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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 13
Physical Assessment
Chapter 13
Physical Assessment
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestion
•Is the following statement true or false?
The first step of the nursing process is planning.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswer
False.
The first step of the nursing process is assessment.
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• First step of the nursing process
– Assessment
• Physical assessment
– One method for gathering health data
Physical Assessment Physical Assessment
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• Purposes
– To evaluate the client’s current physical condition
– To detect early signs of health problems
– To establish baseline for future comparisons
– To evaluate client’s responses to medical and nursing interventions
Overview of Physical AssessmentOverview of Physical Assessment
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• Inspection
– Examining particular body parts
– Looking for specific normal and abnormal characteristics
– Using special instruments to inspect parts of the body inaccessible to ordinary visual inspection techniques
Overview of Physical Assessment: Four Basic Physical Assessment
Techniques
Overview of Physical Assessment: Four Basic Physical Assessment
Techniques
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Overview of Physical Assessment: Four Basic Physical Assessment
Techniques (cont’d)
Overview of Physical Assessment: Four Basic Physical Assessment
Techniques (cont’d)• Percussion
– Striking or tapping the body with fingertips to produce vibratory sounds
– Quality of sounds determines location, size, and density of underlying structures; variation in sound could mean possible pathologic change
– Pain: possible disease process or tissue injury
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Inspection and PercussionInspection and Percussion
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Overview of Physical Assessment: Four Basic Physical Assessment
Techniques (cont’d)
Overview of Physical Assessment: Four Basic Physical Assessment
Techniques (cont’d)• Palpation
– Lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand
– Deep palpation
– Information: normal tissue and unusual masses; bilateral structures; skin temperature and moisture
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Palpation TechniquesPalpation Techniques
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Overview of Physical Assessment: Four Basic Physical Assessment
Techniques (cont’d)
Overview of Physical Assessment: Four Basic Physical Assessment
Techniques (cont’d)• Auscultation
– Used for assessing the heart, lungs, and abdomen
– Soft sounds, loud sounds
– Nurses: practice auscultation repeatedly to gain proficiency; to ensure accuracy, eliminate or reduce environmental noise
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Auscultation Auscultation
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QuestionQuestion
•What is lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand called?
a. Inspection
b. Percussion
c. Palpation
d. Auscultation
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AnswerAnswer
c. Palpation
Palpation involves lightly applying pressure to the body using fingertips, back of the hand, or palm of the hand. Inspection is looking for specific normal and abnormal characteristics. Percussion is striking or tapping the body with fingertips to produce vibratory sounds. Auscultation is listening to the sounds of the heart, lungs, and abdomen with a stethoscope.
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• Equipment
– Items needed for a basic physical assessment
Overview of Physical AssessmentOverview of Physical Assessment
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• Environment
– Special examination room or at bedside
– Easy access to a restroom; a door or curtain to ensure privacy
– Adequate warmth
– Lined receptacle for soiled articles
– Adequate lighting
Overview of Physical Assessment (cont’d)
Overview of Physical Assessment (cont’d)
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• Environment (cont’d)
– Padded, adjustable table or bed
– Sufficient room for movement around client
– Facilities for hand hygiene
– Clean counter or surface for placing examination equipment
Overview of Physical Assessment (cont’d)
Overview of Physical Assessment (cont’d)
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• Gather general data during first contact with client
– Physical appearance; gait; coordinated movement; use of ambulatory aids; mood and emotional tone
– Preliminary data
o Vital signs, weight, height, documentation
Performing a Physical Assessment: Basic Activities During a
Physical Assessment
Performing a Physical Assessment: Basic Activities During a
Physical Assessment
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Assessment of Height and WeightAssessment of Height and Weight
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• Drape and position the client
– Ensure that client is covered with a drape (sheet of soft cloth or paper)
– Begin examination with the client standing or sitting
Performing a Physical Assessment: Basic Activities During a
Physical Assessment (cont’d)
Performing a Physical Assessment: Basic Activities During a
Physical Assessment (cont’d)
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Client Is Prepared for ExaminationClient Is Prepared for Examination
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• Select a systematic approach for collecting data
– Head-to-toe approach: Advantages
– Body systems approach: Advantages; disadvantages
• Examining the client: Outline procedure for performing a physical assessment
Performing a Physical Assessment: Basic Activities During a Physical
Assessment (cont’d)
Performing a Physical Assessment: Basic Activities During a Physical
Assessment (cont’d)
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• Head and neck
– Mental status assessment
– Eyes: accommodation; Snellen eye chart; Jaeger chart; extraocular movements
– Ears: cerumen; Weber test; Rinne test; audiometry
– Nose: abnormalities; smelling acuity
Data Collection: 6 General Areas for Data Collection
Data Collection: 6 General Areas for Data Collection
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Pupil Size Assessment GuidePupil Size Assessment Guide
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Weber TestWeber Test
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Rinne TestRinne Test
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QuestionQuestion
•When preparing a client for the Rinne Test, which of the following equipment should the nurse keep ready?
