Abigail Domingo Physical Assessment

8/3/2019 Abigail Domingo Physical Assessment

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Physical

assesstment

Head to toe


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Physical

assesstment Is a process by which a nurse obtains a data

that describes a persons responses to actual or

potential health problems which is analyzed toform pertinent diagnosis.

Is a head to toe review of each body system

that offers objective information about the client

and allows the nurse to make clinical judgment.


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Importance of

physical

assessment To early detect and treat diseases and disorders.

To identify actual and potential health problems.

To establish a data based from which the subsequent

phases of the nursing evolve. To assess the clients impact of activity and exercise on the

clients overall level of health.

To assess the clients routine exercise pattern and observehow the clients body system response to activity and

exercise. To establish the client-nurse relationship.

To obtain information about the clients health including,physiologic, psychological, socio-cultural, cognitive,developmental and spiritual aspects.

To identify the clients strength and weaknesses.


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Purpose of

physical

assesstment To supplement, confirm or refute data obtained in the

nursing history.

To confirm and identify nursing diagnosis.

To make clinical judgments about a clients changing

health status and management.

To evaluate the physiological outcome of care.

To obtain and gather data about the clients healthbasis of data for future assessment.

An excellent way to evaluate an individuals current

health status.


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Four basic

techniques inphysical

assessment


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Four basic

techniques in

physical assestment1. INSPECTION

It is the use of ones senses of vision and

smell to consciously observe the patient. It is also known as concentrated

watching.

It is a close, careful scrutiny; first of theindividual as a whole and then of each body

system.


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Four basic

techniques in

physical assestment

2. PALPATION

It is the act of touching a patient in atherapeutic manner to elicit specific

information.

It follows and often confirms

points you noted during inspection.


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Palpation applies

your sense of touch

to assess these

factors

Texture

Temperature

Moisture Organ location and size

Any swelling, vibration orpulsation

Rigidity or spasticity

Crepitation

Presence of lumps or masses

Presence of tenderness or pain.


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Two distinct

types of

palpation

A. LIGHT PALPATION

- it is superficial, delicate and gentle.

- finger pads are used to gain information of thepatients skin surface to a depth ofapproximately - 1 inch below the surface.

- reveals information on skin texture andmoisture; overt large or superficial masses;and fluid, muscle guarding and superficialtenderness.


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Two distinct

types of

palpation

B. DEEP PALPATION

-it can reveal information about the position oforgans and masses, as well as their size,shape, mobility, consistency, and areas ofdiscomfort.

-uses the hands to explore the bodys internalstructure to a depth of 1 to 2 inches or more.

-most often used for the abdominal and maleand female reproductive assessments.


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Four basic

techniques in

physical assestment

3. PERCUSSION It is the technique of striking or tapping the persons

skin with short, sharp strokes to assess underlyingstructures.

The strokes yield a palpable vibration and acharacteristic sound that depicts the location, sizeand density of the underlying organ.

These sounds also are diagnostic of normal andabnormal findings.

The thorax and abdomen are the most frequentlypercussed location.


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Four types of

percussion

techniques

I. IMMEDIATE OR DIRECT PERCUSSION

The striking hand directly contacts the body wall. This

produces a sound and is used in percussing theinfants thorax or the adults sinus areas.

II. MEDIATE OR INDIRECT PERCUSSION

It is used more often and involves both hands.T

hestriking hand contacts the stationary hand fixed on

the persons skin. This yields a sound and a subtle

vibration.


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Four types of

percussion

techniques

III. DIRECT FIST PERCUSSION

It is used to assess the presence of tenderness in internal organs,such as the liver or the kidneys. The presence of pain in

conjunction with direct fist percussion indicatedinflammation of that organ or a strike of too high in

intensity.

IV. INDIRECT FIST PERCUSSION

Its purpose is the same as direct fist percussion. In fact, theindirect method is preferred over the direct method. It is

because in this methods, the non dominant hand absorbssome of the force of the striking hand. The resulting

intensity should be sufficient force to produce pain in thepatient if organ inflammation is present .


