1. Physical Exam and Health Assessment

2. The Nursing Process
Assess
Diagnose
Plan
Implement
Evaluate

3. What is assessment?
Systematic and continuous collection, analysis, validation, and communication of patient data
Data gathered from
Nursing history
Other family members
Physical exam
Healthcare records
Other healthcare providers

4. Purposes of assessment
Enables nurse to make judgement about individual’s health status, need for nursing care, and ability to manage his or her own care
Enables nurse to plan and deliver care based on individual’s strengths and needs; promotes optimal functioning and independence
Enables nurse to refer patient to a physician or other health care provider if needed

5. Substeps of assessment
Gather data
Analyze data
Validate data
Communicate data

6. Types of assessment Comprehensive (initial) assessment
Focused assessment
Emergency assessment
Time-lapsed assessment

7. Nursing History
Identifies patient’s health status, strengths, health problems and risks, and need for nursing care
Profile
Health habits
Cultural considerations
State of health, function, pain
Past medical and surgical history
Developmental history, family history, environmental hx
Medications, allergies, immunizations
Personal and family resources
Advance directive

8. Other sources of data Physician’s history and physical, progress notes
PT;OT;ST;RD progress notes
Laboratory results
Radiology results

9. Models to organize data
Human needs (Maslow)
Functional health patterns
Human response pattern
Body systems (Medical model)
See box 11-2

10. Validating data
Validating is necessary to reduce error, bias, and misinterpretation
Look for initial impressions
Identify patterns
Test first impressions
Focus assessment

11. Purposes of Physical Exam
Triage for emergency care
Routine screenings for health promotion
Health insurance, employment, or military eligibility
Admission to hospital or long term care facility
Baseline information about health status
Support or refute subjective data
Identify or confirm nursing diagnoses
Help to make clinical decisions and changes in condition
Evaluate outcome of care

12. The Physical Exam Should be
Organized
Systematic
Based on information from the nursing history
Documented as soon as possible
Documented in the same order as performed

13. Preparing for the physical assessment
Attend to infection control
Attend to environment
Gather necessary equipment
Position or physically prepare patient
Assess patient’s psychological readiness
Assess patient’s age or developmental stage

14. Techniques of Assessment
Inspection
Palpation
Percussion
Auscultation
Olfacation

15. General Survey
Appearance and behavior
Height, weight
Vital signs

16. Body Systems/Areas to Assess
Integumentary
Head and neck
Respiratory
Cardiac and peripheral vasculature
Breasts
Abdomen/GI system
GU system
Musculoskeletal System
Neurological System

17. Integumentary System
Inspect skin for rashes, lesions, thickness, breaks in skin integrity, ulcers, abrasions
Color consistent with ethnicity
Cyanosis, jaundice
Hair growth pattern, check for lice

18. Integumentary system Skin turgor Moisture, tempurature
Vascularity – petichiae, edema
Nails-cleanliness, brittleness, cyanosis, “clubbing”

19. Head and Neck Inspect for symmetry, proportions and contour of skull
Assess visual fields, extraocular movement, visual acuity
PERRLA
Assess external ears for drainage, redness
Hearing acuity
Use inverted otoscope grip to assess ear canal and tympanic membrane
Pull auricle up and back for adult, down and back for child

20. Otoscope grip

21. Head and Neck Assess external nose for drainage, asymmetry, iritation
Palpate for tenderness, obstructed air flow
Palpate sinuses
Inspect oral cavity
Gums, teeth, tongue, lips … inspect for color, lesions

22. Head and Neck Inspect neck muscles for symmetry
Palpate lymph nodes cervical and posterior
Inspect trachea for midline position
Assess carotid pulses gently one at a time

23. Respiratory Inspect chest wall expansion for symmetry
Auscultate lung fields
Three lobes on right, two lobes on left
Do not auscultate over bone
Observe breathing pattern, orthopnea, use of accessory muscles
Palpate for masses, tenderness, movement of chest expansion
Fremitus

24. Stethoscope placement

25. Respiratory Bronchial Bronchovesicular Vesicular sounds
Adventitions sounds
crackles
rhonchi
wheezes
pleural friction rub
Abnormal sounds

26. Cardiac Inspect and palpate… assess for pulsations
Ausculatate at all anatomical landmarks
Auscultate at PMI (apical pulse)
Lub/dub= s1, s2
Murmurs, gallops, clicks, rubs

27. Anatomical landmarks for cardiac assessment

28. Cardiac Assess vascular system Jugular veins distend when pt is supine
Assess strength and equality of brachial, radial, femoral, popliteal, dorsalis pedis pulses
Inspect periphery for cyanosis, pallor
Capillary refill
Inspect for varicosities
Edema

29. Breasts Inspect for skin puckering, scaling, dimpling
Inspect for discharge from nipples
Observe for symmetry
Palpate
For lumps, tenderness
Patient should lie with arm abducted and hand under head to flatten tissue

30. Abdomen/GI system Inspect for contour, splinting, symmetry
Auscultate all four quadrants
listen up to 5 minutes if bowel sounds not heard
gurgling or clicking sounds normal
“silent belly” uncommon
Palpate for tenderness, masses, organomegaly, organ borders
Enquire about last BM

32. Abdominal/GI
We inspect, auscultate, then palpate. Why this order?

33. Genitourinary System
Inspect outer genitalia and perineum for drainage, irritation, trauma.
Internal genital exams are provided by advanced practitioners
Ask about last menstrual period
Keep rest of client covered and maintain professionalism and privacy
Provide appropriate equipment, positioning, tables for reproductive exam
Observe and document amount, color, clarity of urine
Bladder scan when necessary

34. Musculoskeletal System
Observe gait, note missing limbs or extremities
Inspect for symmetry and proportion
Kyphosis, scoliosis, lordosis
Palpate joints for heat, tenderness, swelling
Passive and active range of motion measurement
Muscle tone and strength (push/pull)

35. Musculoskeletal table 33-33
Flexion
Extension
Hyperextension
Pronation
Supination
Abduction
Internal rotation
External rotation
Eversion
Inversion
Dorsiflexion
Plantar flexion

36. Neurological Level of conciousness
Orientation x 4 person place time situation
Glascow coma scale table 33-37
Language

37. Neurological Intellectual functioning Memory Knowledge
Abstract thinking
Judgement

38. Neurological Cranial nerves I-XIII
On Old Olympus’ Towering Tops, a Finn and German Viewed Some Hops Table 33-38

39. Neurological Motor function: balance, coordination
Reflexes tapping tendon with reflex hammer
Sensory nerves