Nursing physical assessment for nursing care.ppt

nursing physical assessment

1. by
ORWA FARES
St
aff development
P
hysical Assessment

2. Outlin
e
1.Definition of physical assessment.
2.Facts about physical assessment.
3.Purposes of physical assessment.
4.Introduction to physical assessment.
5.Physical assessment tools.
6.Assessment of:
•Basic neurological system
•Head, neck and lymphatic regions
•Cardiology system
•Pulmonary system
•Abdomen assessment
•Renal Assessment
•Back and extremities
•Relationship between the PA and NCP

3. Obj
ectives
By the end of this session, the attendees will
be able to:

1.Define physical assessment.
2.Determine PA tools.
3.Provide knowledge on PA to all nurses.
4.Accurately perform a comprehensive PA and
identify the normal findings.
5.Determine the relationship between PA and ND
and NCP.

4. D
efinition
o
f
phy
sical Assessment (PA)
•PA is an organized systemic process of
collecting subjective data based upon a
health history and objective data based
upon a head to toe or general systems
examination.
•It can be complete assessment, an
assessment of a body system, or an
assessment of a body part.

5. F
acts about PA
•A PA should be adjust based on the pt’s
need.
•The PA is the first step in the nursing
process.
•It provides the foundation of the NCP.

6. Why
PA
?
•To obtain baseline physical and mental data on
the pt.
•To supplement, confirm, or question data
obtained in the nursing history.
•To obtain data that will help the nurse establish
ND and plan pt’s care.
•To evaluate the appropriateness of the nursing
interventions in resolving the pt’s identified
pathophysiology.

7. Watch what you say!!!
•Assess language barriers.
•Can the pt hear you? Do you speak the
same language?
•Speak slowly and clearly.
•Address pt by name.
Preparing for the assessment
•Explain when, where and why the
assessment will take place
•Help the client prepare (empty bladder,
change clothes)
•Prepare the environment (lighting,
temperature, equipment, drapes, privacy

8. Look out for your body language
•Listen attentively and make eye contact.
•Use reassuring gestures.
•Be aware of your own nonverbal behaviors.
Positioning
Positions used during nursing assessment,
medical examinations, and during diagnostic
procedures:
Dorsal recumbent
Supine
Sims
Prone
Lithotomy

10. T
o rap up !!!!!

•Wash your hands!!
•Introduce yourself to the patient
•Position the patient
•Explain what you are going to do
•Expose the patient adequately (roll up
trousers/remove shirt
•Reposition patient if required

11. M
ethods of examination

Four primary techniques are used in the physical
examination :
 inspection
 palpation
 percussion
 auscultation

12. I
nspection

is the visual examination , example , assessing by using
the sense of sight . The nurse inspects with the
naked eye and with alighted instrument such as :
otoscope
ophthalmoscope
penlight
nasal and vaginal speculums
This technique assess color, rashes, scars, body shape,
facial expressions, that reflect emotions and body
structures (General Appearance).

13. P
alpation

Is the examination of the body using the sense of
touch . The pads of the fingers are used because
their concentration of nerve endings makes them
highly sensitive to tactile discrimination .
Palpation is used to determine (a) texture,e.g, of
the hair, (b) temperature e.g., skin area, (c)
vibration e.g., of a joint, (d) position, size,
consistency, and mobility of organs or masses
(e) distention, e.g. of the urinary bladder, (f)
presence and rate of peripheral pulses, and (g)
tenderness or pain.

14. T
ypes of Palpation
a. Light - most areas of body except if
abnormality seen - check lungs for decreased or
absent fremitus in abdomen, back, joints
b. Deep -abdominal exam
c. Bimanual - to entrap an organ
d. Ballotment -Used on eyeball and abd.
e. Rebound - in the abd exam to check for
certain types of pain.

