Nur 102 Spring 2015 Belinda Lowry, MSN, RN, CCRN

QUIZ

1. _____ inspection 2. _____ auscultation 3. _____ palpation 4. _____ distention 5. _____ percussion a. examination using fingers and hands to feel underlying body parts b. state of being enlarged or swollen from internal pressure c. examination by listening d. examination by using short, sharp taps of the fingers e. visual examination

Good Morning!

Rationale for Physical Exam Triage, routine, health promotion & wellness, eligibility, military service, new job, admission to hospital Gather baseline data about the patient's health status. Support or refute subjective data obtained in the nursing history. Identify and confirm nursing diagnoses. Make clinical decisions about a patient's changing health status and management. Evaluate the outcomes of care. Sometimes focused assessment is performed first, with comprehensive assessment completed later

Environmental Preparation Respectful & private Patient room Pull curtains when able Private room if home health setting Well-equipped Adequate lighting Proper patient positioning

Equipment Gloves Vitals machine or sphygmomanometer with appropriate size cuff Pulse-ox Pen light Stethoscope Drapes/sheet Patient gown Thermometer Scale Tongue depressors Watch with second hand Advanced Exam: Ophthalmoscope Otoscope Snellen Chart Tuning fork

Patient Positioning

Patient Preparation Explain procedure thoroughly prior to starting Use terms patient can understand Encourage patient to ask questions Consider cultural and social norms Modesty, family presence, another health team member for escort when necessary Encourage patient to verbalize discomfort and adjust as needed Continually reassess patient’s comfort & anxiety

Techniques Inspection Palpation Percussion Auscultation

Inspection Look, listen openly, and smell Guidelines: Adequate lighting, preferable direct light source Inspect size, shape, color, symmetry, position, abnormality Compare bilaterally Validate findings with patient

Palpation Using sense of touch to gather information Skin: temp, moister, texture, turgor, thickness Abdomen: tenderness, distention, masses Etc. Different parts of your hand can detect different characteristics Maintain dignity of patient Always explain before performing Palpate tender areas last

Palpation

Percussion Tapping the skin with the fingertips to vibrate underlying tissues and organs Useful for detecting organ borders, masses, and determining size Mostly used by physicians and advanced practice nurses

Auscultation Listening to body sounds Blood, air, gastric, organ motion

Auscultation Sound characteristics Frequency: sound wave cycles Higher frequency = higher pitch Loudness: amplitude Range soft to loud Quality: sounds of similar frequency Blowing, gurgling Duration: length of time vibrations last Short, medium, long

General Survey General appearance & behavior Signs of distress Gender & race, age, body type, posture Gait, body movement, hygiene/grooming/dress Affect & mood, speech Signs of abuse (physical, substance) Vital signs Height & weight

Skin, Hair, Nails Skin Color Moisture Temperature Texture Turgor Edema Lesions

Skin, Hair, Nails Head & Scalp Be aware of normal hair distribution Assess for hair brittleness, moisture, texture, & alopecia Nails Can generally reflect general health and self-care

Nail Abnormalities Normal Clubbing Causes: Chronic lack of oxygen: heart or pulmonary disease

Nail Abnormalities Beau’s lines Causes: Systemic illness such as severe infection; nail injury Koilonychia (spoon nail) Causes: Iron deficiency, syphilis Splinter hemorrhages Causes: minor trauma, bacteria

Head & Neck Head Eyes Ears

Head & Neck Nose & Sinuses Mouth & Pharynx Neck

Thorax & Lungs Symmetry Overall shape, deformities, bony structures Rate & rhythm of breathing Breath sounds

Breath Sounds SoundSite Auscultated CauseCharacter Are most common in dependent lobes: right and left lung bases Random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways Fine crackles are high- pitched fine, short; interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing. Medium crackles are lower; moister sounds heard during middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing.

Breath Sounds SoundSite AuscultatedCauseCharacter Are primarily heard over trachea and bronchi; if loud enough, able to be heard over most lung fields Muscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulence Loud, low-pitched, rumbling coarse sounds are heard either during inspiration or expiration; sometimes cleared by coughing. Heard over all lung fields High-velocity airflow through severely narrowed or obstructed airway High-pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration; usually louder on expiration.

Breath Sounds Audio e/pulmonar/IMAGES/CD-LungSounds/mac/cugell- 07july11.swf e/pulmonar/IMAGES/CD-LungSounds/mac/cugell- 07july11.swf reference-guide.aspx reference-guide.aspx

Heart Inspection & Palpation Auscultation

Heart

Vascular System Blood pressure Carotid arteries Jugular veins Peripheral arteries & veins Lymphatic system

Abdomen Inspection Skin, umbilicus, contour, symmetry, pulsations Auscultation Bowel motility Palpation

Musculoskeletal System General Inspection Palpation ROM Muscle tone & strength

Neurological System Level of consciousness (LOC) Motor function Intellectual function Mental & emotional status

Completion of Assessment Document! Return patient to comfortable position Bed low, side rails up as necessary Call light in reach Education Hourly rounds When you will return Does patient have any questions/concerns

NCLEX Review The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? A. Appearance and behavior B. Measurement of vital signs C. Observing specific body systems D. Conducting a detailed health history

NCLEX Review On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. The nurse should evaluate the patient for A. Fluid retention. B. Fluid loss. C. Decreased nutritional reserves. D. Anorexia.

NCLEX Review The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient’s femoral artery in the right groin. Which assessment finding would require immediate follow-up? A. Palpation of a femoral pulse with a heart rate of 76 B. Auscultation of a heart murmur over the left thorax C. Identification of mild bruising at the catheter insertion site D. Palpation of a right dorsalis pedis pulse with strength of +1

NCLEX Review A client who is alert and responsive was admitted directly from the provider’s office with a diagnosis of “rule out myocardial infarction.” Of the following alterations found on the initial assessment, which is of greatest concern to the nurse? A. Supine BP is 150/86 B. Respirations are 28 and labored C. Temperature is 99.8 F D. There are infrequent, missed apical beats

Case Study