a. Stethoscope
b. Tuning fork
c. Snellen chart
d. Jaeger chart
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AnswerAnswer
b. Tuning fork
A tuning fork is required to conduct the Rinne test to determine hearing impairment. A stethoscope is used to listen to lung, heart, and abdominal sounds. A Snellen chart and a Jaeger chart are tools for assessing far and near vision respectively.
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• Head and neck (cont’d)
– Mouth and oral mucous membrane
o Unusual breath odors
o Assessment of taste
– Facial skin: alterations in skin
– Hair, scalp
– Neck
Data Collection: Six General Areas for Data Collection (cont’d)
Data Collection: Six General Areas for Data Collection (cont’d)
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• Chest and spine
– Skin turgor
– Assess chest shape and movement; chest expansion
– Spine: lordosis, kyphosis, scoliosis
– Breasts
– Heart sounds: S1, S2, S3, S4
Data Collection: Six General Areas for Data Collection (cont’d)
Data Collection: Six General Areas for Data Collection (cont’d)
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Data Collection: Six General Areas for Data Collection (cont’d)
Data Collection: Six General Areas for Data Collection (cont’d)• Chest and spine (cont’d)
– Lung sounds
o Normal
Tracheal sounds
Bronchial sounds
Bronchovesicular sounds
Vesicular sounds
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Data Collection: Six General Areas for Data Collection (cont’d)
Data Collection: Six General Areas for Data Collection (cont’d)
• Chest and spine (cont’d)
– Lung sounds (cont’d)
o Adventitious lung sounds
Crackles
Gurgles
Wheezes
Rubs
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QuestionQuestion
•Which of the following sounds is not a normal lung sound?
a. Tracheal
b. Bronchial
c. Vesicular
d. Wheezing
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AnswerAnswer
d. Wheezing
Wheezing is an adventitious lung sound; it is not normal. Tracheal sound, bronchial sound, and vesicular sound are normal lung sounds.
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• Extremities
– Assessment of:
o Capillary refill
o Muscle strength
o Fingernails and toenails
o Edema: measurement
o Skin sensation
Data Collection: Six General Areas for Data Collection (cont’d)
Data Collection: Six General Areas for Data Collection (cont’d)
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Criteria for Estimating Pitting Edema Criteria for Estimating Pitting Edema
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• Abdomen
– Bowel sounds: hyperactive, hypoactive, absent
– Abdominal girth measurement
– Genitalia
• Anus and rectum
– Client positioning; trauma; hemorrhoids
Data Collection: Six General Areas for Data Collection (cont’d)
Data Collection: Six General Areas for Data Collection (cont’d)
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• Assessment findings: basis for identifying health problems
– Clients
o Reveal situations that caused health failure
o Ask for more information
Nursing ImplicationsNursing Implications
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• Nursing diagnoses
– Readiness for enhanced knowledge
– Ineffective health maintenance
– Effective or ineffective therapeutic regimen management
– Deficient knowledge; noncompliance
– Health-seeking behaviors
Nursing Implications (cont’d)Nursing Implications (cont’d)
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• Explain purpose of each procedure
• Consider alterations: hearing, vision, mobility
• Ask appropriate questions
• Make appropriate adjustments: physical limitations
• Older women: modifications in pre-procedure positioning
General Gerontologic ConsiderationsGeneral Gerontologic Considerations