Basic Physical Assessment

Head-to-toe assessmentMajor body systems assessment

Purpose

• Gather baseline data

• Supplement, confirm, or refute data in nursing hx

• Confirm and identify nursing diagnosis

• Make clinical judgments about changing status

• Evaluate the physiological outcomes of care

Health History

• Provides baseline subjective information

• Guides and directs your physical assessment

• Identifies– Strengths– Actual or potential health

problems– Support system– Teaching needs– Discharge and referral needs

• Use of effective communications skills

• Family history

• Life patterns

• Sociocultural history

• Spiritual health

• Mental reactions

• Emotional reactions

PHYSICAL ASSESSMENT

• Validates the patient’s complaints related to health

• Assists in formulating nursing diagnoses and interventions

• Monitors current health problems

• Obtains baseline information for future assessments

Assessment techniques

• Inspection …Always first!!!

• Palpation

• Percussion

• Auscultation

Assessment techniques

Palpation

• Temperature

• Texture

• Moisture

• Organ size and location

• Rigidity or spasticity

• Crepitation, Vibration

• Position

• Size

• Presence of lumps or

masses

• Tenderness, or pain

Assessment techniques

Percussion

• Assess underlying structures for location, size, density of underlying organs.

• Direct – sinus tenderness

• Indirect- lung percussion

• Blunt percussion-organ tenderness (CVA tenderness)

Assessment techniques

Percussion sounds

• Flatness – bone or muscle

• Dullness – heart, liver, spleen

• Resonance – air filled lungs (hollow)

• Hyperresonance – emphysematous lung (hyperinflated)

• Tympany – air-filled stomach (drumlike)

Assessment techniques

Auscultation

• Listening to sounds produced by the body:

HeartBlood vesselsLungsAbdomen

• Instrument: stethoscope

– Diaphragm –high pitched sounds

– Bell – low pitched sounds

Assessment techniques

Auscultation• Avoid Interruptions

• Start with a general inspection first

• Proceed for specific observation of the system

• Expose only the part being examined

• Examine the unaffected area or parts first

• Examine external parts first, then internal

• Compare one side to the other side

• Proceed from head to toe

Eyes - PERRLAEyes - PERRLA

• Shine light through pupil onto retina– Cranial nerve III stimulated

•Observe for pupillary constriction•Observe for accomodation

• Pupils: black, round, regular, equal in size, 3-7 mm– PERRLA = Pupils equal, round, reactive to

light, accommodation

PupilsPupils

• Cloudy pupil: cataracts

• Dilated pupil: glaucoma, trauma, neurologic disorder

• Constricted pupil: drug use

• Pinpoint pupil: opioid intoxication

Great vessels of the neck

• Jugular veins– Empty unoxugenated blood directly into the

superior vena cava, which empties into the right side of the heart

• Carotid arteries– Reflects cardiac systole and is timed with S1, Palpate

only one at a time• Carotid artery pulse – correlates with first heart sound

Assessment

• Position client supine

• Then head elevated at 45 degrees

• INSPECTION:

• Lifts, heaves

• PMI (assess location)

GeneralReference Lines

• Sternal Line

• Midclavicular Line• Apical /PMI – left 5 th iCS midclavicular line

• Axillary Line

Heart Auscultatory Sites

• When auscultating sounds, place the stethoscpe over the four different site

• All physicians take money- APTM• Aortic, Pulmonic, Trisuspic, Mitral

• The sites are identified by the names of heart valves… but they are not located directly over the valves.

• Rather, these sites are located along the pathway blood takes as it flows throught the heart’s chambers and valves.

