NURSING 869NURSING 869 Physical Assessment

NURSING 869NURSING 869 Gather baseline data Supplement, confirm, or refute data in nursing hx Confirm and identify nursing diagnosis Make clinical judgments about changing status Evaluate the physiological outcomes of carePurpose

NURSING 869NURSING 869 Subjective Objective Data

NURSING869NURSING869 What client or family tells you Symptoms “I’m in pain” “I feel anxious” “There is a stabbing pain in my chest” Subjective Data

NURSING869NURSING869 Information gained through the nurses’ senses Signs or observations B/P 120/70 Lung sounds clear in all lobes bilaterally Pt grimaces with pain and guards abdomen Abdomen soft, tender, nondistended Objective Data

NURSING 869NURSING 869 Provides baseline subjective information Family history Life patterns Sociocultural history Spiritual health Mental reactions Emotional reactions Health History

NURSING 869NURSING 869 Inspection Palpation Percussion Auscultation Olfaction Skills

NURSING 869NURSING 869 Process of observation Good lighting Position and expose body parts for optimal viewing Inspect for size, shape, color, symmetry, & position Inspection

NURSING 869NURSING 869 Patient should be relaxed and positioned comfortably Tender areas palpated last Warm hands, gentle touch, short fingernails Apply pressure slowly, gently, and deliberately Light palpation precedes deep palpation Assess softness/rigidity, masses, temperature, size Vital arteries NOT palpated in manner that obstructs flow Palpation

NURSING 869NURSING 869 Tapping to evaluate size, borders, and consistency of body organs and discover fluid in body cavities Helps verify abnormalities reported from x-ray Character of sound depends on density of underlying tissue Abnormal sounds suggest mass, air, or fluid in organ or body cavity Direct method Indirect method Percussion

NURSING 869NURSING 869 Sounds produced by body Quiet environment Good stethoscope Stethoscope placed next to skin Diaphragm used for high-pitched sounds Bell used for low pitched sounds Ausculation

NURSING 869NURSING Frequency/pitch: # vibrations per second 2.Loudness: soft, medium, loud 3.Quality: types: gurgling, blowing 4.Duration: short, medium, long Listen….

NURSING 869NURSING 869 Be familiar with nature and source of body odors Foul odors can help detect infections Olfaction

NURSING 869NURSING 869 Head-to-toe assessment Major body systems assessment Sytematic Approach

NURSING 869NURSING 869 Begins at head and progresses down to the toes Most comprehensive Used to obtain baseline information to identify changes in patient status Head-to-toe

NURSING 869NURSING 869 Focuses on one system at a time Cardiac: heart sounds, pulses, capillary refill, B/P Respiratory: breath sounds, rate and depth, skin color Major body systems

NURSING 869NURSING 869 Stethoscope

NURSING 869NURSING 869 Neuro status Mucous membranes and skin Cardiac assessment Respiratory assessment Abdominal assessment Upper and lower extremities Accessories such as IV line, catheters, & dressings Head-to-toe

NURSING 869NURSING 869 Assess during initial contact with client Look for signs of distress Body type Posture Hygiene Dress Mood Speech Signs of abuse General Appearance

NURSING 869NURSING 869 Assessed by talking with client How difficult is it to get the client to respond? Alert and oriented x 3 Oriented to person, place, and time Consciousness Level

NURSING 869NURSING 869 Shine light through pupil onto retina Cranial nerve III stimulated Observe for pupillary constriction Observe for accomodation Pupils: black, round, regular, equal in size, 3-7 mm Pupillary Response

NURSING 869NURSING 869 Cloudy pupil: cataracts Dilated pupil: glaucoma, trauma, neurologic disorder Constricted pupil: drug use Pinpoint pupil: opioid intoxicationPupils

NURSING 869NURSING 869 Pupils equal, round, reactive to light, accommodation PERRLA

NURSING 869NURSING 869 Inside lower lip Inside cheek Nares Conjunctiva Look at : color, hydration, texture, lesions Normal : red, smooth, moist, without lesions Mucous Membranes

