Physical Assessment (Week 1-4).pdf - 1 MIDTERM WEEK 1-4...
MIDTERM WEEK 1-4
Week One: Skin, Hair, Nails, Head, Neck and Related Lymphatic
Subjective Data (always collected first)
o Info that the client experiences, feels, states, documented in “direct quotes”
Example: What they report that they ate for breakfast
***subjective data comes/asked first
o Pain (5th Vital Sign)
o Symptoms
o Emotional Status
o Weight is subjective data if patient is asked to report weight
o Biographical Data (name, age, occupation, etc) Funds ATI p. 129
Health History: info based on the client’s own perception
History of illness and injury: past and present
Family history (3 generations): may skip a generation, check whether is maternal or paternal
Review of Systems: Interview of each system
Example: If you ask the pt how tall they are
***Social History: alcohol, smoking, drugs, caffeine
SATA Question “CADS” caffeine, alcohol, drugs, smoking
Psychosocial: relationship, educational level, support system, occupation hx, financial status, ability to perform ADL’s,
spiritual health, ethnicity, culture, self-concept
Practices: Western Medicine, Eastern, Holistic, etc.
***Health Patterns: exercise, diet, sleep, level of stress (what, how often, specifics)
o Note: accuracy of subjective data depends on the nurse’s ability to clarify the info gathered with follow up questions
o ***OLDCART & ICE: used to clarify subjective data (p.121) and for pain assessment “say “no pain” for Video
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving Factors
Treatment (ICE)
Impact on ADL’s
Coping Strategies
Emotional Response
o ***Inspect, palpate, percuss, auscultate
Objective Data
o What you observe by examination; measurable
o Focus on areas of interest such as chief complaint
o Done in a systematic fashion (head to toe)
o Examples: checking vital signs, measuring weight, auscultating the lungs
General Survey: First part of inspection; similar to head to toe assessment
o 4 + 2components of General survey: physical appearance, mental status, neurologic (mobility), behavior, allergies,
immunizations
o Physical Appearance
Nourishment
Color of skin (cyanotic, etc.)
Older for age
Body shape (banana, pear, hourglass, etc.)
o Mental Status
Orientation (A&Ox?) to person, place, time, situation
Affect and general mood
Level of anxiety
Speech
o Mobility/Neuro
Gait (stumbling, limping, etc.)
Posture
Inability to stand erect
Weakness/stiffness
1
,Physical Assessment (Week 1-4).pdf - 1 MIDTERM WEEK 1-4...
Involuntary movements
Range of motion is fluid
o Behavior
Dress and grooming
2
, 3
Body odor
Facial expressions
Presence of anxiety
Eye contact
Mood and affect
o Allergies:
food, meds, environment
o Immunizations: up to date
age
HPV
flu
pneumonia
Covid
Focused Assessment
o After family history, the nurse will begin to ask more specific questions about a problem
o Enables the nurse to clarify points, collect subjective data, apply knowledge and critical thinking
Nursing Order
o Inspection
o Palpation
o Percussion
o Auscultation
o **Note: order may vary depending on system
o **Abdomen: inspect, auscultate, percuss, palpate
Inspection
o Skill of observing the client in a deliberate, systematic manner
o Begins the moment you meet the client and continue until the end of the client-nurse interaction
o Always proceeds other assessment skills and is never rushed
o Begins with a survey of the client’s appearance and comparison of the right/left side of the body-which should be symmetrical
o Assess each body system or region for:
Color, size, shape, contour, symmetry, movement, drainage, odor
Observe pt, check RR, assess pain level
o Inspection of large body region: general to specific, use of special tools (ophthalmoscope)
Palpation
o The skill of assessing the client through the sense of touch
Size, mobility, position, temperature, texture, tenderness, vibration
Finger pads are used to palpate for crepitus, pulses, lymph nodes, fremitus
o Light palpation: 2 fingertips in circular motion, 1cm deep
Safest, least uncomfortable, use of finger pad of dominant hand
Use in ULQ of abdomen to prevent rupture of spleen
o Moderate palpation: palmer surface of fingers of the dominant hand over the structure; 2cm deep
Used to assess most other structures of the body using moderate pressure
Pressing downward 1-2 cm, rotating fingers in circular motion
o Deep palpation: extended fingers of the nondominant hand placed over the fingers of the dominant hand; 2-4cm
Used to palpate an organ that lies deep within a body cavity (liver)
o Check temperature with dorsal portion of hand
o Fremitus: Vibration heard on the chest wall when speaking/coughing using base of finger and putting hand over patients back,
they will say EEE or Nintey-Nine, assessed via PALPATION
How: palpate the chest wall using the palms of both hands, comparing side to side from top to bottom ask the pt to state
99 each time you move your hand, use the ulnar surface of the hand
Expected Findings: vibration is symmetrical and more pronounced at the top, near the tracheal bifurication
Unexpected Findings: uneven palpation indication pneumonia (increased fremitus) or decreased/absent fremitus
(pneumothorax)
Feel for texture, moisture, vibration, tenderness, edema, bruising