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Percussion elicits

five types of sounds

I. Flatness (dull) bone and muscle

II. Dullness (thud-like) liver, spleen, heart

III. Resonance (hollow) air-filled lung /normal lung

IV. Hyperresonance emphysematous lung

V. Tympany stomach filled with gas (air)


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Four basic

techniques in

physical assestment

4. AUSCULTATION

It is the act of active listening to the body organs to

gather information on patients clinical status. includes listening to sounds that are voluntarily and

involuntarily produced by the body such as the heartand blood vessels and the lungs and abdomen.

Auscultated sounds should be analyzed in relation totheir relative intensity, pitch, duration, quality, andlocation.


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Two types of

auscultation

A) DIRECT OR IMMEDIATE

AUSCULTATION

It is the process of listening with the unaided ear. This can

include listening to the patient from some distance away orplacing the ear directly on the patients skin surface. Andexample is the wheezing that is audible to the unassisted ear

in a person having a severe asthmatic attack.

B) INDIRECT OR MEDIATE

AUSCULTATIONIt is the use of stethoscope, which transmits the sounds to the

nurses ear.


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Nursing

responsibilities


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Nursing

responsibilitiesBEFORE Always dress in clean professional manner, make sure you have your

name pin or workplace identification.

Remove all bracelets, necklaces, or earrings that can interfere during thephysical assessment.

Be sure your hair will not fall forward and obstruct your vision or touch tothe patient.

Ensure that all necessary equipment is ready for use and within reach.

Introduce yourself to the patient. Enlist the patients cooperation byexplaining what you are about to do, where it will be done, and how it mayfeel.

Explain to the patient why you may be spending a long time performingone particular skill.

Do medical hand washing .

Position the patient as dictated by the body system being assessed.

Warm all instruments prior to their use .


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Nursing

responsibilities

DURING

Conduct the assessment in a systematic fashion everytime.

While performing each step in the physical assessment

process, you may need to inform the patient of what toexpect, where to expect it, and how it should feel.

Avoid making crude or negative remarks, be cognizant ofyour facial expression when dealing with malodorous anddirty patients or with disturbing findings.

Proceed from the least invasive to the most invasiveprocedure for each body system.

If the patient complains of fatigue, continue the assessmentlater.


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Nursing

responsibilities

AFTER

Provide recognition to the patient when the physical

assessment concluded; inform the patient what will

happen next.

Place patient in a comfortable position.

Do after care.

Do medical hand washing.Document assessment findings in the appropriate

section ofthe patient record.


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Materials and

Instruments of

PhysicalTreatment


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Materials and Instruments

of Physical Treatment

1. FLASHLIGHT OR

PENLIGHT

To assist in viewing of thepharynx and cervix or to

determine the reaction of

the pupils of the eye.


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2. LARYNGEAL OR

DENTAL

MIRROR

To observe the pharynxand oral cavity


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3. NASAL SEPTUM

To permit visualization of

the lower and middle

turbinates; usually apenlight is used for

illumination.


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4. OPHTHALMOSCOPE

A lighted instrument to visualize

the interior of the eye


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5. OTOSCOPE

A lighted instrument to

visualize the

eardrum and externalauditory canal (a

nasal speculum may be

attached to the

Otoscope to inspect nasal

cavities).


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6. PERCUSSION

(REFLEX)

HAMMER

An instrument with arubber head to test reflexes


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7. TUNING FORK

A two-prolonged metal

instrument used

to test hearing acuity andvibratory

sense.


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8. COTTON

APPLICATORS

To obtain specimens.


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9. GLOVES

To protect the nurse


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10. LUBRICANT

to ease the insertion of

instruments (ex.Vaginal

Speculum)


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11. TONGUE BLADES

(DEPRESSORS)

To depress the tongue

during assessment of themouth and pharynx


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Various

positioning

of thepatient


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Various positioning of

the patient

DORSAL RECUMBENT

Back-lying position with knees flexed and hips externally rotated; smallpillow under the head; soles of feet on the surface. Supine (horizontalrecumbent)

Back-lying position with legs extended; with or without pillow under the head

SITTING -A seated position. The back is unsupported and legs hanging freely. LITHOTOMY

Back-lying position with feet supported in stirrups; the hips should be in linewith the edge of the table.

SIMS

Side-lying position with the lowermost leg flexed at the hip and knee, upperarm flexed at the shoulder and elbow.

PRONE

Lies on the abdomen with head turned to the side, with or without a smallpillow.


