Physical Assessment PN 103

Signs and Symptoms Signs Objective data as perceived by the examiner -seen -heard -measured -verified by more than one person Examples: rashes, altered vital signs, visible drainage or exudate Lab results, diagnostic imaging, and other studies

Signs and Symptoms Symptoms Subjective data Perceived by the patient Examples: pain, nausea, vertigo, and anxiety Nurse unaware of symptoms unless the patient describes the sensation -full description by the patient -onset -course -character of the problem -any factors that aggravate or alleviate

Signs and Symptoms Disease and Diagnosis Disease -disturbance of a structure or function of the body -a pathologic condition of the body -a set of signs and symptoms -clustered in groups to help the physician to make a medical diagnosis -nurse also relies on assessment of signs and symptoms to formulate a nursing diagnosis

Signs and Symptoms Origins of Disease Disease or illness originates from many causes: -hereditary -congenital -inflammatory -degenerative -infectious -deficiency -metabolic -neoplastic -traumatic -environmental Unknown etiology Diseases that have no apparent cause

Signs and Symptoms Risk Factors for Development of Disease increases the vulnerability of an individual or a group to illness or accident -situation -habit -environmental condition -genetic predisposition -physiologic condition

Signs and Symptoms Categories of risk factors Genetic and physiologic Age Environment Lifestyle

Signs and Symptoms Terms Used to Describe Disease Chronic Remission develops slowly persists over a long period often for a person’s lifetime Remission partial /complete disappearance of clinical and subjective characteristics of a disease Acute begins abruptly marked intensity of severe signs and symptoms often subsides after a period of treatment

Signs and Symptoms Organic disease structural change in an organ interferes with its functioning Functional disease manifested as organic disease careful examination fails to reveal evidence of structural or physiologic abnormalities

Signs and Symptoms Frequently Noted Signs and Symptoms Infection invasion of microorganisms -bacteria -viruses -fungi -parasites that produce tissue damage Inflammation Protective response of the body tissues -irritation -injury -invasion by disease-producing organisms

Signs and Symptoms Cardinal signs of infection and inflammation Erythema Edema Heat Pain Purulent drainage Loss of function

assessment Process of making an evaluation or appraisal of the patient’s condition Medical Assessment Physical examination is conducted by the physician The nurse is often expected to carry out certain functions

assessment Medical Assessment Functions that may be expected of the nurse Equipment and supplies Preparing the exam room Assisting with equipment Preparing the patient Collecting specimens

assessment Nursing Assessment Initiating the nurse-patient relationship -first interview is the most challenging to conduct. -introduce yourself (name and position) -purpose of the interview. Give an estimate of time. Ask if the patient has any questions and answer them appropriately. Communicate trust and confidentiality. Convey competence and professionalism.

assessment Nursing Assessment The interview -relaxed, unhurried manner. -quiet, private, well-lighted setting. -feelings of compassion and concern. -what name the patient wishes to be addressed. -accepting posture -relaxed -eye level -pleasant facial expression.

assessment Nursing Health History -initial step in assessment process -information on: -patient’s wellness -changes in life patterns -sociocultural role -mental and emotional reaction to illness

assessment Biographical data Date of birth Sex Address Family members Marital status Religious preference Occupations Source of health care Insurance

assessment Nursing Health History Reasons for seeking health care Chief complaint Document information in patient’s own words. The nurse can use the PQRST method: P provocative/palliative Q quality/quantity R region/radiation S severity T timing

assessment Nursing Health History Present illness /health concerns -relate to the progression of the present illness from the onset of the current signs and symptoms Past health history Previous hospitalizations Allergies Habits and lifestyle patterns Ability to perform ADLs Patterns of sleep, exercise, and nutrition

assessment Nursing Health History Family history Immediate and blood relatives Health or cause of death, -history of illness -patient’s risk for illnesses of a genetic or familial nature -information about family structure, interaction, and function

assessment Nursing Health History Environmental history -patient’s home environment Psychosocial and cultural history -primary language -cultural groups -educational background -attention span -developmental stage Coping skills and family support -major beliefs -values -behaviors

assessment Nursing Health History Review of systems Systematic method Collection of data on all body systems Record in clear and concise manner Appropriate terminology Ask specific questions relating to functioning of each system

assessment Nursing Physical Assessment Determine the patient’s state of health or illness Initial step of the nursing process Forms the nursing care plan When to perform a physical assessment -as soon after admission as possible. -initial assessment is done by an RN. -ongoing assessment -LPN and RN

assessment Nursing Physical Assessment Where to perform a nursing assessment Comfortable, private setting -patient’s own room works -convenient Methods of nursing physical assessment -Head-to-toe -System-by-system -Focused

assessment Nursing Physical Assessment Performing the nursing physical assessment Items needed: Penlight Stethoscope Blood pressure cuff Thermometer Gloves Tongue blade

assessment Senses of touch, smell, sight, and hearing Wash your hands before beginning assessment. Documentation of the interview and assessment -utilize facility forms Telephone consultation

assessment Performing the Nursing Physical Assessment Head-to-toe assessment Neurologic Level of consciousness Level of orientation Hand grips

assessment Skin -color, -temperature -moisture -texture -turgor -injury or skin lesions. -color of sclera -mucous membranes -tongue, -lips -nail beds -palms -soles.

assessment Hair -quantity -quality -distribution of hair. Hair should be: -smooth -not oily or dry. Scalp should be free of: -dandruff -lesions -parasites.

Skin turgor

assessment -facial expression. -symmetry of features. Head and neck -facial expression. -symmetry of features. -palpate arteries, veins, and lymph nodes -feel for enlarged lymph nodes. -carotid arteries. -jugular vein distention. -auscultate the carotids for bruits.

assessment Mouth and throat Eyes Inspect the lips and mucous membranes -tongue blade and penlight. -condition of teeth and gums. -breath odor. Eyes -symmetry. -exudates. -sclera. -pupillary reflex.

assessment Ears Nose -symmetry. -ear canals. -hearing and follow commands. -use of hearing aids Nose -symmetry -nares patent. -bleeding or drainage.

assessment Chest, lungs, and heart and vascular system Breasts -bilateral chest expansion. -rate and rhythm of respirations. -breathing should be QUIET. -posture. Breasts -examine -encourage monthly self-exams.

assessment Lung sounds -breath through mouth quietly -deeply and slowly -stethoscope firmly but not tightly on the skin -listen for one full inspiratory/expiratory cycle at each point. -auscultate using a zigzag pattern.

assessment Spine Heart sounds -curvature -sitting and a standing position. Heart sounds Auscultate -intensity of the sound -faint to strong. -regularity of the rhythm.

Auscultating Cardiac sounds

assessment Peripheral vascular system Palpate peripheral pulses. -strength on a 0-to-4+ scale. Extremities -symmetry -color -varicosities. -temperature -hands and feet. -capillary refill or blanch test.

Peripheral Pulses

assessment Abdomen -shape -contour -lesions -scars -lumps -rashes. Auscultate -bowel sounds in all quadrants. Palpation Percussion

Abdominal assessment Palpation of the liver using moderate palpation. Palpation of the abdomen to assess for distention, masses, or tenderness using light palpation. Palpation of the liver using moderate palpation.

assessment Rectum Genitourinary system Inspect labia/genitalia and pubic hair. Palpate the scrotum. Palpate suprapubic area. Rectum -assess for hemorrhoids or lesions.

assessment Legs and feet Palpate; -femoral, dorsalis pedis, popliteal, and posterior tibial pulses. -edema. Range of motion. Color Motion Sensation Temperature