15. P
ercussion

is an assessment method in which the body surface is
struck to elicit sounds that can be heard or vibrations
that can be felt .
There are two types of percussion :
1) direct or immediate percussion
2) Indirect or mediate percussion

16. S
ounds heard during
p
ercussion
…
•Flatness: Is an extremely dull sound produced by very
dense tissue, such as muscles and bones
•Dullness: Is a thud like sound produced by dense
tissue, such as the liver, heart, or spleen, full bladder
•Resonance: Is a hallow sound like lungs filed with air
•Hyper resonance: Is not produced in the normal body
e.g. ; emphysematous lung
•Tympany: Is a musical or drum like sound produced
from an air filled stomach

17. Au
scultation

Auscultation is the process of listening to sound produced
within the body .
Auscultation may be :
1) direct auscultation : is the use of the unaided ear ,
i.e., listen to respiration wheeze or grating of a moving
joint . ‘
2) Indirect auscultation : is the use of a stethoscope .

18. A
reas
o
f
Au
scultation
a. post/ant lung fields
b. heart
c. peripheral vascular
temporal, carotids, aorta,
pedals, femoral)
d. abdomen

19. L
et us start!!!!!!!!!

20. B
asic neurological assessment

21. G
eneral Considerations
Three major
consideration
determine the
extent of a
neurological exam:
•The client's chief
complaints
•The client's
physical condition (
level of
consciousness and
ability to ambulate)
•The client's
willingness to
participate and
cooperate.
•Always consider left to
right symmetry
• Examination of the
neurological system
includes assessment of :
•Mental Status
•level of consciousness
•Cranial Nerves
•Motor function
•Sensory function
•Coordination and Gait
•Reflexes (Three in the
upper and tow in the
lower extremities)
•Special Tests
(Babinski)

22. •Level of consciousness: alert, oriented to time,
place and persons….
•Motor response: normal, weakness, paralysis,
parasthesia…
•Speech: clear, slurred, aphasia, dysphasia…
•Others: Glasgow Coma Scale normal score is 15

23. G
lasgow Coma Scale
Glasgow Coma Scale or GCS is an scale which is used to
measure the consciousnes of a person.
GCS is used in evaluation of patients specially in ICUs This
scale consists of three tests . A score is given for each test,
and the GCS score is calculated by adding the scores given
to each test. The maximum score is 15, which means the
patient is fully conscious. The minimum score is 3, and is
usually seen in patients with brain death or those in deep
coma.

24. G
lasgow Coma Scale
6 5 4 3 2 1
Eyes

NA NA Open eyes
by himself
Open eyes in
response to
voice
Open eyes
in response
to pain
Does not
open
eyes
Verba
l
NA Oriented
(normal)
Confused
(Disoriented)
Says
Inappropriate
wards
Makes
meaningless
sounds
Makes no
sounds
Motor

Obeys
commands
Localizes

Pain
Withdraws
From painful
Stimulus
Decorticate
posturing
with painful
stimulus
Decerebrate
posturing
with painful
stimulus
Makes no
movement

25. H
ead, Neck
,
a
nd Lymphatic
RE
GIONS
Video2: head and neck

26. G
eneral Approach to Head
a
nd Neck Assessment
Greet patient, explain assessment
techniques
Environment
Quiet
Warm
Private
Adequate lighting
Upright sitting position
Compare right and left sides
Systematic approach

27. Assessment of the Head and face
•Inspection
•Shape
•Symmetry
•Palpation
•Contour
•Masses
•Depression
•Tenderness

28. Assessment of the Neck
•The neck is symmetrical smooth.
•Masses, scars, distended neck veins are
abnormal findings.
•Palpate the length and position of the
trachea using your fingers and thumb.
•Assess for lymph nodes behind the ears
and under the jaw line.
•Also assess the lymph nodes along the
side of the neck.

29. Cont’d
•Lymph nodes are assessed by standing in
front of the pt using your index and middle
fingers.
•Apply pressure gently by moving the skin
up and down.
•Locate the thyroid gland by locating the
isthmus of the thyroid gland located at the
third tracheal ring.

