Physical Assessment

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Physical Assessment
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Physical Assessment
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Chapter 4
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  1. Signs
    Can be seen, heard, measured, or felt by the examiner (nurse).
  2. Objective Data
    Information that is observable and measureable and can be verified by more than one person.
  3. Examples of Signs
    Rashes, altered vital signs, abnormal lung or heart sounds, visible drainage or exudate.
  4. Drainage
    The removal of fluids from a body cavity, wound, or other source of discharge by one or more methods.
  5. Examples of drainage
    Closed urinary drainage system or an open drainage such us Penrose drain.
  6. Exudate
    Refers to fluid, cells, or other substances that have been slowly exuded, or discharged, from cells or blood vessels through small pores or breaks in cell membrane as a result of inflammation or injury.
  7. Examples of Exudates
    Perspiration, pus, & serum.
  8. Gathering objective data
    Nurse uses senses of sight, hearing, touch, and smell.
  9. Symptoms
    Subjective indications of illness that are perceived by the patient.
  10. Examples of symptoms
    Pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety.
  11. Subjective Data
    A full description by the patient of the onset, the course, and the character of the problem and any factors that aggravate or alleviate it.
  12. Pruritus
    Itching
  13. Disease
    Any disturbance of a structure or function of the body; a pathologic condition of the body. Characterized by a recognized set of signs & symptoms.
  14. Hereditary Diseases
    Transmitted genetically from parents to children.
  15. Examples of hereditary diseases
    Cystic fibrosis, sickle cell anemia, color blindness, and hemophilia.
  16. Etiology
    Cause
  17. Congenital Diseases
    Appear at birth or shortly after but not caused by genetic abnormalities. Result from some failure in development during embryonic stage or first two months of pregnancy. Structural (absence of limbs) and functional (blindness) can occur.
  18. Contributing factors of congenital diseases
    Inadequate oxygen, maternal infection, drugs, alcohol, malnutrition, & radiation.
  19. Inflammatory Diseases
    Body reacts to causative agents with an inflammatory response.
  20. Degenerative Diseases
    Implies a degeneration of various parts of the body. The aging process plays a role.
  21. Example of degenerative disease
    Osteoarthritis
  22. Infectious Diseases
    Result from the invasion of microorganisms into the body.
  23. Examples of infectious diseases
    AIDS, tuberculosis, measles, & pneumonia.
  24. Deficiency Diseases
    Result from the lack of a specific nutrient.
  25. Nutrient
    Minerals, vitamins, proteins, fats, and carbohydrates.
  26. Examples of deficiency disease
    • Scurvy - lack of vitamin C
    • Iron deficiency anemia - severe deficiency of iron in the diet
  27. Metabolic Diseases
    Caused by a dysfunction that results in a loss of metabolic control of homeostasis in the body. Usually involves endocrine glands.
  28. Examples of metabolic diseases
    • Diabetes mellitus - results from dysfunction in pancreas
    • Hypothyroidism
    • Acromegaly
  29. Neoplastic Diseases
    Described as an abnormal growh of new tissue. May be benign or malignant.
  30. Traumatic conditions
    Results from both physical and emotional trauma. Physical trauma such as motor vehicle accident can result in traumatic brain injury. Emotional trauma such as loss of a loved one can result in the individual being unable to manage ADL's.
  31. Environmental diseases
    A group of conditions that develop from exposure to a harmful substance in the environment.
  32. Examples of environmental diseases
    Tight building syndrome - individual complains of headache, vertigo, & respiratory infection. Result from not allowing circulation of fresh air and instead recycle air containing fumes & microorganisms.

    Randon gas & asbestos are also substances that can contribute
  33. Autoimmune response
    The body develops immunoglobulins (antibodies) against its own tissues or body substances.
  34. Risk Factor
    Any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other variable that increaes the vulnerability of an individualor group to illness or accident.
  35. Risk Factors for Disease
    • Genetic
    • Physiologic
    • Age
    • Environment
    • Lifestyle
  36. Risk factors for coronary artery disease
    • Hereditary
    • Cigarette smoking
    • High blood levels of cholesterol
    • Stress
  37. Chronic Disease
    Develops slowly and persists over a long period, often for a person's lifetime. Can be described as early, late, terminal, or being in remission.
  38. Example of chronic disease
    Diabetes Mellitus (inability of the body to use glucose)
  39. Remission
    Means there has been a partial or complete disappearance of clinical and subjective characteristics of the disease. May be spontaneous or a result of therapy.
  40. Acute disease
    Begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment.
  41. Example of acute disease
    Episod eof appendicitis
  42. Organic Disease
    Results in structural change in an organ that interferes with its functioning.
  43. Example of organic disease
    Stroke is an organic disease of the brain.
  44. Functional Disease
    May be manifested as organic disease but careful examination fails to reveal evidence of structural or physiologic abnormalities.
  45. Examples of functional disease
    Many nervous & mental diseases
  46. Infection
    Caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites, that produces tissue damage.
  47. Inflammation
    A protective response of body tissues to irritation, injury, or invasion by disease-producing organisms.
  48. Cardinal signs of inflammation & infection
    • Erythema - redness
    • edema - swelling
    • heat
    • pain
    • purulent - drainage (pus)
    • loss of function
  49. Assessment
    Is the process of making an evaluation or appraisal of the patient's condition.
  50. Psychologic Preparation for a Physical Exxamination
    The nurse's highest priority before the examinaion. Must use simple yerms when describing steps.
  51. Physical Assessment Techniques
    Inspection - Most frequently used technique. Nurse inspects patient's body and observes moods, and nonverbal behavior. Use head-to-toe assessment.


