1. Physical Assessment
PN 103

2. 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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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.

15. 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.

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

26. 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

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

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

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

30. Skin turgor

31. 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.

32. 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.

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

34. 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.

35. 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.

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

37. Auscultating Cardiac sounds

38. 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.

39. Peripheral Pulses

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

41. 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.

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

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