preprinted Forms
• Checklists
• History Forms
• Aftercare Sheets
• Problem Lists

3
Basic History Questions (Subjective)

• CHIEF COMPLAINT
• DWC1
• Doctors First Report
• Quotes My manager made me come. I dont have
  time for this.
• OLD CART
• IMPORTANT QUESTIONS (open-ended if possible)
• When did you first notice it? What were you
  doing?
• Have you ever injured this part of your body
  before?
• How were you treated?
• What else do you think could be causing it?
• Does it hurt anywhere else?
• Why did you come in today as opposed to last year
  when it started?
• Do you honestly think your work caused this? Yes
  or No?

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Focused History

• OLD CARTI
• Chief Complaint
• O Onset (when, where, how)
• L Location (of pain or radiation)
• D Duration (off and on, continuous)
• C Characteristics (burning, throbbing)
• A Aggravating (sitting, running,)
• R Relieving (Ibuprofen, sitting,)
• T Treatments (chiropractor, acupuncture)
• I - Intensity

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Specific History Questions

• Auto Accidents - other major trauma
• Medications for what purpose?
• Allergies to what - what reaction?
• Could you be pregnant? any female of
  childbearing age
• Do you have stomach problems?
• (Domestic violence questions)

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Environment

• Prepare the setting
• Coffee cups out of sight
• Proper distance 4 5 feet
• Face-to-face position
• Avoid standing
• Assumes superiority
• Communicates haste

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Vital Signs

• Blood Pressure have at least one in the chart
• JNC VII
• Sitting, both feet on floor, empty bladder, wait
  15 min
• Nurse holds the arm at the level at the heart
• Orthostatic Hypotension lying, sitting,
  standing
• ? 20 mm/Hg or ? pulse 20 bpm with quick
  change to a standing position

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JNC VII Classification
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JNC Treatment

• Stage 1 Hypertension
• (SBP 140-159 or DSP
• 90/99 mmHg
• Thiazide- type diuretics for most. May consider
  ACEI, ARB, BB, CCB or combination

• Stage 2 Hypertension
• (SBP gt 160 OR DBP gt 100 mmHg
• 2-drug combination for most (usually thiazide
  type and ACEI, ARB, BB, CCB

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Starting the Exam (Objective)

• Describe the patient
• NAD, tearful, concerned, frustrated, cheerful and
  relaxed, poor historian
• Sitting erect, leaning against the wall, standing
• Some difficulty with language but refuses help
  of an interpreter
• Accompanied by coworker, husband, manager
• Flat affect, very thin, pale, flushed, shouting,
  use quotes

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Least Invasive

• Start with the hands
• Pulses
• Nails eating disorders, psoriasis, malignancy
• Scars/Rashes
• Nodules
• Strength to Resistance (upper extremities)

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Eyes

• EOMS - 6 cardinal fields of gaze
• PEARRLA
• Visual Acuity Exam

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Examination of Nose

• Use Otoscope or nasal speculum to examine the
  nose
• If complaints of loss of smell, test each
  nostril, one at time. Patient should have eyes
  closed

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Exam of Oral Cavity

• Start with a plan e.g. front to back
• Note posterior pharynx red, cobblestone etc
• Note soft and hard palate
• Allow patient to participate

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Sinus Exam
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Sinus Exam
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Sinusitis

• Acute Sinusitis
• URI SxS persisting beyond the usual viral
  course
• but for less than 3 weeks
• Chronic Sinusitis
• SxS persisting beyond 3 months with history
  of symptoms that resolve with therapy but then
  recur.
• Treatment
• Sinusitis or Migraine?

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Lymph Nodes and Neck

• Ask the patient about swollen glands
• Start with posterior LNs

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Lymph Nodes and Neck

• Palpate LNs in circular motion
• Tender posterior LNs consider Mono, TB
• Come up in a wedge
• occipital to preauricular
• Palpate neck and shoulder muscles
• Note spasms and tenderness
• Discuss history of neck pain
• Thyroid

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Skin

• Rashes wide range of causes
• Measure and draw lesions
• To draw finger or toe, trace a finger or thumb
  and use as a template
• Use anatomical stamps for multiple injuries or
  draw a figure
• Use a magnifying glass
• ABCDEE

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Bruises (look at the areas in question)

• No scientific method to support accurate dating
  of bruises
• There are guidelines
• New bruises are pink to red
• Develops purple-blue coloring in 12 36 hours
• Then blue-green ? green ? green-brown
• ? brownish-yellow

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Lung Sounds

• This is a good time to assess the skin of the
  back
• Best Position for listening to sounds
• Take a breath deeper and faster than normal
  every time I move the stethoscope
• If you get dizzy let me know
• Dont forget the right middle lobe

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Heart Sounds

• It is easier to examine the patients carotid
  arteries after the lung exam because it is easier
  for them to hold their breath
• To begin with heart sounds instruct the patient,
  
• just breathe normally while I listen to your
  heart
• Remember conscious and unconscious breathing come
  from different parts of the brain, sometimes it
  takes several breaths to allow unconscious
  breathing to occur

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Heart Sounds

• Sitting, standing and lying positions are
  important for a good cardiac assessment
• Start anywhere but always use the same pattern
• Consider using a Z pattern
• A before P, you try before you buy
• The bell is designed to delineate lower sounds
  which may be more pathologic
• Describe the sound

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Abdominal Assessment

• Inspection
• Consciously look for scars and ask about them if
  the cause is not addressed on the history form
• Splenectomy scar, carpal tunnel scar
• Note all piercings
• Right upper abdominal tenderness
• General abdominal tenderness
• Start or end the exam with percussion of the CVAs

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Musculoskeletal Testing

• Visualize the area before palpating
• Completely uncover the area to be examined
• No visual abnormalities compare joints
• Palpate before moving the joint
• Note crepitus
• Cracking or popping
• Test tendon integrity in all planes
• Examine at least a joint above a joint below
• Strength to resistance

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Neuro Exam

• Necessary on those with elements of concern found
  in history trauma, new headache, prolonged
  headache etc
• Cranial Nerves
• Neurological Examination
• Deep Tendon Reflexes

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