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Physical Assessment Chapter 5 Chapter 5 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Assessment Chapter 5 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc

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Page 1: Physical Assessment Chapter 5 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc

Physical Assessment

Chapter 5Chapter 5

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Slide 2Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Signs and SymptomsSigns and Symptoms

• Signs Objective data as perceived by the examiner Can be seen, heard, and measured and can be

verified by more than one person Examples: rashes, altered vital signs, visible drainage

or exudate Lab results, diagnostic imaging, and other studies

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Slide 3Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

• Symptoms Subjective data Perceived by the patient Examples: pain, nausea, vertigo, and anxiety Nurse unaware of symptoms unless the patient

describes the sensation Encourage a full description by the patient of the

onset, the course, the character of the problem, and any factors that aggravate or alleviate

Signs and SymptomsSigns and Symptoms

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Slide 4Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

• Disease and Diagnosis Disease

• It is any disturbance of a structure or function of the body; a pathologic condition of the body

• It is recognized by a set of signs and symptoms

• Signs and symptoms are clustered in groups to help the physician to make a medical diagnosis

• The nurse also relies on assessment of signs and symptoms to formulate a nursing diagnosis

Signs and SymptomsSigns and Symptoms

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• Origins of Disease Disease or illness originates from many causes:

hereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, and environmental

Unknown etiology• Diseases that have no apparent cause

Signs and SymptomsSigns and Symptoms

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• Risk Factors for Development of Disease A risk factor is any situation, habit, environmental

condition, genetic predisposition, physiologic condition, and other that increases the vulnerability of an individual or a group to illness or accident

Risk factors do not necessarily mean that a person will develop a disease condition, only that the chances of disease are increased

Categories of risk factors• Genetic and physiologic, age, environment, and lifestyle

Signs and SymptomsSigns and Symptoms

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• Terms Used to Describe Disease Chronic

• Develops slowly and persists over a long period, often for a person’s lifetime

Remission• Partial or complete disappearance of clinical and

subjective characteristics of a disease Acute

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

Signs and SymptomsSigns and Symptoms

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Slide 8Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

• Terms Used to Describe Disease Organic disease

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

Functional disease• May be manifested as organic disease, but careful

examination fails to reveal evidence of structural or physiologic abnormalities

Signs and SymptomsSigns and Symptoms

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• Frequently Noted Signs and Symptoms Infection

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

Inflammation• Protective response of the body tissues to irritation,

injury, or invasion by disease-producing organisms

Signs and SymptomsSigns and Symptoms

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• Frequently Noted Signs and Symptoms Cardinal signs of infection and inflammation

• Erythema

• Edema

• Heat

• Pain

• Purulent drainage

• Loss of function

Signs and SymptomsSigns and Symptoms

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AssessmentAssessment

• Process of making an evaluation or appraisal of the patient’s condition

• Medical Assessment Physical examination is conducted by the physician The nurse is often expected to carry out certain

functions

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• Medical Assessment Functions that may be expected of the nurse Equipment and supplies

• Preparing the exam room

• Assisting with equipment

• Preparing the patient

• Collecting specimens

AssessmentAssessment

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• Nursing Assessment Initiating the nurse-patient relationship

• The first interview is the most challenging to conduct.

• Introduce yourself and state name, position, and purpose of the interview.

• Give an estimate of time.

• Ask if the patient has any questions and answer them appropriately.

• Communicate trust and confidentiality.

• Convey competence and professionalism.

AssessmentAssessment

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• Nursing Assessment The interview

• Provide relaxed, unhurried manner.

• Conduct in a quiet, private, well-lighted setting.

• Convey feelings of compassion and concern.

• Determine by what name the patient wishes to be addressed.

• Nurse should have an accepting posture, relaxed, eye level, and pleasant facial expression.

AssessmentAssessment

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• Nursing Health History The initial step in assessment process Information on patient’s wellness, changes in life

patterns, sociocultural role, and mental and emotional reaction to illness

Biographical data• Date of birth, sex, address, family members’, marital

status, religious preference, occupations, source of health care, and insurance

AssessmentAssessment

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• Nursing Health History Reasons for seeking health care

• Chief complaint Document information in patient’s own words. The nurse can use the PQRST method:

P provocative/palliative

Q quality/quantity

R region/radiation

S severity

T timing

AssessmentAssessment

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• Nursing Health History Present illness or health concerns

• The data collected relate to the progression of the present illness from the onset of the current signs and symptoms

Past health history• Previous hospitalizations

• Allergies

• Habits and lifestyle patterns

• Ability to perform ADLs

• Patterns of sleep, exercise, and nutrition

AssessmentAssessment

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• Nursing Health History Family history

• Immediate and blood relatives

• Includes health or cause of death, as well as history of illness

• Objective is to determine patient’s risk for illnesses of a genetic or familial nature

• Provides information about family structure, interaction, and function

AssessmentAssessment

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• Nursing Health History Environmental history

• Provides data about patient’s home environment Psychosocial and cultural history

• Data about primary language, cultural groups, educational background, attention span, and developmental stage

• Coping skills and family support

• Identify major beliefs, values, and behaviors when treating them

AssessmentAssessment

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• Nursing Health History Review of systems

• Systematic method for collecting data on all body systems

• Record in clear and concise manner with appropriate terminology

• Ask specific questions relating to functioning of each system

AssessmentAssessment

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• Nursing Physical Assessment The purpose is to determine the patient’s state of

health or illness Initial step of the nursing process and in forming the

nursing care plan When to perform a physical assessment

• Perform assessment as soon after admission as possible.