Palmar surface/base of fingertips sense vibration
o Finger Pads: used for discrimination of underlying structure/functions
Checks pulse, lymph nodes, crepitus
Percussion
o Striking a body part to produce a “measurable sound” or assess for tenderness using object, finger, or reflex hammer
o Used to determine the size and shape of organs or if solid/fluid/air filled sacs
o Detection of Ascites: (shifting dullness, fluid trill)
o The denser the tissue, the quieter the sound
o Three types of percussion (p.85
3
, 3
Direct
Tapping the body with fingertips of the dominant hand
Used to assess sinuses in adults or thorax of an infant
Goal: no pain, no tenderness
Blunt
Palm of nondominant hand flat against the body surface and striking the nondominant hand with the
dominant hand
Assess pain and tenderness in sternum, gallbladder, liver, kidneys,cva tenderness (organs=dull)
Indirect
Most commonly used; produces sound
A hammer or tapping finger used to strike an object is called a plexor (dominant finger doing tapping)
The hyperextended middle finger of the nondominant hand is placed firmly over the area being examined.
o Q) strike the stationary finger at the distal interphalangeal joint
Pleximeter (measure): the device that accepts the tap or blow from a hammer (ex: finger of non-dominant
hand)
The plexor is the fingertip of the flexed middle finger of the dominant hand
Other fingers and palm raised to avoid contact with body surface
Most common percussion for abdomen or flatness (bones/muscles)
Percussion Sounds: The less dense the tissue, the louder and longer the tone, more dense=quieter
o Tympany: loud, drum-like tone, medium duration, normal finding over abdomen (air filled intestines)
o Resonance: loud, low pitch, hallow tone, long duration • (normal lungs)
o Hyperresonance: abnormally loud, low tone, longer duration, heard when air is trapped in the lungs • (emphysema, COPD
pneumothorax-abnormal)
o Dullness: high pitched, soft, short duration, heavy over solid body organs • (liver or stool filled colon) normal
o Flatness: high pitched, soft • (muscle, bone, tissues) normal
Auscultation
o The skill of listening to the sound produced by the body.
o Bruits: blows/swishing sounds that indicate obstructed blood flow (Bell side)
o Murmurs: blows/swishing sounds heard when blood volume in the heart is increased or flow is impeded
o Bell • low frequency (used to hear heart murmurs, bruits
thyroid glands: normal you hear nothing; hold breath, carotid arteries => listening for bruits or swishing sounds)
o Diaphragm • high pitched sounds (bowel, lungs and heart)
o ***tell patient to hold breath when auscultating carotid, only do one side of the carotid arteries at a time
o Don’t auscultate over gowns, clothing or tubing
Vital Signs • In the order in which the tests are performed
o Temperature
o Pulse (radial, BPM, if irregular check apical for 1 min)
o RR
o BP (Always last to measure)
o Pain (5th vital sign)
o ***obese patient, keep HOB elevated. Adult larger bp cuff/gown, always have them sitting up
Korotkoff’s Sounds- (auscultate)
o When measuring BP, auscultate 5 phases
o Phase 1 • systolic bp, first faint sound
o Phase 2-sound, softer/longer
o Phase 3-sound, crisper/longer
o Phase 4- muffled, soft; used for a child’s diastolic
o Phase 5 • diastolic BP, absent sound
o Children: Systolic (phase 1) / Diastolic (phase 4)
Inspect skin • perspiration is normal, cyanosis, pallor, erythema, jaundice
o **Cyanosis is detected in darker skinned peoples skin, lips, mucous membranes, blue tinged, the conjunctivae, nail beds
are blue
o Begins with a survey of the client’s appearance and a comparison of the right and left sides of the body which should be nearly
symmetrical
o Assess each body system or region for: color, size, shape, contour, symmetry, movement, drainage
o Eccrine gland: made up of water and salts
o Apocrine glands: produce a secretion made up of water, salts, fatty acids, and proteins, which is released into hair follicles. When
apocrine sweat mixes with bacteria on the skin surface, it assumes a musky odor
o B.O. at puberty
3
MIDTERM WEEK 1-4
Week One: Skin, Hair, Nails, Head, Neck and Related Lymphatic
Subjective Data (always collected first)
o Info that the client experiences, feels, states, documented in “direct quotes”
Example: What they report that they ate for breakfast
***subjective data comes/asked first
o Pain (5th Vital Sign)
o Symptoms
o Emotional Status
o Weight is subjective data if patient is asked to report weight
o Biographical Data (name, age, occupation, etc) Funds ATI p. 129
Health History: info based on the client’s own perception
History of illness and injury: past and present
Family history (3 generations): may skip a generation, check whether is maternal or paternal
Review of Systems: Interview of each system
Example: If you ask the pt how tall they are
***Social History: alcohol, smoking, drugs, caffeine
SATA Question “CADS” caffeine, alcohol, drugs, smoking
Psychosocial: relationship, educational level, support system, occupation hx, financial status, ability to perform ADL’s,
spiritual health, ethnicity, culture, self-concept
Practices: Western Medicine, Eastern, Holistic, etc.