Heart• Review: heart is in the center of the chest, behind

and to left of the sternum

• Base is at top, apex is the bottom tip

• Apex touches anterior chest wall at 5th intercostal space medial to left midclavicular line

• Heart pumps blood through 4 chambers

• Events on left side occurs just before those on right

• Valves open and close, pressures within rise and fall and chambers contract as blood flows though each chamber

Cardiac CycleCardiac Cycle

• Systole: ventricles contract and eject blood from left ventricle into aorta and from right ventricle into pulmonary system

• Diastole: ventricles relax and atria contract to move blood into ventricles and fill coronary arteries

• Diahragm of the stethoscpe – for highpitched sounds – heart sounds

• Bell- for low pitched sounds – bruits, murmurs

Heart Sounds

S1: Lub: mitral valve closure

S2: Dub: Aortic valve closure

Heart Sounds – S1 & S2

• S1:– Closure of mitral and

tricuspid valves (M1 before T1)

• Correlates with the carotid pulse

• Can be split but not often

• S2: – Closure of aortic and

pulmonic valves

• May have a split sound (A2 before P2)

Heart Sounds

• S1 loudest at the apex (tricuspid), this sound corresponds to the closure of M1& T1

• May be split.• S2 loudest at the base (aortic),

• Physiologic S2 splitting- heard best at pulmonic area during peak inspiration

• S2 splitting – when the pulmonic valve closes later than the aortic valve – normal during inspiration

• Fixed split – ASHD – no variation with insp.

Extra Heart Sounds- S3…• a low-pitch vibration in early diastole immediately after S2

• Rapid ventricular filling: ventricular gallop May be a cardinal sign of CHF in adults

• May be normal in children, and patients with high cardiac output (athletes)

• Pathological in adults: CHF, HTN, CAD

• S1 -- S2-S3

• Sounds like: Ken--tuc-ky

Extra Heart Sounds- S4…

• Soft, low-pitched sound in late diastole immediately before S1

• Atria contract and eject blood into resistant ventricles (slow ventricular contraction): atrial gallop

• May be physiological in infants and small children

• Common in HTN pts

• S4-S1 — S2

• Sounds like Ten-nes--see

Heart Sounds

• Normal (Lub-dub, Lub-dub)

• S1 Lub (Closure of AV Valves at start of systole)

• S2 Dub – (Closure of pulmonic and aortic valves upon end diastole)

• 3rd Heart Sound – Middle 3rd of diastole

• 4th Heart Sound – Atrial

S1 Systole S2 Diastole S1 Systole S2

S4 M T A P S3 S4 M T AP

Peripheral PulsesPeripheral Pulses

• Apply firm pressure with pads of index and middle finger on pulse site without occluding pulse

• Measure strength of pulse and equality

• Assess carotid, radial, and pedal

• Also assess brachial, posterior tibial, and dorsalis pedis

Peripheral PulsesPeripheral Pulses

• Apply firm pressure with pads of index and middle finger on pulse site without occluding pulse

• Measure strength of pulse and equality

• Assess carotid, radial, and pedal

• Also assess brachial, posterior tibial, and dorsalis pedis

• Documentation of Pulses

Grading

• 0 = Absent, not palpable

• 1+- Diminished, barely palpable

• 2+- Easily palpable, normal pulse

• 3+ - Full pulse, increased

• 4+ - Strong, bounding, cannot be obliterated

Lower ExtremitiesLower Extremities

• Pedal pulses

• Foot strength bilaterally

• Homan’s Sign

• Capillary refill (see next slide)

• Edema

• Pain

Capillary Refill

• Should test fingers and toes

• Press down on nail to compress capillaries

• Color goes white, then release

• Color should return briskly; < 3 seconds

• Document “sluggish” if > 3 seconds

Assessing for Edema

• Depress pretibial area & medial malleolus for 5 seconds

• Grade pitting edema1+ to 4+

Lungs – Anatomy and Landmarks

• Lungs are paired but not symmetrical (see next slide)

• right lung = 3 lobes RUL, RML, RLL• left lung=2 lobes LUL , LLL

• Lung border locations:• Apices – 1 inch above the clavicles• Bases – located at the level of the 6th rib (T10)

• Lateral chest – extend from the apex of the axilla to the 7th or 8th rib.

