Physical Exam and Health Assessment

Purposes of Physical Exam Triage for emergency care Routine screenings for health promotion Health insurance, employment, or military eligibility Admission to hospital or long term care facility Baseline information about health status Support or refute subjective data Identify or confirm nursing diagnoses Help to make clinical decisions and changes in condition Evaluate outcome of care

The Nursing Process Assess Diagnose Plan Inplement Evaluate

The Physical Exam Should be Organized Systematic Based on information from the nursing history Documented as soon as possible Documented in the same order as performed

Preparing for the physical assessment Attend to infection control Attend to environment Gather necessary equipment Position or physically prepare patient Assess patient’s psychological readiness Assess patient’s age or developmental stage

Techniques of Assessment Inspection Palpation Percussion Auscultation Olfacation

General Survey Appearance and behavior Height, weight Vital signs

Body Systems/Areas to Assess Integumentary Head and neck Respiratory Cardiac and peripheral vasculature Breasts Abdomen/GI system GU system Musculoskeletal System Neurological System

Integumentary System Inspect skin for rashes, lesions, thickness, breaks in skin integrity, ulcers, abrasions Color consistent with ethnicity Cyanosis, jaundice Hair growth pattern, check for lice

Integumentary system Skin turgor Moisture, tempurature Vascularity – petichiae, edema Nails-cleanliness, brittleness, cyanosis, “clubbing”

Head and Neck Inspect for symmetry, proportions and contour of skull Assess visual fields, extraocular movement, visual acuity PERRLA Assess external ears for drainage, redness Hearing acuity Use inverted otoscope grip to assess ear canal and tympanic membrane Pull auricle up and back for adult, down and back for child

Otoscope grip

Head and Neck Assess external nose for drainage, asymmetry, iritation Palpate for tenderness, obstructed air flow Palpate sinuses Inspect oral cavity Gums, teeth, tongue, lips … inspect for color, lesions

Head and Neck Inspect neck muscles for symmetry Palpate lymph nodes cervical and posterior Inspect trachea for midline position Assess carotid pulses gently one at a time

Respiratory Inspect chest wall expansion for symmetry Auscultate lung fields Three lobes on right, two lobes on left Do not auscultate over bone Observe breathing pattern, orthopnea, use of accessory muscles Palpate for masses, tenderness, movement of chest expansion Fremitus

Stethoscope placement

Respiratory Bronchial Bronchovesicular Vesicular sounds Adventitions sounds crackles rhonchi wheezes pleural friction rub Abnormal sounds

Cardiac Inspect and palpate… assess for pulsations Ausculatate at all anatomical landmarks Auscultate at PMI (apical pulse) Lub/dub= s1, s2 Murmurs, gallops, clicks, rubs

Anatomical landmarks for cardiac assessment

Cardiac Assess vascular system Jugular veins distend when pt is supine Assess strength and equality of brachial, radial, femoral, popliteal, dorsalis pedis pulses Inspect periphery for cyanosis, pallor Capillary refill Inspect for varicosities Edema

Breasts Inspect for skin puckering, scaling, dimpling Inspect for discharge from nipples Observe for symmetry Palpate For lumps, tenderness Patient should lie with arm abducted and hand under head to flatten tissue

Abdomen/GI system Inspect for contour, splinting, symmetry Auscultate all four quadrants listen up to 5 minutes if bowel sounds not heard gurgling or clicking sounds normal “silent belly” uncommon Palpate for tenderness, masses, organomegaly, organ borders Enquire about last BM

Abdominal/GI We inspect, auscultate, then palpate. Why this order?

Genitourinary System Inspect outer genitalia and perineum for drainage, irritation, trauma. Internal genital exams are provided by advanced practitioners Ask about last menstrual period Keep rest of client covered and maintain professionalism and privacy Provide appropriate equipment, positioning, tables for reproductive exam Observe and document amount, color, clarity of urine Bladder scan when necessary

Musculoskeletal System Observe gait, note missing limbs or extremities Inspect for symmetry and proportion Kyphosis, scoliosis, lordosis Palpate joints for heat, tenderness, swelling Passive and active range of motion measurement Muscle tone and strength (push/pull)

Musculoskeletal table 33-33 Flexion Extension Hyperextension Pronation Supination Abduction Internal rotation External rotation Eversion Inversion Dorsiflexion Plantar flexion

Neurological Level of conciousness Orientation x 4 person place time situation Glascow coma scale table 33-37 Language

Neurological Intellectual functioning Memory Knowledge Abstract thinking Judgement

Neurological Cranial nerves I-XIII On Old Olympus’ Towering Tops, a Finn and German Viewed Some Hops Table 33-38

Neurological Motor function: balance, coordination Reflexes tapping tendon with reflex hammer Sensory nerves