30. Thyroid Gland
•Normal findings
•Symmetrical movement with swallowing
•Adam’s apple more pronounced in
males
•No masses, tenderness, or
enlargement
•Absent bruit
(continues)

31. Thyroid Gland
•Abnormal findings
•Mass
•Enlarged gland
•Goiter
•Asymmetrical enlargement
•Presence of a nodule or bruit

32. C
ardiovascular system

33. H
eart

34. Examining the Heart
and Circulation
• Inspect the patient
• Feel the pulses, rate and
rhythm
• Measure the BP
• Inspect the neck veins
• Palpate and auscultate
the carotids
• Palpate the precordium
and apex
• Palpate the peripheral
pulses and listen for
bruits
• Examine the extremities
for venous
insufficiency/trophic

35. Peripheral pulses pointsPERIPHERAL
PULSES

36. Peripheral pulses points

37. Carotid
Artery

38. Peripheral Perfusion
Capillary Refill
•Press down firmly on the patient's finger or toe nail so it
blanches.
•Release the pressure and observe how long it takes the nail
bed to "pink" up.
•Capillary refill times greater than 2 to 3 seconds suggest
peripheral vascular disease, arterial blockage, heart failure,
or shock.

39. HEART

40. S1: Lub: mitral valve closure
S2: Dub: Aortic valve closure
APE to Man: Aortic, pulmonic, Erb’s Point, Tricuspid,
Mitral

Heart SoundsHeart Sounds

41. HEART

42. Now comes to the heart
Start With Inspection?
1 – Evaluate the thorax for size, shape and symmetry, look
from the front and from the side
2 -Observe for the apical pulse. It is located at the 4
th
and 5
th

left midclavicular intercostal space.
3 -Palpate for the apical and carotid pulse together

43. P
alpation
...Locate the Suprasternal notch, it is a U shape cavity at the
junction of the trachea and top of the sternum. To locate it
place a finger at the trachea at midline and move towarde
the sternum until the bone concavity is palpated. Then
locate the sternal angel by sliding your fingers down the Lt
sternal border until a bony ridge is felt. Now locate the 2
nd
rib
immediately adjacent to the sternal angle. Count the chest
and Palpate for the 2
nd
, 3
rd
. 4
th
and 5
th
intercostals spaces .

44. P
ercussion
Start percussion parallel or perpendicular to the third Lt
intercostals space medial to the midclavicular line.
Observe the changes of sound from resonance to
dullness. Note the change where dullness appear it is the
border of the heart. Do the same from the 4
th
and 5
th

intercostals spaces and up.

45. End
with Cardiac Auscultation
•S1: “lub” from systole
•S2: “dub” from pre-diastole
•Listen for rate, rhythm and regularity
•Apical heart rate for full 1 minute
•S3 (Ventricular diastolic gallop) classic sign of heart
failure. Best heard at the apex 3with the bell.
•S4(Atrial diastolic gallop) Myocardial infarction
aftereffect. Best heard over tricuspid or mitral valve.

46. Also Auscultate For Murmurs
1-Patient is seated up and leaning forward. Use the bell of
the stethoscope.
2-Murmures are relatively prolonged extra sounds,
occurring either during systole or diastol.
3-murmures result because of sum disruption in the flow of
blood into,through, or out of the heart.
4-Some common causes are diseased valves, they either
do not open or do not close

47. R
espiratory Assessment

48. Start with inspection…
•How is the pt is seated and if comfortable.
•Notice the respiratory rate, rhythm,
symmetry of the chest expansion, thoracic
shape, and thoracic contour.
•Notice the breathing cycle: normally
inspiration is followed by short pause, then
expiration which is usually rapid and faster
than inspiration.

49. Go to palpation
•Identify areas of tenderness
•Assess shape and symmetry
•Assess respiratory excursion (thoracic
expansion) at the sites of palpation.

51. Go to percussion…
•Percussion is done to identify if the tissue
we are assessing is filled with air, solid, or
liquid and to mark the borders of the
organs.
•Percussion can penetrate 5 to 7 cm.
•Deeper lesions can be detected by x-rays.