Lungs

• Inspection• Color, Size and shape of chest, any deformities or lesions

• Resp. rate and depth

• Pattern of respiration – regular rhythm

• Abnormal patterns

– Hyperventilation-fast rate and deep breathing

– Tachypnea >28 vs. bradypnea <10

– Stertorous -“death rattle” –seen in comatose patient

Lungs• Inspection

– Check size, shape, symmetry• Altered shape ex., COPD, barrel chest

• Altered symmetry ex., kyphosis (hunchback), scoliosis (S)

• Altered breathing ex., rib fractures, pneumothorax

• Altered color ex., hypoxia

• Retractions from airway obstruction, respiratory distress

• Scars from lung surgery, trauma

Looking at related structures

• Skin: cyanosis, pallor

• Nails: Clubbing– Spongy nail matrix and nail angle of

greater than 160 degrees– Associated with congenital heart disease

AP DiameterAnterior Posterior Diameter

• The diameter of the chest from front to back should half the width of the chest.

• AP-Transverse/Lateral diameter= 1:2; • Transverse/Lateral should twice as wide as front to back

• Barrel chest – emphesyma pts (alveoli lost its eleasticity so lung tissue does not recoil back to normal

• COPD / Emphysema classically produces the "Barrel Chest Deformity" Lungs are overinflated, and pushing the chest wall out

• Pectus carinatum (Pigeon chest)– sternum protrudes out beyond the front of the abdomen– may be related to Rickkets

• Pectus excavatum (funnel chest)– sternum pushed in; depressed on all or part of the sternum

Normal Breath Sounds

• Bronchial over trachea

• Bronchiovescular over main bronchi

• Vesicular over lesser bronchi, bronchioles, and lobes

Adventitious/AbnormalBreath Sounds

Note whether the sound occur during inhalation or exhalation, or both.

Continuous sounds• Wheezes• Rhonchi

Discontinuous sounds• Crackles (Rales)

– Fine– Course– *Atelectic crackles

– Pleural friction rub

Wheeze & RhonchiContinuous Sound

Wheeze• high-pitched musical sounds heard first when a patient exhales

• Partial blockage in airflow

• Severe blockage – wheezes also heard when patient inhales

• Asthma, CHF, or foreign body obstruction, tumors

Rhonchi• low pitched – snoring, rattling sound

heard primarily when the pt exhales

• may also be heard on inhalation

• disappears with coughing

• Uncleared secretions, bronchitis, pneumonia,

Crackles Discontinuous Sound

• Crackles (Rales) -Caused by collapsed or fluid-filled alveoli

popping open.

• FINE Crackles–– usually heard in the lung bases; – CHF, Pneumonia, restrictive diseases – pulm fibrosis, asbestosis,

atelectasis (early CHF)

• COURSE Crackles– during inhalation and may be present in exhalation – Sounds like bubbling or gurgling as air moves through secretions in the

larger airways– COPD, pulm edema

Crackles Discontinuous Sound

• Crackles (Rales) -Caused by collapsed or fluid-filled

alveoli popping open.

• Atelectic crackles– common in elderly, disappears after several deep breaths

• Pleural friction rub – pericarditis– fluid in the pericardial space due to inflamed pleura

– pain on deep inspiration.

Pulmonary Edema

• Accumulation of fluid in the air sacks (aveoli) of the lungs

Abnormal Breath Sounds

• Diminished breath sounds– Obese, muscular chest wall– poor inspiratory effort– pleural effusion

• Absent breath sounds– Missing lung/lobe– airway obstruction, pneumothorax

Lungs - Palpation• Crepitus – SQ air pockets = abnormal

– Indicates subcutaneous air in the chest – Feels like puffed rice cereal crackling under the skin and

indicates air is leaking from the airways or lungs due to chest tube or open wound

• Tactile fremitus – increased fluid accumulation = abnormal• A palpable vibration that is caused by the transmission of air

through the broncho pulmunary system

– Decreased fremitus – over areas where pleural fluid collects (effusion, and pneumothorax, atelectasis, emphysema)

– Increased fremitus – abnormally seen in areas in which alveoli are filled with fluid and exudate, occurs with consolidation of lung tissue (pneumonia). You will feel more vibration.