    Palpation - Examiner uses hands and sense of touch to gather data. Used to detect tenderness, texture, vibration, pulsations, massess, and any changes in structural integrity. Three palpation techniques are light, moderate, and deep.

    Auscultation - the process of listening to sounds produced by the body. Threee system produce sounds for the examiner 1. cardiovascular system 2. respiratory system 3. gastrointestinal system

    Percussion - Use of the fingertips to tap the body's surface to produce vibration and sound. Sounds indicate the density of the underlying tissue and detect the location of body organs. Each area should be tapped two to three times.
  52. Tympany
    drumlike sound
  53. Dullness
    thudlike sound
  54. Flatness
    Flat sound
  55. Nursing assessment
    The process of gathering, verifying, and communicating data about the patient. To obtain the health history the nurse interviews the patient by initiating the nurse-patient realtionship.
  56. * The skills of inspection, palpation, auscultation, and percussion are used to collect data for the physical examination
  57. * First step in initiating the nurse-patient relationship is for the nurse to introduce themself, stating their name, position, and purposes.
  58. *The next step in nurse-patient relationship is to communicate trust and confidentiality to patients.
  59. * Finally the nurse-patient realtionship is enhanced by the professionalism and competence conveyed by the nurse.
  60. The Interview
    Conducted in a relaxed, unhurried manner in a quiet, private, well-lighted setting. Convey feeelings of compassion and concern. Demonstrate an interest in patient's wellness. Sit in a relaxed manner at eye level. Use pleasant facial expressions. Use nonjudgemental language. Summarize & restate what patient said in order to clarify.
  61. Nursing Health History
    It's the initial step in the assessment process. Provides nurse with info about patient's level of wellness, changes in life patterns, sociocultural role, & mental & emotional reations to illness. Objective is to identify patterns of illness, risk factors for physical & behavorial health problems, & deviations from normal adaptation to life's changes.
  62. Biographic Data
    Obtained in the admitting department & nurse refers to this info to begin interview. Includes date of birth, sex, address, family member names & addresses, marital status, religious belief, occupation, insurance. Verify info with patient to make sure it is correct.
  63. Reasons for Seeking Health Care
    • Nurse asks aptient for Chief complaint. To get the most info nurse can use PQRST method.
    • P- Provocation
    • Q - Quality/Quantity
    • R - Region/ Radiation
    • S - Severity Scale
    • T - Timing
    • Make sure to document info obtained in patient's own words using quotation marks.
  64. Review of Systems
    A systemic method for collecting data on all body systems. Nurs easks patient about normal functioning of systems and any changes noted.
  65. * Patient interview at the beginning of the physical assessment gives the nurse much more info than what is actually spoken.
  66. * Level of consciousness (LOC)
  67. Nursing Assessment
    Referred to as physical examination. Purpose is to determine patients state of health or illness.
  68. * Best time to assess patient is as soon after admission as possible. Initial nursing assessment is performed by RN but ongoing assessment is responsibility of both RN & LPN.
  69. * Head-to-toe is completed when patient is admitted.
  70. *Location for performing assessment should be comfortable for the patient.
  71. Neurological
    After taking radial pulse ask patient to grasp hands to test for equal grip. ALways beging with patients level of consciousness & level of orientation. whether alert, drowsy, lethargic, difficult to arose. x1 - person, x2 - person & place, x3 - person, place, & time, x4 - person, place, time, and purpose.
  72. Skin & hair
    Skin observed for color, temperature, moisture, texture, turgor, evidence of injury. Color in sclera, mucous membranes, tongue, lips, nail beds, palms, and soles. Examine hair. Hairless lower extremeties may indicate arterial disorder.
  73. Turgor
    elasticity of the skin
  74. Head & Neck
    Includes ears, eyes, nose, & mouth. Neck involves arteries, veins, and lymph nodes. Use pad of fingers to palpate neck for enlarges lymph nodes. ROM can be done by having patient nod or move head from side to side. Observe for Jugular venous distention. Auscultate carotid with stethoscope.
  75. Thrill
    Vibrating sensation along the artery
  76. Bruits
    Abnormal swishing sounds heard over organs, glands, and arteries.