***Health Patterns: exercise, diet, sleep, level of stress (what, how often, specifics)
o Note: accuracy of subjective data depends on the nurse’s ability to clarify the info gathered with follow up questions
o ***OLDCART & ICE: used to clarify subjective data (p.121) and for pain assessment “say “no pain” for Video
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving Factors
Treatment (ICE)
Impact on ADL’s
Coping Strategies
Emotional Response
o ***Inspect, palpate, percuss, auscultate
Objective Data
o What you observe by examination; measurable
o Focus on areas of interest such as chief complaint
o Done in a systematic fashion (head to toe)
o Examples: checking vital signs, measuring weight, auscultating the lungs
General Survey: First part of inspection; similar to head to toe assessment
o 4 + 2components of General survey: physical appearance, mental status, neurologic (mobility), behavior, allergies,
immunizations
o Physical Appearance
Nourishment
Color of skin (cyanotic, etc.)
Older for age
Body shape (banana, pear, hourglass, etc.)
o Mental Status
Orientation (A&Ox?) to person, place, time, situation
Affect and general mood
Level of anxiety
Speech
o Mobility/Neuro
Gait (stumbling, limping, etc.)
Posture
Inability to stand erect
Weakness/stiffness
1
,Physical Assessment (Week 1-4).pdf - 1 MIDTERM WEEK 1-4...
Involuntary movements
Range of motion is fluid
o Behavior
Dress and grooming
2
, 3
Body odor
Facial expressions
Presence of anxiety
Eye contact
Mood and affect
o Allergies:
food, meds, environment
o Immunizations: up to date
age
HPV
flu
pneumonia
Covid
Focused Assessment
o After family history, the nurse will begin to ask more specific questions about a problem
o Enables the nurse to clarify points, collect subjective data, apply knowledge and critical thinking
Nursing Order
o Inspection
o Palpation
o Percussion
o Auscultation
o **Note: order may vary depending on system
o **Abdomen: inspect, auscultate, percuss, palpate
Inspection
o Skill of observing the client in a deliberate, systematic manner
o Begins the moment you meet the client and continue until the end of the client-nurse interaction
o Always proceeds other assessment skills and is never rushed
o Begins with a survey of the client’s appearance and comparison of the right/left side of the body-which should be symmetrical
o Assess each body system or region for:
Color, size, shape, contour, symmetry, movement, drainage, odor
Observe pt, check RR, assess pain level
o Inspection of large body region: general to specific, use of special tools (ophthalmoscope)
Palpation
o The skill of assessing the client through the sense of touch
Size, mobility, position, temperature, texture, tenderness, vibration
Finger pads are used to palpate for crepitus, pulses, lymph nodes, fremitus
o Light palpation: 2 fingertips in circular motion, 1cm deep
Safest, least uncomfortable, use of finger pad of dominant hand
Use in ULQ of abdomen to prevent rupture of spleen
o Moderate palpation: palmer surface of fingers of the dominant hand over the structure; 2cm deep
Used to assess most other structures of the body using moderate pressure
Pressing downward 1-2 cm, rotating fingers in circular motion
o Deep palpation: extended fingers of the nondominant hand placed over the fingers of the dominant hand; 2-4cm
Used to palpate an organ that lies deep within a body cavity (liver)
o Check temperature with dorsal portion of hand
o Fremitus: Vibration heard on the chest wall when speaking/coughing using base of finger and putting hand over patients back,
they will say EEE or Nintey-Nine, assessed via PALPATION
How: palpate the chest wall using the palms of both hands, comparing side to side from top to bottom ask the pt to state
99 each time you move your hand, use the ulnar surface of the hand
Expected Findings: vibration is symmetrical and more pronounced at the top, near the tracheal bifurication
Unexpected Findings: uneven palpation indication pneumonia (increased fremitus) or decreased/absent fremitus
(pneumothorax)
Feel for texture, moisture, vibration, tenderness, edema, bruising