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Various positioning

of the patient


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Assessment

of body

parts


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The skin


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Skin

First line of defense

Composed of the superficial epidermis and the dermis.

SKIN DISCOLORATIONS

S PALLOR (PALE)

-result of inadequate circulating blood or hemoglobin.

-cause: anemia


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Skin

S JAUNDICE (YELLOW-ORANGE)

- Resulting from accumulation of bilirubin.

- cause: hemolysis, liver disease & cholestasis

S CYANOSIS (BLUE)

- Increased concentration of deoxyhemoglobin

- Cause: heart or lung disease and cold environment


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Skin

S ERYTHEMA (REDNESS)

- Resulting from some rashes

- Cause: fever, direct trauma, blushing and alcohol

intake


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Skin lesions

The skin normally has no lesions, except for commonfreckles or age-related changes such as skin-tags,senile keratosis, cherry angiomas and atropic warts.

PRIMARY LESIONS

Appear initially in response to some change in internal orexternal environment of the skin.

SECONDARY LESIONS

Do not appear initially but result from modifications such aschronicity, trauma or infection.


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Primary lesions

I. FLAT LESIONS unelevated changes in color

Macule - circumscribed 1mm to 1cm in size

Patch - irregularly-shaped and larger than 1cm.

II. ELEVATED LESIONS

Papule - circumscribed solid skin elevations less than 1cm

Plaque - larger than 1cm

Nodule - solid hard mass with circumscribed border thatextends deeper into the dermis and 0.5-2cm in size.

Tumor- solid hard mass with irregular border that may extendthrough the subcutaneous tissue larger than 2cm.


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Primary lesions

III. FLUID-FILLED LESIONS

Wheal - irregularly-shaped, reddened, elevated localizedcollection of edema fluid that varies in size.

Vesicle - translucent circumscribed, round or oval elevation

of the skin which is filled with serious fluid or blood andsmaller than 0.5cm.

Bulla - thin-walled blister of the skin or mucous membranesgreater then 0.5cm containing clear, serous fluid.

Pustule - circumscribed elevation of the skin that varies n

size and is similar to a vesicle but filled with pus. Cyst - 1cm or large, elevated, encapsulated in or under the

skin lined with epithelium and containing fluid or semisolidmaterial.


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Secondary

lesions

LOSS OF SKIN SURFACE:

Erosion- wearing away of the superficial epidermis causing amoist, shallow depression. Since erosions do not extend intothe dermis, they do not bleed and they heal without scarring.

Ulcer- deep, irregularly-shaped area of the skin loss extendinginto the dermis or subcutaneous tissue which may bleed andmay leave a scar.

Fissure- a linear crack with sharp edges that extends into thedermis.

Excoriation- an injury to a surface of the body caused bytrauma, such as scratching, abrasion, or a chemical or thermalburn.


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Materials on the

skin surface Crust- dry blood, serum or pus left on the skin surface when

vesicles or pustules burst. It can be red-brown, orange, oryellow. Scabs are large crusts that adhere to the skin surface.

Scar- flat, irregular area of connective tissue left after a lesion orwound has healed. New scars may be red or purple, while older

scars may be white or silvery. Scales- shedding flakes of greasy, keratinized skin tissue. The

color varies from whit, gray or solver. While, the texture mayrange from fine to thick.

Keloid- elevated, irregular, darkened area of excess scar tissuecaused excessive collagen formation during healing. It extendsbeyond the site of the original injury and has a higher incidencein people of African descent.

Lichenification- rough, thickened, hardened area of theepidermis that resulted from chronic irritation such asscratching or rubbing.


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Other skin

variations

Petechiae- pinpoint-sized, red or purple spots

on the skin resulting from small hemorrhages in

the skin layer.

Edema- swollen areas from abdominal

accumulation of fluid in interstitial spaces of

tissues.


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Skin malignancies

in older adults

Basal cell carcinoma - 0.5-1.0cm crusted lesion that may be flator raised and may have rolled and somewhat scaly border.There are frequently underlying and widely dilated bloodvessels that can be seen within the lesion.

Squamous cell carcinoma - 0.5-1.5cm scaly lesions that may beulcerated or crusted. It appears more frequently, grows morerapidly and occurs more often on the mucosal surfaces andnon-exposed areas of the skin as compared to basal cell.