  77. Mouth & throat
    inspection of lips & mucous membranes. Mucous membranes should be pink & free of lesions. Lips smooth, moist, free of cracking. Condition of teeth & gums. Breath should not be foul, fruity, or musty.
  78. Eyes
    Note whether symmetric. No exudate. Sclera should be white & conjunctiva pink. Periorbital edema (edema around eye) abnormal. Eyes assessed individually. Check pupillary reflex. Constrict pupil when light applied. PERRLA
  79. Ears
    Check if ears are symmetric. examine ear canal by using pen light. Pull ear back & up for child under 3 back & down. Should be free of excees ear wax, blood, or any discharge. Check for hearing by indicating if patient follows commands.
  80. Nose
    Symmetric. Nurse presses against one nostril and asks patient to breath....air should flow through the nose. Check for bleeding or drainage.
  81. Chest, Lungs, heart & vascular system
    For chest & lungs patient in sitting position. Inspect chest for bilateral chest expansion. Note rate & depth of respiration. Breathing should be quiet. Posture can be indicative of respiratory disease. Large rounded barrel chest is diagnostic for pulmonary disease such as emphysema. Assess arterial oxygen saturation via pulse oximeter.
  82. Breasts
    Examine during assessment as well as monthly by patient.
  83. Lung sounds
    Use diaphragm of stethoscope to auscultate. Instruct patient to breath through mouth slowly. Listen for one full cycle. Use zigzag approach. ADventitious breath sounds are classified as crackles (rales) or wheezes (rhonchi/gurgles)
  84. Crackles
    produced by fluid in the bronchioles and alveoli. A short discrete interrupted crackling or bubbling sound most commonly heard during inspiration. Can be fine. medium, or coarse
  85. Wheezes
    • Sounds produced by the movement of air through narrowed passages in the tracheobronchial tree. Predominate in expiration, however, can occur in both phases. Classified as Sibilant or Sonorous.
    • Sibilant - have a high pitched musical quality and produced by airflow through narrow airways.
    • Sonorous - lower pitched coarser gurgling, snoring quality and indicate mucus in trachea & large airways.
  86. Pleural friction rubs
    Produced by inflammation of the pleural sac and have rubbing, grating, or squeaky sound.
  87. * whenever adventitious breath sounds are auscultated instruct patient to cough. Sonorous wheezes are most likely to clear.
  88. Spine
    With patient in sitting position note curvature of spine. Assess posture when standing.
  89. Heart Sounds
    Auscultated using both bell & diaphragm. Normal lubb-dupp sound. Listen in four points. Determine regularity of rythm.
  90. Peripheral Vascular system
    Palpate peripheral pulses. Assess pulse rate. CHeck rythm for regularity. Measure strngth of pulse 1+ thready 2+ weak 3+ normal 4+ bounding. Inspect for varicosities & color. Check capillary refill by pressing firmly for 5 seconds on fingernail. Normal Capillary refill should take less than 3 seconds. 5 seconds is considered abnormal.
  91. Abdomen
    Patient in supine position with knees elevated. Inspect shape, contour, lesions, scars, lumps, or rashes. Before palpating auscultate for bowel sounds using diaphragm. Bowel sounds occur every 15 to 60 seconds and classified as active, hypoactive, hyperactive, or absent. Normal rate of BS is 4 to 32 per minute. Listen for at least 5 minutes before concluding no bowel sounds. Listen to each quadrant for 1 minute. After listening palpate. Warm hands. Use light & deep palpation.
  92. Peristalsis
    wavelike movements of the intestine
  93. borborygmi
    rushing sound
  94. Genitourinary System
    Use observation and palpation. Inspect labia for lesions. Leukorrhea is white vaginal discharge & is normal. Scotum palpated for lumps or hernias. Palpate femoral artery. Palpate suprapubic area for distention.
  95. Rectum
    Patient in Sims position. Look for hemmorhoids or lesions. Skin around anus darker than surrounding skin.
  96. Legs & feet
    Final area. palpate femoral, dorsalis pedis, popliteal, and posterior tibial. Observe & palpate feet for edema. Edema may occur with pitting. Pitting (indentation) may occur. To check for pitting press for 5 seconds & observe & feel area for identation. 1+ Slight pitting 2+ somewhat deeper pitting 3+ noticeably deep pitting 4+ very deep pitting.
  97. Mnemonic used for quick follow-up assessments after initial one is completed.
    • ABC, in and out, PS
    • A - Airway
    • B - Breathing
    • C - Circulation
    • In - What's going in
    • Out - WHat's coming out
    • P - Pain
    • S - Safety

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