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Basic Physical Assessment Head-to-toe assessment Major body systems assessment

Basic Physical Assessment Head-to-toe assessment Major 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.

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Basic Physical Assessment Head-to-toe assessment Major body systems assessment

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  1. Basic Physical AssessmentHead-to-toe assessmentMajor body systems assessment

  2. 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

  3. 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 Health History

  4. 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

  5. Assessment techniques • Inspection …Always first!!! • Palpation • Percussion • Auscultation

  6. Temperature Texture Moisture Organ size and location Rigidity or spasticity Crepitation, Vibration Position Size Presence of lumps or masses Tenderness, or pain Assessment techniques Palpation

  7. 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

  8. Assessment techniques Percussionsounds • Flatness – bone or muscle • Dullness – heart, liver, spleen • Resonance – air filled lungs (hollow) • Hyperresonance – emphysematous lung (hyperinflated) • Tympany – air-filled stomach (drumlike)

  9. Assessment techniques Auscultation • Listening to sounds produced by the body: Heart Blood vessels Lungs Abdomen • Instrument: stethoscope • Diaphragm –high pitched sounds • Bell – low pitched sounds

  10. 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 Assessment techniques Auscultation

  11. Eyes - 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

  12. Pupils • Cloudy pupil: cataracts • Dilated pupil: glaucoma, trauma, neurologic disorder • Constricted pupil: drug use • Pinpoint pupil: opioid intoxication

  13. 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

  14. Assessment • Position client supine • Then head elevated at 45 degrees • INSPECTION: • Lifts, heaves • PMI (assess location)

  15. GeneralReference Lines • Sternal Line • Midclavicular Line • Apical /PMI – left 5 th iCS midclavicular line • Axillary Line

  16. 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.

  17. 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

  18. Cardiac 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

  19. Heart Sounds S1: Lub: mitral valve closure S2: Dub: Aortic valve closure

  20. 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 & S2

  21. 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.

  22. 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

  23. 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

  24. 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

  25. S1 Systole S2 Diastole S1 Systole S2 S4 S3 S4 M T A P M T A P

  26. Peripheral 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

  27. 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 Peripheral Pulses

  28. Grading • 0 = Absent, not palpable • 1+- Diminished, barely palpable • 2+- Easily palpable, normal pulse • 3+ - Full pulse, increased • 4+ - Strong, bounding, cannot be obliterated

  29. Lower Extremities • Pedal pulses • Foot strength bilaterally • Homan’s Sign • Capillary refill (see next slide) • Edema • Pain

  30. 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

  31. Depress pretibial area & medial malleolus for 5 seconds Grade pitting edema 1+ to 4+ Assessing for Edema

  32. 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.

  33. 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

  34. 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

  35. 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

  36. 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

  37. Normal Breath Sounds • Bronchial over trachea • Bronchiovescular over main bronchi • Vesicular over lesser bronchi, bronchioles, and lobes

  38. Continuous sounds Wheezes Rhonchi Discontinuous sounds Crackles (Rales) Fine Course *Atelectic crackles Pleural friction rub Adventitious/AbnormalBreath SoundsNote whether the sound occur during inhalation or exhalation, or both.

  39. 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,

  40. Crackles Discontinuous Sound • Crackles(Rales) -Caused by collapsed or fluid-filled alveoli popping open. • FINECrackles– • 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

  41. Crackles Discontinuous Sound • Crackles(Rales) -Caused by collapsed or fluid-filled alveoli poppingopen. • 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.

  42. Pulmonary Edema • Accumulation of fluid in the air sacks (aveoli) of the lungs

  43. Abnormal Breath Sounds • Diminishedbreath sounds • Obese, muscular chest wall • poor inspiratory effort • pleural effusion • Absent breath sounds • Missing lung/lobe • airway obstruction, pneumothorax

  44. 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.

  45. 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.

  46. 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

  47. Abdomen • 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

  48. Abdomen • 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, bladder Epigastric, umbilical, suprapubic

  49. 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 Different Sequence of Assessment

  50. 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)

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