Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 27 Physical Assessment

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Chapter 27

Physical Assessment


Purposes of Physical Examination

• Determine client’s level of health and functioning

• Identify risk for problems

• Determine areas of preventive nursing

• Confirm issues to perform ADLs

(continued)


Purposes of Physical Examination

• Identify needs for testing or examinations

• Evaluate outcomes of treatment


Preparation for Physical Examination

• Environment

• Equipment

• Positioning and draping


Environment

• Accommodate special needs

• Place equipment on clean, immovable surface

• Keep room quiet, warm, and well-lit

• Ensure privacy


Equipment

• Wash hands

• Collect necessary equipment

• Gather assessment forms

• Secure supply of clean gloves


Positioning and Draping

• Position client to access body part being assessed

• Drape client to prevent unnecessary exposure


General Survey

• Signs of distress

• Health, stature, and sexual development

• Weight, height, and vital signs

• Posture, motor activity, and gait

• Dress, grooming, and personal hygiene

• Facial expressions and behaviors

• Reactions to people and environment

(continued)


General Survey

• Quality of speech

• Level of consciousness

• Sexual history

• Older adults

• Disabled clients

• Abused clients– Sexual assault nurse examiner (SANE)


Assessment Techniques

• Inspection

• Palpation

• Percussion

• Auscultation


Integument

• Skin

• Hair

• Nails


Head and Neck

• Skull and face

• Eyes

• Ears

• Nose and sinuses

• Mouth and pharynx

• Neck


Thorax and Lungs

• Normal breath sounds– Vesicular

– Bronchovesicular

– Bronchial

(continued)


Thorax and Lungs

• Adventitious breath sounds– Crackles

– Rhonchi

– Wheezes

– Pleural friction rub

– Stridor


Heart and Vascular System

• Heart– Aortic area

– Pulmonic area

– Erb’s point

– Tricuspid area

– Mitral area

(continued)


Heart and Vascular System

• Vascular system– Skin temperature

– Color

– Sensation

– Pulses


Breasts and Axillae

• Inspection

• Palpation

• ACS Guidelines for Breast Cancer Screening (2003)– Breast self-examination (BSE)

– Clinical breast examination (CBE)

– Mammogram


Abdomen

• Inspection

• Auscultation of four quadrants

• Percussion

• Light palpation


Musculoskeletal System

• Inspection

• Palpation

• Range of motion (ROM)

• Muscle testing


Neurologic System

• Mental status– Physical appearance and behavior

– Communication

– Level of consciousness

• Cognitive abilities and mentation

• Sensation

(continued)


Neurologic System

• Cranial nerves

• Motor function

• Cerebellar function– Coordination

– Balance and gait

• Reflexes


Reproductive System

• Female genitalia

• Male genitalia


Anus and Rectum

• Position

• Gloves

• Lubricant

• Prostate gland palpation


Post Assessment Care of the Client

• Outpatient setting

• Inpatient setting


Data Documentation

• Use specific forms

• Record as data collected

• Report information as needed

• Include subjective and objective findings

• Address all abnormal findings

Documents

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 27 Physical Assessment