NURSING 869NURSING 869 Apply firm pressure with pads of index and middle finger on pulse site without occluding pulse Measure strength of pulse and equality Assess carotid, radial, and pedal Also assess brachial, posterior tibial, and dorsalis pedis Peripheral Pulses

PERIPHERAL PULSES

NURSING 869NURSING – Absent, not palpable 1+- Diminished, barely palpable 2+- Easily palpable, normal pulse 3+ - Full pulse, increased 4+ - Strong, bounding, cannot be obliterated Grading

NURSINGN 869NURSINGN 869 Should test fingers and toes Press down on nail to compress capillaries Color goes white, then release Color should return briskly; < 3 seconds Document “sluggish” if > 3 seconds Capillary refill

NURSING 869NURSING 869 Review: heart is in the center of the chest, behind and to left of the sternum Base is at top, apex is the bottom tip Apex touches anterior chest wall at 5 th intercostal space medial to left midclavicular line Heart pumps blood through 4 chambers Events on left side occurs just before those on right Valves open and close, pressures within rise and fall and chambers contract as blood flows though each chamber Heart

HEART

NURSING 869NURSING 869 Systole: ventricles contract and eject blood from left ventricle into aorta and from right ventricle into pulmonary system Diastole: ventricles relax and atria contract to move blood into ventricles and fill coronary arteries Cardiac Cycle

NURSING 869NURSING 869 S1: Lub: mitral valve closure S2: Dub: Aortic valve closure APE to Man: Aortic, pulmonic, Erb’s Point, Tricuspid, Mitral Heart Sounds

HEART

NURSING NUR 869NURSING NUR 869 Apex and bases opposite from heart: apex at top, bases at bottom Right lung has 3 lobes, left has two Angle of Louis where 2 nd rib articulates with sternum 2 nd intercostal space is below 2 nd rib and is starting point on right Use diaphragm of stethoscope Inspiration and expiration = one breath Listen to both in each area Go from apex to bases comparing side to side Lung Sounds

LUNGS

NURSING 869NURSING 869 Measure respiratory rate without client’s awareness After checking radial pulse, keep hand at pulse site and begin counting respirations Observe depth of respirations Documentation for normal: lungs sounds clear and equal in all lobes bilaterally Respiratory Rate

NURSING 869NURSING 869 Color Turgor Assess for breakdown Skin

NURSING 869NURSING 869 Sounds, masses, tenderness Divide into four quadrants: RUQ, RLQ, LUQ, LLQ Inspect then auscultate Bowel sounds: absent, hypoactive, hyperactive Listen continuously for 5 minutes to determine absence Palpate and/or percuss after listening Abdomen should be soft, non-tender, non-distended Abdomen

ABDOMEN

NURSING 869NURSING 869 Pedal pulses Foot strength bilaterally Homan’s Sign Capillary refill Edema Pain Lower Extremities

EDEMA

NURSING 869NURSING 869 Temperature Pulse Respirations Blood Pressure Vital Signs

NURSING 869NURSING 869 Oral Rectal (one degree higher than oral) Axillary (one degree lower than oral) Tympanic Esophageal Pulmonary artery Urinary bladder Nursing 110 Midway College Temperature Sites

NURSING 869NURSING 869 Age Exercise Hormone level Circadian rhythm Stress Environment Temperature alteration Factors

NURSING 869NURSING 869 Lateral force on walls of artery by pulsing blood under pressure from heart Maximum pressure with ejection is systolic Minimum pressure with ventricular relaxation is diastolic Measured in mm Hg Normal Adult: /60-90 Blood Pressure

NURSING 869NURSING 869 Age – B/P increases with age Stress Race – increased in African-Americans Medications Diurnal Variation Gender Factors affecting B/P

NURSING 869NURSING 869 Decrease in blood pressure when changing from lateral to upright position Can be caused by dehydration, anemia, prolonged bedrest, vasodilation from B/P medications Record B/P and pulse with client lying, sitting, and standing. Obtain readings 1-3 minutes after position change. Orthostatic Hypotension