Melanoma - 0.5-1.0 am brown, flat lesion that may arise on sun-

exposed or non-exposed skin. There are varieties ofpigmentation, irregular borders, and indistinct margins.Meanwhile, ulceration, recent growth, or recent changes in long-standing mole are ominuous sign.


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The head


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HEAD

S INSPECTION:

For size, shape & symmetry

S NORMALFINDINGS:

The head should beround (normocephalic)

and symmetrical.

S PALPATION:

For contour, masses,depressions.

S NORMALFINDINGS:

The normal skull issmooth, and

without masses ordepressions,non tender


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HAIRS INSPECTION:

For color, evenness of

growth over the scalp,

presence of parasites,

amount of body hair.

S NORMAL

FINDINGS:

Can be black, brown or

burgundy depending on the

race, evenly distributedcovers the whole scalp

(no evidences of Alopecia),

no parasites, and the amount

is variable.

S PALPATION:Thickness or thinnesstexture and oiliness.

S NORMAL

FINDINGS:Maybe thick or thin,coarse or smooth neitherbrittle nor dry.


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SCALP

S INSPECTION:

For Color, oiliness, presence

of scars, lice and dandruff.

S NORMAL

FINDINGS:

Lighter in color than the

complexion, can be moist oroily,no scars noted, free from

lice, nits and dandruff.

S PALPATION:

For lesions or masses

tenderness.

S NORMALFINDINGS:

NO lesions should be noted,

neither tenderness nor

masses


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FOREHEAD

S INSPECTION:

For symmetry, skin

appearance,presence of

rushes, scars or

pimples.

S NORMAL

FINDINGS:

Symmetrical, light to darkbrown, no rushes, scars and

pimples.

S PALPATION:

For masses, lumps and

tenderness

S NORMALFINDINGS:

Non-tender, no lumps and

absence of masses


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FACE

S INSPECTION:For shape and symmetry,presence of scars, pimplesor acne

S NORMAL

FINDINGS:

The shape of the face can beoval, round, or slightlysquare, the face issymmetrical, absence ofscars, pimples or acne.There should be no edema,disproportionate structures,or involuntary movements.

S PALPATION:For any swelling, masses,lumps, and the four sinuses(sphenoidal sinuses, frontalsinuses, ethmoid sinuses

and maxillary sinuses).S NORMAL

FINDINGS:

No lumps and swelling of the

face, absence of masses andthere is no pain felt duringpalpation of face


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EYESANDVISION

PERRLA-Pupils should be Equal, Round, Reactive to Light and Accomodation.

ANISOCORIA

- Unequal pupil

CONSTRICTION

- Normal reaction to light and near accomodation.

3-7 mm in diameter-Normal pupil

20/20 normal vision

20/200 - legal definition of blindness

MYOPIA nearsightedness

HYPEROPIA- farsightedness PRESBYOPIA - loss of elasticity of the lens due to aging, thus loss ability to

see close objects.

ASTIGMATISM - an uneven curvature of the cornea that prevents horizontaland vertical rays from focusing on the retina.

SNELLEN CHART- test visual acuity


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Snellen chart


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EYES

S INSPECTION:

For symmetry

S NORMAL FINDINGS:

Symmetrical or evenly placed and

inline with each other.N

onprotruding and equal palpebral

fissure.


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EYEBROWS

S INSPECTION:For hair distribution and alignmentand skin quality and movement,presence of pimples, dandruff andcolor of the hair.

S NORMAL FINDINGS:Hair evenly distributed; skin intact.Eyebrows symmetrically aligned;equal movement, absence ofpimples and dandruff, maybe blackbrown or blond depending on race.

S PALPATION:For the presence of lumps,pain and nodules.