Objective Data• Respiratory

• Rate: 18 resp/min• Depth: deep, even, shallow• Effort: labored, unlabored

– Breath Sounds• Describe: clear, rhonchi, inspiratory/expiratory wheezes,

crackles

• Location: all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat.

• Cough: present/not present– Describe: productive, moist, nonproductive

• Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.

Interventions• Position, Turn, Cough, Deep breathe

• O2 Method: nc, venti mask, rebreathing mask– Flow rate: 2L/min; 3l/min– Humidity: yes/no

• Pulse Oximeter: continuous, spot monitoring

• Incentive Spirometer: in use, n/a– Time used: 10 am, 11 am, 1 pm, 3 pm– Volume: 500 cc, 500 cc, 600 cc, 800 cc

• Oropharyngeal Suctioning: Describe- moderate amount thick tan secretions

• Med List: Albuterol inhaler, Prednisone, Theophylline

AbdomenAbdomen

• Sounds, masses, tenderness• Divide into four quadrants: RUQ, RLQ, LUQ,

LLQ• Inspect then auscultate• Bowel sounds: absent, hypoactive,

hyperactive• Listen continuously for 5 minutes to

determine absence• Palpate and/or percuss after listening• Abdomen should be soft, non-tender, non-

distended

AbdomenAbdomen

• RUQ – liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of colon, ascending /transverse colon, right kidney

• LUQ – stomach, spleen, body of pancreas, left kidney, splenic flexure of colon, transverse/descending colon

• RLQ – cecum, appendix, right ovary, tube, ureter, and spermatic cord

• Midline – aorta, uterus, bladderEpigastric, umbilical, suprapubic

Different Sequence of Assessment

• Inspect Auscultate• Percuss• Palpate

• Procedure:

– Have patient empty bladder

– Position patient supine with knees slightly flexed

• Note the abdominal shape and contour.

• The abdomen should be flat to rounded in people of average weight.

• A protruding abdomen may be due to obesity, pregnancy, ascites, or abdominal distention.

• A slender person may have a slightly concave abdomen

Abdomen - Inspection• Lesions – benign, scars from sx or trauma, striae, etc.

•  Distention - can be from fluid, air, mass, or obstruction

•  Pulsations - or movement of abdominal wall from peristalsis, pulsations and respiratory movement

– Peristalsis usually can’t be seen. If seen, slight wavelike motions.

– Visible rippling waves may indicate bowel obstruction -reported immediately.

– In thin pts, abdominal aortic pulsations may be seen in the epigastric area.

– Marked pulsations may indicate HTN, Aortic insuff, AAA, or other condition causing widening pulse pressure (see next slide)

Aneurysm

• Note vascular sounds – presence of bruits over aorta, renal, iliac, femoral

• Normally no bruits noted

• Abdominal aortic aneurysm – surg emerg.-tx immed to prevent hemorrhage, shock, and death

• If you see bounding pulsation on abd wall, feel for pulsations, and measure (greater than 6 cm- most likely aneurysm) report.

Auscultation of Bowel Sounds

• Absent– no BS for 5 min

• Hypoactive– less than 5/min

• Active– 5-30 per min

• Hyperactive– > 30 /min

Abdomen - procedure

• BOWEL SOUNDS• VENOUS HUMS• RENAL BRUITS• INGUINAL BRUITS

• Use diaphragm of stethoscope lightly on skin to prevent stimulating bowel sounds

• Start in RLQ (BS often present here) then proceed all four quadrants

• Listen for 3-5 minutes

• Note character and frequency of BS

Bowel Sounds• Normal BS are high-pitched, gurgling noises caused be air mixing with fluid

during peristalsis. The noises vary in frequency and pitch, and intensity. They are loudest before meal times. Normal BS – 5-30 per minute

• Borborygmus, or stomach growling – are the loud, gurgling, splashing bowel sound heard over the large intesting as gas passes through it.

