Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 13 Physical Assessment

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? The first step of the nursing process is planning.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. The first step of the nursing process is assessment.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins First step of the nursing process –Assessment Physical assessment –One method for gathering health data Physical Assessment

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Purposes –To evaluate the client’s current physical condition –To detect early signs of health problems –To establish baseline for future comparisons –To evaluate client’s responses to medical and nursing interventions Overview of Physical Assessment

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Inspection –Examining particular body parts –Looking for specific normal and abnormal characteristics –Using special instruments to inspect parts of the body inaccessible to ordinary visual inspection techniques Overview of Physical Assessment: Four Basic Physical Assessment Techniques

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) Percussion –Striking or tapping the body with fingertips to produce vibratory sounds –Quality of sounds determines location, size, and density of underlying structures; variation in sound could mean possible pathologic change –Pain: possible disease process or tissue injury

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Inspection and Percussion

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) Palpation –Lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand –Deep palpation –Information: normal tissue and unusual masses; bilateral structures; skin temperature and moisture

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Palpation Techniques

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) Auscultation –Used for assessing the heart, lungs, and abdomen –Soft sounds, loud sounds –Nurses: practice auscultation repeatedly to gain proficiency; to ensure accuracy, eliminate or reduce environmental noise

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Auscultation

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question What is lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand called? a. Inspection b. Percussion c. Palpation d. Auscultation

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer c. Palpation Palpation involves lightly applying pressure to the body using fingertips, back of the hand, or palm of the hand. Inspection is looking for specific normal and abnormal characteristics. Percussion is striking or tapping the body with fingertips to produce vibratory sounds. Auscultation is listening to the sounds of the heart, lungs, and abdomen with a stethoscope.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Equipment –Items needed for a basic physical assessment Overview of Physical Assessment

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Environment –Special examination room or at bedside –Easy access to a restroom; a door or curtain to ensure privacy –Adequate warmth –Lined receptacle for soiled articles –Adequate lighting Overview of Physical Assessment (cont’d)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Environment (cont’d) –Padded, adjustable table or bed –Sufficient room for movement around client –Facilities for hand hygiene –Clean counter or surface for placing examination equipment Overview of Physical Assessment (cont’d)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Gather general data during first contact with client –Physical appearance; gait; coordinated movement; use of ambulatory aids; mood and emotional tone –Preliminary data oVital signs, weight, height, documentation Performing a Physical Assessment: Basic Activities During a Physical Assessment

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Height and Weight

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Drape and position the client –Ensure that client is covered with a drape (sheet of soft cloth or paper) –Begin examination with the client standing or sitting Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Client Is Prepared for Examination

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Select a systematic approach for collecting data –Head-to-toe approach: Advantages –Body systems approach: Advantages; disadvantages Examining the client: Outline procedure for performing a physical assessment Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Head and neck –Mental status assessment –Eyes: accommodation; Snellen eye chart; Jaeger chart; extraocular movements –Ears: cerumen; Weber test; Rinne test; audiometry –Nose: abnormalities; smelling acuity Data Collection: 6 General Areas for Data Collection

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pupil Size Assessment Guide

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Weber Test

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Rinne Test

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question When preparing a client for the Rinne Test, which of the following equipment should the nurse keep ready? a. Stethoscope b. Tuning fork c. Snellen chart d. Jaeger chart

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. Tuning fork A tuning fork is required to conduct the Rinne test to determine hearing impairment. A stethoscope is used to listen to lung, heart, and abdominal sounds. A Snellen chart and a Jaeger chart are tools for assessing far and near vision respectively.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Head and neck (cont’d) –Mouth and oral mucous membrane oUnusual breath odors oAssessment of taste –Facial skin: alterations in skin –Hair, scalp –Neck Data Collection: Six General Areas for Data Collection (cont’d)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Chest and spine –Skin turgor –Assess chest shape and movement; chest expansion –Spine: lordosis, kyphosis, scoliosis –Breasts –Heart sounds: S1, S2, S3, S4 Data Collection: Six General Areas for Data Collection (cont’d)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Collection: Six General Areas for Data Collection (cont’d) Chest and spine (cont’d) –Lung sounds oNormal  Tracheal sounds  Bronchial sounds  Bronchovesicular sounds  Vesicular sounds

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Collection: Six General Areas for Data Collection (cont’d) Chest and spine (cont’d) –Lung sounds (cont’d) oAdventitious lung sounds  Crackles  Gurgles  Wheezes  Rubs

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following sounds is not a normal lung sound? a. Tracheal b. Bronchial c. Vesicular d. Wheezing

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer d. Wheezing Wheezing is an adventitious lung sound; it is not normal. Tracheal sound, bronchial sound, and vesicular sound are normal lung sounds.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Extremities –Assessment of: oCapillary refill oMuscle strength oFingernails and toenails oEdema: measurement oSkin sensation Data Collection: Six General Areas for Data Collection (cont’d)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Criteria for Estimating Pitting Edema

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Abdomen –Bowel sounds: hyperactive, hypoactive, absent –Abdominal girth measurement –Genitalia Anus and rectum –Client positioning; trauma; hemorrhoids Data Collection: Six General Areas for Data Collection (cont’d)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment findings: basis for identifying health problems –Clients oReveal situations that caused health failure oAsk for more information Nursing Implications

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing diagnoses –Readiness for enhanced knowledge –Ineffective health maintenance –Effective or ineffective therapeutic regimen management –Deficient knowledge; noncompliance –Health-seeking behaviors Nursing Implications (cont’d)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Explain purpose of each procedure Consider alterations: hearing, vision, mobility Ask appropriate questions Make appropriate adjustments: physical limitations Older women: modifications in pre- procedure positioning General Gerontologic Considerations