142 Physical Assessment

• 1-Provides indication of the person’s overall health state
• 2-Can provide additional information about the clinical significance of reported symptoms
• 3-Can provide indication of how person is responding to treatment already given (reevaluate)

• 1-Subjective: something not measurable, family/friend/Patient tells you (coughing for 2 weeks)
• 2-Objective: (never stands alone) if measurable,what find in physical exam, or diagnostic test, lab studies, observations

• -Differs in focus from medical assessment [because we are moreglobal]—we wonder if pt understands meds and has transportation
• -Holistic approach with client and family
• a. physical
• b. psychosocial-(feeling and emotions)
• c. spiritual (esp with terminal)

• --done when first meet pt (ex: do you feel safe at home, do they wanna see clergy, who lives in home
• a. A comprehensive assessment is performed with a health history and complete physical examination
• b. This type of examination is done on admission to a hospital or when first meeting a client a home or in an office or clinic setting if appropriate. [admission assessment more in depth to find baseline]
• c. This exam provides baseline data that we can use for comparison in later exams.

• a. This is conducted at regular intervals such as the
• beginning of each shift or at each home visit, and may be repeated as needed
• --(depends where you are and circumstances)
• b. This is the type of exam you will perform each week
• c. This assessment focuses on identified health problems as well as a general screening parameters to measure any positive or negative changes, and to evaluate the effectiveness of interventions

• a. A focused assessment is conducted to address one specific problem. (ex: asthma)
• b. This may stand alone or be a part of a ongoing assessment or a more comprehensive assessment.

• a. A rapid assessment used to detect life threatening situations
• b. Airway,breathing, circulation come first (A,B,C’s)
• c. First survey is followed by a more complete assessment

• --Preparing the environment--> privacy, clean, comfortable physically and emotionally, cultural awareness, good light
• --Gathering equipment--first before pt in position
• --Preparing the client--explain what you are doing, introduce your self, identify pt, privacy cultural
• --Maintaining cultural sensitivity

• -Stethoscope
• -BP cuff -
• Thermometer-
• Scale-Measuring Tape
• -Reflex hammer-
• Otoscope
• -Snellen Chart (eye chart)-
• Vaginal spectulum (ex:OB/GYN
• -Gloves
• -Mask
• -Gown
• -Goggles
• -Lubricant

• Supine
• Semi-fowlers
• Supine
• Dorsal recumbant
• Side lying
• Lithotomy (vagina exam)
• Knee chest (forarms down and lower leg down, like all 4’s)rectal exam
• Sims

• --The process of deliberate, purposeful observations performed in a systematic manner.
• (includes all senses; use all senses!)
• --One area at a time
• --Compare one side to the other.

• --Uses sense of touch to gather information that cannot be
• obtained through inspection alone.{ex touch for fever, bump, sweaty-diaphoretic}
• ----Light
• ----Deep-(don’t want to do this as nusrse)

--need to be able to describe! (voab words) Weber to clinical

• - finger pads very sensitive, moisture, texture, masses, pulsations, edema, crepidis
• (air under skin feel like rice crispy); vibrations

- use back of hand (most sensitive to temperature); want to see if knee is hot b/c of injury and compare both

• - organ size, contracted (hold fingers together) DO Not Press More Than a ½ INCH!
• Ex: bowel sounds, watch face for reaction

• --Act of tapping a person’s skin in order to set up a vibration that can be interpreted by you the health professional.
• --The sound wave produced is called a percussion tone
• --Characteristics of these sounds can be described
• 1-Indirect Percussion –Use middle finger of non-dominant hand on the body, hit it with the dominant hand finger, look for consolidation or fluid
• 2-pleximeter (non-dominant hand middle finger)
• 3-plexor (dominant hand middle finger)

• a. Flatness Soft Thigh
• b. Dullness Medium Liver
• c. Resonance Loud Normal Lung
• (hollow air, normal lung)
• d. Hyperresonance Very Loud Emphysema
• (lost elasticity of aveoli, larger air sac) (ex left lower lobe)
• e. Tympany Loud Air in Abdomen
• (drum like)

• -Use of stethoscope to listen to body sounds.(use all of time)
• ex: lung, heart, bowel sounds
• -Listen for:
• 1-pitch-high to low (notes)
• 2-loudness-volume
• 3-quality-characteristics (wheeze, gurgle, swish, crackles)
• 4-duration-length (short, medium, long)
• ex: high pitch end of expiration wheeze, soft (lung)

• -First Component of any exam
• -Most important of all parts of exam
• -Can get most information from initial meeting
• -Uses inspection technique including sight, smell, and, hearing
• -Includes observation of appearance and behavior, taking vital signs, and measuring height and weight