52. G
o to auscultation
…
•Bronchial sounds are loud, hollow, and high pitched
louder and longer during expiration than inspiration.
•Normally are heard over trachea, large bronchi and
between scapulae.
•Broncho-vesicular are medium pitched sounds. Equal
during inspiration and expiration. Heard over the main
steam bronchi.
•Vesicular are soft, low pitched and more prominent during
inspiration and then fade during the first part of expiration.
when we hear these sound we say that the lungs are
clear.

54. Abnormal breath sounds
1.Crackles: also called rales, discontinuous crackling
sounds due to the opening of previously deflated
airways. More prominent during inspiration. Can be
found with pts having pneumonia, CHF, pulmonary
fibrosis.
2.Rhonci: are continuous, low pitched gurgling
sounds. Are caused by air passing through spaces
narrowed by secretions or swelling. Are more
audible during expiration. Such in chronic
bronchitis.

55. Cont’d
•Wheezes: are high frequency musical sounds of
variable pitch produced by the passage of air
through a narrowed bronchus. Are more prominent
during expiration. Such as in COPD, asthma and
emphysema.
•Friction rub: is a loud grating sound due to rubbing
together of inflamed pleural surface. Rubs sound like
crackles but are heard on more localized area.

57. A
BDOMINAL ASSESSMENT

58. SUBDIVISION OF ABDOMEN
•RIGHT UPPER QUADRANT - RUQ
•RIGHT LOWER QUADRANT - RLQ
•LEFT UPPER QUADRANT - LUQ
•LEFT LOWER QUADRANT - LLQ

59. NINE ABDOMINAL QUADRANTS

60. RIGHT UPPER QUADRANT
•LIVER
•GALLBLADDER
•DUODENUM
•HEAD OF PANCREAS
•RIGHT KIDNEY AND ADRENAL
•HEPATIC FLEXURE OF COLON
•PART OF ASCENDING AND
TRANSVERSE COLON

61. LEFT UPPER QUADRANT
•STOMACH
•SPLEEN
•LEFT LOBE OF LIVER
•BODY OF PANCREAS
•LEFT KIDNEY AND ADRENAL
•SPLENIC FLEXURE OF COLON
•PARTS OF TRANSVERSE AND
DESCENDING COLON

62. RIGHT LOWER QUADRANT
•CECUM
•APPENDIX
•RIGHT OVARY AND TUBE
•RIGHT URETER

63. LEFT LOWER QUADRANT
•PART OF DESCENDING COLON
•SIGMOID COLON
•LEFT OVARY AND TUBE
•LEFT URETER

64. PREPARATION
•EQUIPMENT - STETHOSCOPE,
MARKING PEN, RULER
•PATIENT LIE ON BACK, PILLOW UNDER
HEAD, KNEES SLIGHTLY FLEXED
•EMPTY BLADDER
•SHORT FINGERNAILS

65. SEQ
UENCE OF ASSESSMENT
•INSPECTION
•AUSCULTATION
•PERCUSSION
•PALPATION
Video: abdomen assessment

66. INSPECTION
•ENTIRE PATIENT
•SKIN
•a. PIGMENTATION
•b. LESIONS
•c. STRIAE
•d. TURGOR
•SUPERFICIAL VESSELS

67. AUSCULTATION
•ACTIVE BOWEL SOUNDS
• BRUITS

68. PERCUSSION
•TO DETERMINE THE SIZE OF SOLID
ORGANS AND PRESENCE OF MASSES,
FLUID AND GAS
•TYMPANIC SOUND
•PERCUSS IN ALL FOUR QUADRANTS
•PERCUSS FOR LIVER
•PERCUSS FOR SPLEEN
•PERCUSS BLADDER IF INDICATED