• Initial assessment is done by an RN.

• Ongoing assessment is the responsibility of LPN and RN.

AssessmentAssessment

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• Nursing Physical Assessment Where to perform a nursing assessment

• Comfortable, private setting

• In most cases, the patient’s own room works very well and is convenient

Methods of nursing physical assessment• Head-to-toe

• System-by-system

• Focused

AssessmentAssessment

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• Nursing Physical Assessment Performing the nursing physical assessment

• Items needed: penlight, stethoscope, blood pressure cuff, thermometer, gloves, and a tongue blade

• Nurse also makes use of the senses of touch, smell, sight, and hearing

• Always wash your hands before beginning assessment.

• Documentation of the interview and assessment is necessary utilizing facility forms

• Telephone consultation

AssessmentAssessment

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Figure 5-1Figure 5-1

Equipment used during a physical examination.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

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• Performing the Nursing Physical Assessment Head-to-toe assessment

• Neurologic Level of consciousness Level of orientation Hand grips

AssessmentAssessment

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Head-to-Toe Assessment (continued)• Skin and hair

Observe skin for color, temperature, moisture, texture, turgor, and evidence of injury or skin lesions.

Note color of sclera, mucous membranes, tongue, lips, nail beds, palms, and soles.

Determine the quantity, quality, and distribution of hair. Hair should be smooth, not oily or dry. Scalp should be free of dandruff, lesions, or parasites.

AssessmentAssessment

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Figure 5-3Figure 5-3

Assess skin turgor by grasping fold of skin on back of patient’s hand,

sternum, forearm, or abdomen.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

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Head-to-Toe Assessment (continued)• Head and neck

Note facial expression. Note symmetry of features. Assess arteries, veins, and lymph nodes. Palpate beneath the jaw and down each side of the neck

to feel for enlarged lymph nodes. Palpate carotid arteries. Assess jugular vein distention. Auscultate the carotids for bruits.

AssessmentAssessment

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Figure 5-4Figure 5-4

Palpation of carotid artery.

(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)

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Head-to-Toe Assessment (continued)• Mouth and throat

Inspect the lips and mucous membranes with tongue blade and penlight.

Note condition of teeth and gums. Note breath odor.

• Eyes Note symmetry. Assess for exudates. Assess sclera. Observe pupillary reflex.

AssessmentAssessment

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Head-to-Toe Assessment (continued)• Ears

Note symmetry. Assess ear canal. Note ability to hear and follow commands. Note use of hearing aids if applicable.

• Nose It should be symmetrical. Assess patency. Observe for bleeding or drainage. Assess nares.

AssessmentAssessment

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Head-to-Toe Assessment (continued)• Chest, lungs, and heart and vascular system

Inspect for bilateral chest expansion. Note rate and rhythm of respirations. Breathing should be QUIET. Note posture.

• Breasts Examine and encourage monthly self-exams.

AssessmentAssessment

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Head-to-Toe Assessment (continued)• Lung sounds

Instruct patient to breath through mouth quietly and more deeply and slowly than a usual respiration.

Place stethoscope firmly but not tightly on the skin and listen for one full inspiratory/expiratory cycle at each point.

Systematically auscultate using a zigzag pattern.

AssessmentAssessment

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Head-to-Toe Assessment (continued)• Spine

Note the curvature while in a sitting and a standing position.

• Heart sounds Auscultate with stethoscope. Listen for intensity of the sound, faint to strong. Determine the regularity of the rhythm.

AssessmentAssessment

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Figure 5-8Figure 5-8

Sequence of patient positions for auscultation of heart sounds.

(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)

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Head-to-Toe Assessment (continued)• Peripheral vascular system

Palpate peripheral pulses. Rate the strength on a 0-to-4+ scale. Assess extremities for symmetry, color, and varicosities. Assess temperature of hands and feet. Perform capillary refill or blanch test.

AssessmentAssessment

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Figure 5-9Figure 5-9

Palpation of arterial pulses.

(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)

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Head-to-Toe Assessment (continued)• Abdomen

Inspect for shape, contour, lesions, scars, lumps, or rashes.

Auscultate for bowel sounds in all quadrants. Perform palpation and percussion.

• Genitourinary system Inspect labia/genitalia and pubic hair. Palpate the scrotum. Palpate suprapubic area.

AssessmentAssessment

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Figure 5-11Figure 5-11

Palpation of the abdomen to assess for distention, masses, or tenderness using light palpation.

(From Thompson, J.M., Wilson, S.F. [1996]. Health assessment for nursing practice. St. Louis: Mosby.)

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Figure 5-12Figure 5-12

Palpation of the liver using moderate palpation.

(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)

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Head-to-Toe Assessment (continued)• Rectum

Spread buttocks and assess for hemorrhoids or lesions.

• Legs and feet Palpate femoral, dorsalis pedis, popliteal, and posterior

tibial pulses. Observe and palpate for edema. Test for range of motion. Check color, motion, sensation, and temperature of both

feet.

AssessmentAssessment