Assessment Physical Assessment Part 1 Helen Harkreader, RN, PhD

Nursing Assessment gathering information about the health status of a person gathering information about the health status of a person identify concerns and needs that can be treated or managed by nursing care. identify concerns and needs that can be treated or managed by nursing care. look, listen, touch, look, listen, touch, to make an informed decision about care. to make an informed decision about care.

Types of Assessment Initial Initial Focused Focused Ongoing Ongoing Shift Assessment Shift Assessment Emergency Emergency

Health History Reason for admission/chief complaint Reason for admission/chief complaint Demographic information Demographic information History of present illness History of present illness Family history Family history Other history Other history Medical: diabetes, heart disease, renal disease Medical: diabetes, heart disease, renal disease Surgical history Surgical history

Health History It’s important to remember: It’s important to remember: Nursing care is more concerned with Nursing care is more concerned with helping the person manage or function with a health problem helping the person manage or function with a health problem Not with Not with diagnosing and treating illnesses. diagnosing and treating illnesses.

Physical Exam Usually follows history Usually follows history Head to toe approach Head to toe approach Includes (as needed): inspection, palpation, auscultation, and percussion Includes (as needed): inspection, palpation, auscultation, and percussion

General Survey How do they look overall? How do they look overall? What can you discern just by looking at and talking with them? What can you discern just by looking at and talking with them? Are they oriented? Are they oriented? What is their mood? What is their mood? How about nutritional status? How about nutritional status? Vital signs? Vital signs?

General Survey As you introduce your self and establish trust with the patient your are beginning the general survey As you introduce your self and establish trust with the patient your are beginning the general survey

General Survey Level of consciousness Level of consciousness Orientation Orientation Confusion Confusion Memory Memory Mood, affect Mood, affect Signs of distress: dyspnea, anxiety Signs of distress: dyspnea, anxiety

Planes of the Body Sagittal (through midline)-divides right and left; medial and lateral Sagittal (through midline)-divides right and left; medial and lateral Frontal plane- divides anterior and posterior Frontal plane- divides anterior and posterior Transverse – divides top to bottom through pelvis; superior and inferior Transverse – divides top to bottom through pelvis; superior and inferior Proximal and distal Proximal and distal

Inspection Visual examination - looking Visual examination - looking Color, shape, size, symmetry, position and movement Color, shape, size, symmetry, position and movement Good lighting is very important Good lighting is very important

Palpation Assessment through touch Assessment through touch Temperature, moisture, texture, tenderness, masses, and edema Temperature, moisture, texture, tenderness, masses, and edema May be light or deep, one hand or two May be light or deep, one hand or two Make sure your hands are clean and fingernails short! Make sure your hands are clean and fingernails short!

Percussion Short, sharp strikes to the body surface to produce palpable vibrations and sounds Short, sharp strikes to the body surface to produce palpable vibrations and sounds Maybe direct (one hand) or indirect (two hands) Maybe direct (one hand) or indirect (two hands) Can detect size, shape, density and location of structures Can detect size, shape, density and location of structures

Auscultation Listening to the sounds in the body (usually with a stethoscope) Listening to the sounds in the body (usually with a stethoscope) Used to listen to lung sounds, heart sounds and abdominal sounds Used to listen to lung sounds, heart sounds and abdominal sounds Keep your stethoscope clean! Keep your stethoscope clean!

HEENT Head, Eyes, Ears, Nose, Throat Head, Eyes, Ears, Nose, Throat Look at distribution of hair. Are there any lumps on the head? Discolorations? Look at distribution of hair. Are there any lumps on the head? Discolorations? Is head normal size? Upright? Are the facial structures symmetrical in shape? Is head normal size? Upright? Are the facial structures symmetrical in shape?

HEENT Basically a Cranial nerve assessment Basically a Cranial nerve assessment You do not need to check each cranial nerve at this point, but be aware of what they are and how to assess them. You do not need to check each cranial nerve at this point, but be aware of what they are and how to assess them.

HEENT Does the mouth droop? Does the mouth droop? Talk to the patient. Do all the facial muscles move together? Talk to the patient. Do all the facial muscles move together? Can the person see and hear well? Can the person see and hear well? Pupils equal, round and reactive to light and accommodation. Pupils equal, round and reactive to light and accommodation. What does this mean? What does this mean? Check the eye muscle function. Have the patient follow your finger to all eight positions. Check the eye muscle function. Have the patient follow your finger to all eight positions. Inspect the ear and assess hearing by talking to the patient Inspect the ear and assess hearing by talking to the patient

Cranial Nerves examine sensation and movement of the face: the facial nerve--CN VII and the trigeminal nerve--CN V examine sensation and movement of the face: the facial nerve--CN VII and the trigeminal nerve--CN V List the function of each cranial nerve. Which ones are used for swallowing? List the function of each cranial nerve. Which ones are used for swallowing?

Other HEENT Check the nose for abnormalities Check the nose for abnormalities If warranted, palpate the sinuses for tenderness If warranted, palpate the sinuses for tenderness Look at mouth and neck. Take a look at the tongue. Are there white patches? Red patches? Look at mouth and neck. Take a look at the tongue. Are there white patches? Red patches? Check range of motion for the neck (gently!). Check range of motion for the neck (gently!). Look at the neck for jugular vein distention. This could indicate a heart problem. Look at the neck for jugular vein distention. This could indicate a heart problem.

Other HEENT Where are these structures? Where are these structures? Lymph nodes Lymph nodes Jugular veins Jugular veins Carotid arteries Carotid arteries Trachea Trachea Trapezius and sternocleidomastoid Trapezius and sternocleidomastoid

Other HEENT To assess the lymph nodes, place both hands on the neck at the same time and palpate using the pads of your fingers. To assess the lymph nodes, place both hands on the neck at the same time and palpate using the pads of your fingers. Normal: not palpable or smooth, firm, less than 1 cm, mobile, and nontender Normal: not palpable or smooth, firm, less than 1 cm, mobile, and nontender

Head and Neck size, symmetry, position and movement of head size, symmetry, position and movement of head temporomandibular joint temporomandibular joint

Skin Inspection Inspection Intact, free of lesions Intact, free of lesions Pink toned or underlying healthy glow Pink toned or underlying healthy glow Palpation Palpation Warm, cold, moist, dry Warm, cold, moist, dry Lesion: Hard, firm, feels like fluid Lesion: Hard, firm, feels like fluid Movable, fixed, attached to underlying structures Movable, fixed, attached to underlying structures

Skin Color cyanosis (central, peripheral, circumoral), cyanosis (central, peripheral, circumoral), jaundice, jaundice, pink tone, glowing, ashen pink tone, glowing, ashen pallor, pallor, erythema erythema

Skin Turgor Turgor Moisture Moisture Temperature Temperature

Skin Disruptions macules, papules, nodules macules, papules, nodules vesicles, bulla vesicles, bulla scales, plaque, patches (vitiligo) scales, plaque, patches (vitiligo) petechiae, necrosis, keloid petechiae, necrosis, keloid linear, annular linear, annular

Describing Lesions Size, color, type (primary, secondary), location, distribution Size, color, type (primary, secondary), location, distribution local vs. generalized local vs. generalized Annular, linear Annular, linear Abrasion, laceration Abrasion, laceration

Hair Distribution Distribution Texture Texture Cleanliness, grooming Cleanliness, grooming Scalp for lesions Scalp for lesions Infestations Infestations

Nails Capillary refill Capillary refill Abnormal shape Abnormal shape Clubbing Clubbing