69. PERCUSSION
•IF DULLNESS IN FLANKS - CHECK FOR
SHIFTING DULLNESS
•IF INDICATED CHECK FOR FLUID
WAVE

70. PALPATION
•LIGHT PALPATION TO EVALUATE GENERAL
CONDITION, NATURE OF ANY DISTENTION,
AND GROSS ABNORMALITIES AND
PAINFULNESS
•DEEP PALPATION TO DETECT ANY ORGAN
ENLARGEMENT, ABDOMINAL MASSES OR
SWELLINGS
•PALPATE FOR LIVER AND SPLEEN

71. PALPATION OF LIVER

72. PALPATION OF SPLEEN

73. REBOUND TENDERNESS

74. ON BACK
•CHECK FOR RENAL BRUITS
•COSTOVERTEBRAL ANGLE
TENDERNESS

75. PERCUSION OF KIDNEY

76. RULES IF IN ABDOMINAL PAIN
•DO NOT ADMINISTER PAIN MEDICATIONS,
ANTISPASMODICS, ANTICHOLINERGICS, OR
SMOOTH MUSCLE RELAXANTS BEFORE A
MEDICAL EXAM B/C MASK PAIN

77. CONTRAINDICATIONS FOR
ABDOMINAL ASSESSMENT
•NEVER PALPATE IF SUSPECTED
APPENDICITIS OR DISSECTING ABD.
AORTIC ANEURSYM
•NEVER PALPATE WITH POLYCYSTIC
KIDNEYS
•DO NOT PALPATE OF PERCUSS
TRANSPLANTED ORGANS

78. T
he Renal System

79. General Consideration:
•Pain passing urine (dysuria)
•Sever suprapubic pain
•Passing urine more often than usual (frequency)
•A sudden need to pass urine (urgency)
•Passing a larger volume of urine than normal (polyuria)
•Passing a smaller volume of than normal (oliguria)
•Passing urine during the night (nocturia)
•Total absence of urine output (anuria)
•Blood in the urine (haematuria)
•Air bubbles in the urine (pneumaturia)

80. Inspection
•Previous abdominal or flank surgical scars
•Edema (facial, peripheral)
Palpation
•Suprapubic tenderness
•Bladder distension
•Abdominal tenderness or masses
•Postvertebral angle tenderness
•Enlargement of kidney (normal kidneys are usually not
palpable unless client is thin)
•Inguinal nodes or swellings
Percussion
•Suprapubic or postvertebral angle tenderness
•Bladder distension

81. Examination of the Extremities
and Back
Video: extremities

82. Inspection
•Look for scars, rashes, or other lesions.
•Look for asymmetry, deformity, or atrophy.
•Always compare with the other side.
Palpation
•Examine each major joint and muscle group in turn.
•Identify any areas of tenderness.
•Identify any areas of deformity.
•Always compare with the other side.

83. Range of Motion
•Start by asking the patient to move through an active
range of motion (joints moved by patient). Proceed to
passive range of motion (joints moved by examiner) if
active range of motion is abnormal.

84. Active
•Ask the patient to move each joint through a full range of motion.
•Note the degree and type (pain, weakness, etc.) of any limitations.
•Note any increased range of motion or instability.
•Always compare with the other side.
•Proceed to passive range of motion if abnormalities are found.
Passive
•Ask the patient to relax and allow you to support the extremity to be
examined.
•Gently move each joint through its full range of motion.
•Note the degree and type (pain or mechanical) of any limitation.
•If increased range of motion is detected, perform special tests for
instability as appropriate.
•Always compare with the other side.

85. Edema, dehydration, Cyanosis, and Clubbing
•Check for the presence of edema (swelling) of the feet
and lower legs or the opposite which is impaired skin
integrity in case of renal failure and hyperthermia.
•Check for the presence of cyanosis (blue color) of the
feet or hands.
•Check for the presence of clubbing of the fingers.
Lymphatic
•Check for the presence of epitrochlear lymph nodes.
•Check for the presence of auxiliary lymph nodes.
•Check for the presence of inguinal lymph nodes

86. Thank you!!!