S NORMAL FINDINGS:

No lumps, no nodules and nopain felt during palpation


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EARSANDHEARINGS DIVIDED INTO 3 PARTS:

1. Outer Auricle or pinna

External canal

Tympanic membrane

2. Middle 3 ossicles ( malleus, incus, stapes; decrease magnitude of sound)

Eustachian tube

3. Inner ear Cochlea

Vestibule

Semicircular canal

To straighten the ear canal of adult

- pull pinna up and backwards

To straighten the ear canal of child

- pull pinna down and backwards


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Parts of the

ear


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EARSANDHEARING

S WEBERS TEST- Lateralization test that compares right and left ear.

negative normal finding

-sound is heard in both ears or is localized at the center of thehead.

positive abnormal finding

-sound is heard better in impaired ear (bone conductivehearing loss)

-sound is heard better in normal ear (sensorineural hearingloss)


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Webers test


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EARSANDHEARING

S RINNES TEST

- Compares air conduction with bone conduction.

positive rinne- normal finding

-air conduction is greater than bone conduction.

negative rinne- abnormal finding

-bone conduction time is equal to or longer than airconduction (conductive hearing loss)


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Rinnes test


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EARSANDHEARING

S INSPECTION:For position, color, size, shape,anydeformities, inflammation, orlesions

S NORMAL FINDINGS:

The ear matches the flesh color ofthe rest of the patients skin andshould be positioned centrally andin proportion to the head. The topof the ear should cross animaginary line drawn from theouter canthus of the eye to theocciput with no swelling orthickening. Cerumen should bemoist and not obscure thelympanic membrane. There shouldbe no foreign bodies, redness,drainage, deformities, nodules orlesions.

S PALPATION:Presence of pain, tenderness, andlumps.

S NORMAL FINDINGS:

They should feel firm (not tender)and movement produce pain.


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NOSEAND

PARANASALSINUSES

S THE FACIAL SINUSES INCLUDE:

1. Frontal

2. Supra orbital

3. Ethmoidal4. Sphenoidal

5. Maxillary

S NASAL SPECULUM, PENLIGHT OR

OTOSCOPE

-used to visually examine the nose.


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NOSES

EXTERNAL INSPECTION:Inspect the nose nothing anybleeding, inflammation, or lesions,masses, swelling, and symmetry,discharges and color, sense ofsmell.

S NORMAL FINDINGS:The shape of the external nose canvary greatly among individual.Normally, it is locatedsymmetrically on the midline of theface that is without swelling,

bleeding, lesions, or masses.N

odischarge or flaring and uniformcolor, there is a sense of smell.

S EXTERNAL PALPATION:

For tenderness and presence ofpain.

S NORMAL FINDINGS:

Non-tender; absence of pain

S INTERNAL INSPECTION:Inspect for nasal septum fordeviation, perforation, lesions andbleeding.

S NORMAL FINDINGS:

The nasal mucosa should be pinkor dull red without swelling. Theseptum is at the midline andwithout perforation, lesions orbleeding, the small amount ofwatery discharge is normal.


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FRONTALSINUSES

S INSPECTION:For any swelling around the eyes

S NORMAL FINDINGS:

There is no evidence of swelling

around the eyes.

S PALPATION:

Presence of pain and tenderness

S NORMAL FINDINGS:

The patient should not feel painduring palpation and notendernessfelt.

S PERCUSSION:

Note any sound

S NORMAL FINDINGS:

The sound should be flat or dull.


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MAXILLARYSINUSES

S INSPECTION:

For any swelling around the eyes

S NORMAL FINDINGS:

There is no evidence of swellingaround the nose and eyes.

S PALPATION:presence of pain and tenderness

S NORMAL FINDINGS:

The patient should not feel any

pain and tenderness duringpalpation.

S PERCUSSION:

Note any sound

S NORMAL FINDINGS

The sound should be flat or dull


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MOUTHAND

PHARYNX

The first teeth (central lower incisors)appear at 5 to 8 months after birth.

20 temporary teeth are completed at 2

years old and lost at 6 to 7 years old.

It is replaced by 32 permanent teeth

including the appearance of wisdom tooth.(3rd molar).

The buccal mucosa is best for

identification of central cyanosis.


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Mouth and

pharynx

S 3 PAIRS OF SALIVARY GLANDS

1. PAROTID the largest ; emptiesthrough the Stensens duct.

2. SUBMANDIBULAR - empties throughthe wharton duct.

3. SUBLINGUAL located in the floor ofthe mouth.

Salivary


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Salivary

glands


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Mouth and

pharynx

S PHARYNX

Is an organ shared by the gastrointestinal system

and the respiratory system.

S NASOPHARYNX

Is where the eustachian tube opens to the middle

ear and oropharynx open into the GIT while thelaryngopharynx opens to the respiratory

system.


