P N 1 0 3

PHYSICAL ASSESSMENT

SIGNS AND SYMPTOMS

• Signs• Objective data as perceived by the examiner -seen -heard -measured -verified by more than one personExamples: rashes, altered vital signs, visible drainage or exudate• Lab results, diagnostic imaging, and other studies

SIGNS AND SYMPTOMS

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

the sensation -full description by the patient -onset -course -character of the problem -any factors that aggravate or alleviate

SIGNS AND SYMPTOMS

• Disease and Diagnosis• Disease

• -disturbance of a structure or function of the body• -a pathologic condition of the body• -a set of signs and symptoms• -clustered in groups to help the physician to make a

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

SIGNS AND SYMPTOMS

• Origins of Disease• Disease or illness originates from many causes: -hereditary -congenital -inflammatory -degenerative -infectious -deficiency -metabolic -neoplastic -traumatic -environmental

Unknown etiology• Diseases that have no apparent cause

SIGNS AND SYMPTOMS

• Risk Factors for Development of Disease• increases the vulnerability of an individual or a group to

illness or accident -situation -habit -environmental condition -genetic predisposition -physiologic condition

SIGNS AND SYMPTOMS

• Categories of risk factors• Genetic and physiologic• Age• Environment• Lifestyle

SIGNS AND SYMPTOMS

• Terms Used to Describe Disease• Chronic

• develops slowly • persists over a long period• often for a person’s lifetime

• Remission• partial /complete disappearance of clinical and subjective

characteristics of a disease

• Acute• begins abruptly • marked intensity of severe signs and symptoms • often subsides after a period of treatment

SIGNS AND SYMPTOMS

• Organic disease• structural change in an organ • interferes with its functioning

Functional disease• manifested as organic disease • careful examination fails to reveal evidence of structural or

physiologic abnormalities

SIGNS AND SYMPTOMS

• Frequently Noted Signs and Symptoms• Infection

• invasion of microorganisms -bacteria -viruses -fungi -parasites that produce tissue damage

Inflammation• Protective response of the body tissues -irritation -injury -invasion by disease-producing organisms

SIGNS AND SYMPTOMS

• Cardinal signs of infection and inflammation• Erythema• Edema• Heat • Pain• Purulent drainage• Loss of function

ASSESSMENT

• 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

ASSESSMENT

• 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

ASSESSMENT

• Nursing Assessment• Initiating the nurse-patient relationship

• -first interview is the most challenging to conduct.• -introduce yourself (name and position) • -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.

ASSESSMENT

• Nursing Assessment• The interview

• -relaxed, unhurried manner.• -quiet, private, well-lighted setting.• -feelings of compassion and concern.• -what name the patient wishes to be addressed.• -accepting posture• -relaxed• -eye level• -pleasant facial expression.

ASSESSMENT

• Nursing Health History• -initial step in assessment process• -information on: -patient’s wellness -changes in life patterns -sociocultural role -mental and emotional reaction to illness

ASSESSMENT

• Biographical data• Date of birth• Sex• Address• Family members• Marital status• Religious preference• Occupations• Source of health care• Insurance

ASSESSMENT

• 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

ASSESSMENT

• Nursing Health History• Present illness /health concerns

• -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

ASSESSMENT

• Nursing Health History• Family history

• Immediate and blood relatives• Health or cause of death, -history of illness -patient’s risk for illnesses of a genetic or familial nature -information about family structure, interaction, and function

ASSESSMENT

• Nursing Health History• Environmental history

• -patient’s home environment• Psychosocial and cultural history

• -primary language• -cultural groups• -educational background• -attention span• -developmental stage• Coping skills and family support• -major beliefs• -values• -behaviors

ASSESSMENT

• Nursing Health History• Review of systems

• Systematic method • Collection of data on all body systems• Record in clear and concise manner • Appropriate terminology• Ask specific questions relating to functioning of each system

ASSESSMENT

• Nursing Physical Assessment• Determine the patient’s state of health or illness• Initial step of the nursing process • Forms the nursing care plan• When to perform a physical assessment

• -as soon after admission as possible.• -initial assessment is done by an RN.• -ongoing assessment• -LPN and RN

ASSESSMENT

• Nursing Physical Assessment• Where to perform a nursing assessment

• Comfortable, private setting• -patient’s own room works • -convenient• Methods of nursing physical assessment• -Head-to-toe• -System-by-system• -Focused

ASSESSMENT

• Nursing Physical Assessment• Performing the nursing physical assessment

• Items needed: • Penlight• Stethoscope• Blood pressure cuff• Thermometer• Gloves• Tongue blade

ASSESSMENT

• Senses of touch, smell, sight, and hearing• Wash your hands before beginning assessment.• Documentation of the interview and assessment • -utilize facility forms• Telephone consultation

ASSESSMENT

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

• Neurologic• Level of consciousness• Level of orientation • Hand grips

ASSESSMENT

• Skin • -color,• -temperature• -moisture• -texture• -turgor• -injury or skin lesions.• -color of sclera• -mucous membranes• -tongue,• -lips• -nail beds• -palms• -soles.

ASSESSMENT

• Hair• -quantity• -quality• -distribution of hair.• Hair should be: • -smooth• -not oily or dry.• Scalp should be free of: • -dandruff• -lesions• -parasites.

SKIN TURGOR

ASSESSMENT

• Head and neck

• -facial expression.• -symmetry of features.• -palpate arteries, veins, and lymph nodes• -feel for enlarged lymph nodes.• -carotid arteries. • -jugular vein distention.• -auscultate the carotids for bruits.

ASSESSMENT

• Mouth and throat• Inspect the lips and mucous membranes • -tongue blade and penlight. • -condition of teeth and gums.• -breath odor.

• Eyes• -symmetry.• -exudates.• -sclera.• -pupillary reflex.

ASSESSMENT

• Ears• -symmetry.• -ear canals.• -hearing and follow commands.• -use of hearing aids

• Nose• -symmetry• -nares patent.• -bleeding or drainage.

ASSESSMENT

• Chest, lungs, and heart and vascular system• -bilateral chest expansion.• -rate and rhythm of respirations.• -breathing should be QUIET.• -posture.

• Breasts• -examine • -encourage monthly self-exams.

ASSESSMENT

• Lung sounds• -breath through mouth quietly • -deeply and slowly • -stethoscope firmly but not tightly on the skin • -listen for one full inspiratory/expiratory cycle at

each point.• -auscultate using a zigzag pattern.

ASSESSMENT

• Spine• -curvature -sitting and a standing position.

• Heart sounds• Auscultate • -intensity of the sound• -faint to strong.• -regularity of the rhythm.

AUSCULTATING CARDIAC SOUNDS

ASSESSMENT

• Peripheral vascular system• Palpate peripheral pulses.• -strength on a 0-to-4+ scale.

• Extremities • -symmetry• -color• -varicosities.• -temperature • -hands and feet.• -capillary refill or blanch test.

PERIPHERAL PULSES

ASSESSMENT

• Abdomen• -shape• -contour• -lesions• -scars• -lumps• -rashes.• Auscultate • -bowel sounds in all quadrants.• Palpation • Percussion

ABDOMINAL ASSESSMENT

• Palpation of the liver using moderate palpation.

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

ASSESSMENT

Genitourinary systemInspect labia/genitalia and pubic hair.Palpate the scrotum.Palpate suprapubic area.

Rectum -assess for hemorrhoids or lesions.

ASSESSMENT

• Legs and feet• Palpate; • -femoral, dorsalis pedis, popliteal, and posterior tibial pulses.• -edema.• Range of motion.• Color• Motion• Sensation• Temperature