1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 13 Physical Assessment

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? The first step of the nursing process is planning.

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. The first step of the nursing process is assessment.

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical Assessment First step of the nursing process –Assessment Physical assessment –One method for gathering health data

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview of Physical Assessment 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

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview of Physical Assessment: Four Basic Physical Assessment Techniques 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

7. Copyright © 2009 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

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Inspection and Percussion

9. Copyright © 2009 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

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Palpation Techniques

11. Copyright © 2009 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

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Auscultation

13. Copyright © 2009 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

14. Copyright © 2009 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.

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview of Physical Assessment Equipment –Items needed for a basic physical assessment

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview of Physical Assessment (cont’d) 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

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview of Physical Assessment (cont’d) 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

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Performing a Physical Assessment: Basic Activities During a Physical Assessment 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

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Height and Weight

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) 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

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Client Is Prepared for Examination

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) Select a systematic approach for collecting data –Head-to-toe approach oAdvantages –Body systems approach oAdvantages; disadvantages

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) Examining the client –Discuss the procedure for performing a physical assessment

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Collection: 6 General Areas for Data Collection 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

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Pupil Size Assessment Guide

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Weber Test

27. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Rinne Test

28. Copyright © 2009 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

29. Copyright © 2009 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.

30. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Collection: Six General Areas for Data Collection (cont’d) Head and neck (cont’d) –Mouth and oral mucous membrane oUnusual breath odors oAssessment of taste –Facial skin: alterations in skin –Hair, scalp –Neck

31. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Collection: Six General Areas for Data Collection (cont’d) Chest and spine –Skin turgor –Assess chest shape and movement; chest expansion –Spine: lordosis, kyphosis, scoliosis –Breasts –Heart sounds: S1, S2, S3, S4

32. Copyright © 2009 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

33. Copyright © 2009 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

34. Copyright © 2009 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

35. Copyright © 2009 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.

36. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Collection: Six General Areas for Data Collection (cont’d) Extremities –Assessment of: oCapillary refill oMuscle strength oFingernails and toenails oEdema: measurement oSkin sensation

37. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Criteria for Estimating Pitting Edema

38. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Collection: Six General Areas for Data Collection (cont’d) Abdomen –Bowel sounds: hyperactive, hypoactive, absent –Abdominal girth measurement –Genitalia Anus and rectum –Client positioning; trauma; hemorrhoids

39. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Implications Assessment findings: basis for identifying health problems –Clients oReveal situations that caused health failure oAsk for more information

40. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Implications (cont’d) Nursing diagnoses –Readiness for enhanced knowledge –Ineffective health maintenance –Effective or ineffective therapeutic regimen management –Deficient knowledge; noncompliance –Health-seeking behaviors

41. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins General Gerontologic Considerations 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