142 Physical Assessment

  1. I. Purpose of the Physical Exam
    • 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)
  2. A. Assessment Data
    --Two Types of Data -Go Hand in Hand!
    • 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
  3. II. Nursing Assessment
    • -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)
  4. A. Types of Assessment

    1- Comprehensive Examination
    • --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.
  5. 2- Ongoing Partial Assessment
    • 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
  6. 3-Focused Assessment
    • 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.
  7. 4- Emergency 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
  8. 5- Physical 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
  9. B- Gathering Equipment
    • -Stethoscope
    • -BP cuff -
    • Thermometer-
    • Scale-Measuring Tape
    • -Reflex hammer-
    • Otoscope
    • -Snellen Chart (eye chart)-
    • Vaginal spectulum (ex:OB/GYN
    • -Gloves
    • -Mask
    • -Gown
    • -Goggles
    • -Lubricant
  10. C-Positioning During Exams

    • 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
  11. III. Inspection
    • --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.
  12. A. Palpation
    • --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
  13. 1- Palmar Surface of Hand
    • - finger pads very sensitive, moisture, texture, masses, pulsations, edema, crepidis
    • (air under skin feel like rice crispy); vibrations
  14. 2-Dorsal Surface of Hand
    - use back of hand (most sensitive to temperature); want to see if knee is hot b/c of injury and compare both
  15. 3- Light Palpation
    • - organ size, contracted (hold fingers together) DO Not Press More Than a ½ INCH!
    • Ex: bowel sounds, watch face for reaction
  16. B. Percussion
    • --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)
  17. - Percussion Tones
    • 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)
  18. 2- Auscultation
    • -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)
  19. IV. General Survey
    • -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
Card Set
142 Physical Assessment
Notes from physical assessment 142