Physical Assessment

Can be seen, heard, measured, or felt by the examiner (nurse).

Information that is observable and measureable and can be verified by more than one person.

Rashes, altered vital signs, abnormal lung or heart sounds, visible drainage or exudate.

The removal of fluids from a body cavity, wound, or other source of discharge by one or more methods.

Closed urinary drainage system or an open drainage such us Penrose drain.

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.

Perspiration, pus, & serum.

Nurse uses senses of sight, hearing, touch, and smell.

Subjective indications of illness that are perceived by the patient.

Pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety.

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.

Itching

Any disturbance of a structure or function of the body; a pathologic condition of the body. Characterized by a recognized set of signs & symptoms.

Transmitted genetically from parents to children.

Cystic fibrosis, sickle cell anemia, color blindness, and hemophilia.

Cause

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.

Inadequate oxygen, maternal infection, drugs, alcohol, malnutrition, & radiation.

Body reacts to causative agents with an inflammatory response.

Implies a degeneration of various parts of the body. The aging process plays a role.

Osteoarthritis

Result from the invasion of microorganisms into the body.

AIDS, tuberculosis, measles, & pneumonia.

Result from the lack of a specific nutrient.

Minerals, vitamins, proteins, fats, and carbohydrates.

• Scurvy - lack of vitamin C
• Iron deficiency anemia - severe deficiency of iron in the diet

Caused by a dysfunction that results in a loss of metabolic control of homeostasis in the body. Usually involves endocrine glands.

• Diabetes mellitus - results from dysfunction in pancreas
• Hypothyroidism
• Acromegaly

Described as an abnormal growh of new tissue. May be benign or malignant.

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.

A group of conditions that develop from exposure to a harmful substance in the environment.

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

The body develops immunoglobulins (antibodies) against its own tissues or body substances.

Any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other variable that increaes the vulnerability of an individualor group to illness or accident.

• Genetic
• Physiologic
• Age
• Environment
• Lifestyle

• Hereditary
• Cigarette smoking
• High blood levels of cholesterol
• Stress

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.

Diabetes Mellitus (inability of the body to use glucose)

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.

Begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment.

Episod eof appendicitis

Results in structural change in an organ that interferes with its functioning.

Stroke is an organic disease of the brain.

May be manifested as organic disease but careful examination fails to reveal evidence of structural or physiologic abnormalities.

Many nervous & mental diseases

Caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites, that produces tissue damage.

A protective response of body tissues to irritation, injury, or invasion by disease-producing organisms.

• Erythema - redness
• edema - swelling
• heat
• pain
• purulent - drainage (pus)
• loss of function

Is the process of making an evaluation or appraisal of the patient's condition.

The nurse's highest priority before the examinaion. Must use simple yerms when describing steps.

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.

drumlike sound

thudlike sound

Flat sound

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.

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.

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.

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.

• 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.

A systemic method for collecting data on all body systems. Nurs easks patient about normal functioning of systems and any changes noted.

Referred to as physical examination. Purpose is to determine patients state of health or illness.

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.

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.

elasticity of the skin

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.

Vibrating sensation along the artery

Abnormal swishing sounds heard over organs, glands, and arteries.

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.

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

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.

Symmetric. Nurse presses against one nostril and asks patient to breath....air should flow through the nose. Check for bleeding or drainage.

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.

Examine during assessment as well as monthly by patient.

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)

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

• 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.

Produced by inflammation of the pleural sac and have rubbing, grating, or squeaky sound.

With patient in sitting position note curvature of spine. Assess posture when standing.

Auscultated using both bell & diaphragm. Normal lubb-dupp sound. Listen in four points. Determine regularity of rythm.

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.

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.

wavelike movements of the intestine

rushing sound

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.

Patient in Sims position. Look for hemmorhoids or lesions. Skin around anus darker than surrounding skin.

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.

• 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