Palmar surface/base of fingertips sense vibration
o Finger Pads: used for discrimination of underlying structure/functions
Checks pulse, lymph nodes, crepitus
Percussion
o Striking a body part to produce a “measurable sound” or assess for tenderness using object, finger, or reflex hammer
o Used to determine the size and shape of organs or if solid/fluid/air filled sacs
o Detection of Ascites: (shifting dullness, fluid trill)
o The denser the tissue, the quieter the sound
o Three types of percussion (p.85
3
, 3
Direct
Tapping the body with fingertips of the dominant hand
Used to assess sinuses in adults or thorax of an infant
Goal: no pain, no tenderness
Blunt
Palm of nondominant hand flat against the body surface and striking the nondominant hand with the
dominant hand
Assess pain and tenderness in sternum, gallbladder, liver, kidneys,cva tenderness (organs=dull)
Indirect
Most commonly used; produces sound
A hammer or tapping finger used to strike an object is called a plexor (dominant finger doing tapping)
The hyperextended middle finger of the nondominant hand is placed firmly over the area being examined.
o Q) strike the stationary finger at the distal interphalangeal joint
Pleximeter (measure): the device that accepts the tap or blow from a hammer (ex: finger of non-dominant
hand)
The plexor is the fingertip of the flexed middle finger of the dominant hand
Other fingers and palm raised to avoid contact with body surface
Most common percussion for abdomen or flatness (bones/muscles)
Percussion Sounds: The less dense the tissue, the louder and longer the tone, more dense=quieter
o Tympany: loud, drum-like tone, medium duration, normal finding over abdomen (air filled intestines)
o Resonance: loud, low pitch, hallow tone, long duration • (normal lungs)
o Hyperresonance: abnormally loud, low tone, longer duration, heard when air is trapped in the lungs • (emphysema, COPD
pneumothorax-abnormal)
o Dullness: high pitched, soft, short duration, heavy over solid body organs • (liver or stool filled colon) normal
o Flatness: high pitched, soft • (muscle, bone, tissues) normal
Auscultation
o The skill of listening to the sound produced by the body.
o Bruits: blows/swishing sounds that indicate obstructed blood flow (Bell side)
o Murmurs: blows/swishing sounds heard when blood volume in the heart is increased or flow is impeded
o Bell • low frequency (used to hear heart murmurs, bruits
thyroid glands: normal you hear nothing; hold breath, carotid arteries => listening for bruits or swishing sounds)
o Diaphragm • high pitched sounds (bowel, lungs and heart)
o ***tell patient to hold breath when auscultating carotid, only do one side of the carotid arteries at a time
o Don’t auscultate over gowns, clothing or tubing
Vital Signs • In the order in which the tests are performed
o Temperature
o Pulse (radial, BPM, if irregular check apical for 1 min)
o RR
o BP (Always last to measure)
o Pain (5th vital sign)
o ***obese patient, keep HOB elevated. Adult larger bp cuff/gown, always have them sitting up
Korotkoff’s Sounds- (auscultate)
o When measuring BP, auscultate 5 phases
o Phase 1 • systolic bp, first faint sound
o Phase 2-sound, softer/longer
o Phase 3-sound, crisper/longer
o Phase 4- muffled, soft; used for a child’s diastolic
o Phase 5 • diastolic BP, absent sound
o Children: Systolic (phase 1) / Diastolic (phase 4)
Inspect skin • perspiration is normal, cyanosis, pallor, erythema, jaundice
o **Cyanosis is detected in darker skinned peoples skin, lips, mucous membranes, blue tinged, the conjunctivae, nail beds
are blue
o Begins with a survey of the client’s appearance and a comparison of the right and left sides of the body which should be nearly
symmetrical
o Assess each body system or region for: color, size, shape, contour, symmetry, movement, drainage
o Eccrine gland: made up of water and salts
o Apocrine glands: produce a secretion made up of water, salts, fatty acids, and proteins, which is released into hair follicles. When
apocrine sweat mixes with bacteria on the skin surface, it assumes a musky odor
o B.O. at puberty
3