• Hyperactive BS - > 30 /min – loud, high pitch, tinkling that occur frequently – may occur with diarrhea, constipation, and laxative use

• Hypoactive < 5 per min; - occur infrequently – assoc. with bowel obstruction, ileus, peritonitis, and indicate diminished peristalsis.

(paralytic ileus, use of narc meds can decrease peristalsis)

• Absent, no BS for 5 minutes.

• Be sure to allow enough time for listing in each quadrant before you decide that bowel sounds are absent. If NGT to suction, turn off suction as to not obscure or mimic sounds

Percussion

  To assess

-Density of abdominal contents -Locate organs -Screen for abnormal fluid or masses

   Tympany – predominantly over the abdomen – gas-filled   Dull over organs in the abdominal cavity (liver, spleen)

CVA tenderness Costovertebral AngleCVA tenderness – positive in pyelonephritis

Abdomen - Palpate• Palpate all four quadrants:

• To check for muscle resistance or rigidity; masses, fluid, tenderness.

– To palpate, put finger of one hand close together and make gentle rotating movements as you depress ½ inch (1.3 cm)

Light palpation – depress 1 cm:Relaxation; Tenderness; Masses

•    Palpate areas of pain and tenderness last

•   Normal: the abd should be soft and nontender. As you palpate, note any

• Abnormal findings: tenderness, masses, and rigidity

Palpation

• Light Palpation

• TENDERNESS, MASSES, RIGIDITY

• Deep Palpation

• Deep palpation - depress 5-8 cm; that’s about 2-3 inches.

• In obese, patient, put one hand over the other and push down.

• Palpate the entire abd on a clockwise direction and not any: Tenderness;  Masses; Enlarged organs

Normally Palpable Structures

• Know what is underneath so you can determine what can be expected from normal to abnormal

– Ex. suprapubic distention, full bladder or tumor?

– Sigmoid colon, stool can be palpated there

• Liver – should not be able to palpate liver way below the rib = enlarged

Rebound Tenderness

• Use when found abdominal pain or tenderness

• Hold hand at 90 deg angle & push slowly & deeply

• Lift hand quickly

• Norm. response is no pain on release of pressure

• Perform at end

ABDOMEN (summary)

• INSPECT-SKIN, PULSATION

• AUSCULTATE FOR BOWEL SOUNDS IN 4 QUADRANTS FOR 2-5 MIN & DETERMINE IF AUDIBLE, ABSENT, HYPOACTIVE, HYPERACTIVE

• PERCUSS FOR TYMPANY & LIVER DULLNESS

• PALPATE LIGHTLY FOR TENDERNESS, MASSES, RIGIDITY

References• ASSESSMENT OF HEAD & NECK

http://e-courses.cerritos.edu/rsantiago/My%20Webs/ASSESSMENT%20OF%20HEAD%20&%20NECK_SP%2004.ppt

• Health History and Physical Assessment http://e-courses.cerritos.edu/rsantiago/My%20Webs/PowerPoint%20Presentations.htm

• Physical AssessmentPhysical Assessment http://webteach.mc.uky.edu/nursing/nur869/webquests/lab1/Presentationphysical%20assessment.ppt

References

• Rachel S. Natividad, RN,MSN: Assessment of the Abdomen http://e-courses.cerritos.edu/rsantiago/My%20Webs/ASSESSMENT%20OF%20THE%20ABDOMEN%20N212_n251%20SP04.ppt

• Rachel S. Natividad, RN,MSN: Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system http://e-courses.cerritos.edu/rsantiago/My%20Webs/Cardiovascular%20Assessment%20_N212_N251%20SP04.ppt

• Rachel S. Natividad, RN, MSN:The Respiratory System, Thorax and Lungs

• http://e-courses.cerritos.edu/rsantiago/My%20Webs/Resp%20Assess%20N212_251%20SP04.ppt