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LipsS

INSPECTION:For color, texture, cracking,

symmetry, lesions and

hydration

S NORMAL FINDINGS:

The lips should be pink, soft

moist, smooth texture with

no evidence of lesions or

inflammation. Not crack andsymmetrical.

S PALPATION:For any presence of pain,

lumps and tenderness.

S NORMAL FINDINGS:

There is no presence of

lumps and pain. It is tender.


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gums

S INSPECTION:For color, texture, swelling,

bleeding, retraction form the

teeth

S NORMAL FINDINGS:

The gums should be pink,

moist, firm texture, no

retraction, no swelling or

bleeding. The gum marginsat the teeth are tight and

well-defined.

S PALPATION:For the presence of pain,

tenderness and lumps.

S NORMAL FINDINGS:

There should be no pain felt

during palpation, no lumps

and non- tender.


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teeth

S INSPECTION:For discoloration, numbers of toothand texture.

S NORMAL FINDINGS:

The adult normally has 32 teeth,which should be white, straight

and smooth edges in properalignment or evenly placed, cleanand free of debris or decay


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tongue

S INSPECTION:For color, texture, surfacecharacteristics, symmetry,presence of lesions, and sense oftaste.

S NORMAL FINDINGS:The tongue is in the midline of the

mouth, the dorsal surface shouldbe pink, moist, rough and withoutlesions. The tongue is symmetricaland moves freely. The strength ofthe tongue is symmetrical andstrong.The ventral surface of the tongueahs prominent blood vessels andshould be moist without lesions,looks smooth and glistening. Thereis a sense of taste.


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tonsils

S INSPECTION:For color, shape, size and

discharge

S NORMAL FINDINGS:

It is pink in color and smooth. Oval

in shape. No discharge. Of normal

size or not visible, no inflammation,and not swollen.


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The 12

cranial

nerves

The 12 cranial


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The 12 cranial

nerves

S OLFACTORY

Class : sensory

Basic function: smell

Test: test smell using non-irritating substances

S OPTIC

Class: sensoryBasic function: sight

Test: visual acuity like snellen chart and visual field

The 12 cranial


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The 12 cranial

nerves

S OCULOMOTORClass: motor

Basic function: extraocular eye movement

Test: test eye movement and pupillary responseto light

S TROCHLEAR

Class: motorBasic function: extraocular eye movement

Test: test eye movement and pupillary response tolight

The 12 cranial


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The 12 cranial

nerves

S TRIGEMINAL

Class: both

Basic function: S- facial sensation

M- chewingTest: check pain sensation (dull or sharp stimuli using

safety pin, hot and cold using test tube, light touch

using wisp of cotton); test corneal reflex; test

clenching of teeth.


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The 12 cranial


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The 12 cranial

nerves

S ACOUSTIC (VESTIBULOCOCHLEAR)

Class: sensory

Basic function: hearing and sense of balance

Test: assess hearing using rinne and weber test.

S GLOSSOPHARYNGEAL

Class: both

Basic function: S- taste of posterior 1/3 of the tongue

M- swallowing

Test: listen to patients voice. Ask the patient to say ah andnot the movement of soft palate and pharynx. Test gag reflex.

The 12 cranial


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The 12 cranial

nerves

S VAGUS

Class: both

Basic function: innervation of the pharynx, respiratory,

cardiac and circulatory system

Test: listen to patients voice. Ask the patient to say

ah and note movement of the soft palate and

pharynx.T

est gag reflex.

The 12 cranial


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The 12 cranial

nerves

S SPINAL ACCESORYClass: motor

Basic function: shoulder and head movement

Test: ask the patient to shrug shoulder against yourhand.

S HYPOGLOSSAL

Class: motorBasic function: tongue movement

Test: note tongue and ask the patient to stick outtongue

The 12 cranial


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The 12 cranial

nerves

S MNEMONICS FOR THE 12 CRANIAL NERVES

Oh, Oh, Oh, To Touch and Feel a Girls

Vagina So Heavenly.

S TO REMEMBER WHETHER THE CN IS MOTOR,

SENSORY OR BOTH:

Some Say Marry Money But My Brother Says

Bad Business Make Money.


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FINISH

Thank you!

Documents

Abigail Domingo Physical Assessment