Introduction to the Physical

Assessment

Madeline GervaseMSN,CCRN,FNP,RN

Assessment Systematic & continuous

collection, validation, and communication of client data

Nursing process Initial and ongoing Medical vs Nursing Essential components

Purposes of Assessment Obtain Baseline Date regarding functional

abilities Supplement, confirm, or refute date

obtained in nursing history Obtain data that helps establish nursing

diagnoses and plan care Evaluate physiologic outcomes of health

care and thus client progress Screen for presence of risk factors

Types of Assessment

Initial Focused Emergency Ongoing

Types of DataObjective Data

“signs” info perceived by

the senses

Ex: T 101, moist skin

Subjective Data “symptoms” info perceived

only by affected person

Ex: feeling nervous, tired

Characteristics of Data Complete

Factual & Accurate

Relevant

Problems r/t Data Collection

Organization Omission Irrelevant or

Duplicate Data Misinterpretatio

n Too little data Documentation

Why is a health history taken? Patterns of

wellness/illness Physical &

Behavioral risk factors

Deviations from norm

Nurse as a resource

Functional Health Patterns Health Perception/

Management Nutritional-Metabolic Elimination Activity-Exercise Sexuality-

Reproduction Sleep-Rest

Sensory-Perceptual Cognitive Role-Relationship Coping-Stress

Tolerance Value-Belief

Nursing Health History Chief Complaint Present Problem

Usual health status Chronological story Impact on functioning Medications

Past Medical History Family History Personal & Social

History Review of Systems or

Functional Patterns

Client Profile – UK Clinical Setting Biographical Data Chief Complaint History of Present

Illness Current Medications

Current Treatments Past Illnesses or Past

Hospitalizations Allergies

General Survey – Clinical Setting Age/Sex/Race Mental Status Behavior Mood Appearance Body Type Posture Body Mechanics

Speech Use of language Thought Process Reliability as historian

Height/Weight Vital Signs

Explanation- Affect/Mood Affect – observable behaviors which

indicate the feelings or emotional status of the client.

Mood – term which refers to the client’s emotional state as described by the client.

Documentation Terms Affect

Broad Restricted Blunted Flat Labile

Mood Appropriate Inappropriate Depressed Anxiety Agitated Elated Manic Euphoric Euthymic (normal) irritable

General Principles - History Explain purpose Communication techniques Utilization of data sources Document Avoid interruptions or tiring the

client Consider client’s developmental

level

Developmental Principles Pediatric

Parent/child interactions

Integrate child Respect

adolescent, give choices

Geriatric Do not

stereotype Assess and

accommodate: sensory &

physical functioning

Psychosocial Considerations - History Avoid stereotypes Healthcare beliefs Language differences Eye contact Non-judgmental Stressors/Coping Mechanisms

Cultural Awareness Considerations Time Orientation Activity Orientation Human Nature Orientation Human-Nature Orientation Relational Orientation

Seidel, 2003, pp. 43.

History - Biographical Data Name Race Age Gender Marital status

Birthplace, date Address Source of medical

care Insurance coverage

Past Health History Previous hosp. &

surgeries Allergies Illnesses &

Accidents Immunizations Medications Habits/Lifestyle ADLs

Client’s Family History Blood relatives

Significant others

Health history

Family as resource

Stressors in family

Present Illness/Health Concerns

Onset Duration Location, quality, and intensity Precipitating factors Relief factors Client’s expectations Subjective and Objective data

PQRST – Characterize Symptoms Precipitating factors Quality Radiation Severity Temporal Factors

OLD CARTS – Onset Location Duration Character Aggravating factors Relieving factors Temporal factors Severity

Reasons for Seeking Healthcare Chief complaint Why? Quotes Specify Clarify

Resources Home and outside environment Community resources Financial Family & significant others Consider Basic Human Needs

Medical Diagnostic Data Medical vs

Nursing Diagnosis

Nursing Implications r/t Medical Diagnosis

Contributions of Lab Data Verifies data Provides baseline

information Evaluates

outcomes Identifies problems

missed in history and assessment

Test: Complete Blood Count(CBC) Analysis of peripheral venous blood

specimen Main components:

RBC = red blood cell count (erythrocytes) WBC = white blood cell count

(leukocytes) Hgb = hemoglobin Hct = hematocrit

Test: Urinalysis (UA) Analysis of a urine

specimen Screens for:

urinary infection renal disease diabetes mellitus

Urinalysis Main components

pH- 4.6 - 8.0 Protein- up to 10mg/100ml Specific gravity- 1.003 - 1.030 Glucose- negative Ketones- negative Blood- up to 2 RBCs

Test: Electrolytes (lytes, e-) Inorganic

substances in the body that conduct electrical current

Usage: Assess fluid balance

Electrolytes Main Components:

Na+ sodium K+ potassium Cl- chloride Ca calcium P phosphate Mg magnesium

Test: Chest X-Ray (CXR, PA Chest, PA & LAT Chest) Radiographic

exam of the thorax

Visualizes respiratory & cardiac function

Identifies & follows progression/ remission of dx process

Test: Arterial Blood Gas (ABG) Assesses the

adequacy of ventilation and oxygenation via arterial blood

Use: measures respiratory and metabolic (renal) disturbances

Arterial Blood Gases Main

Components: pH PaCO2 PaO2 HCO3 SaO2

General Nursing Implications Assess client’s readiness to learn Explain procedure to client Assist client in dealing with the

test Provide privacy Prepare client for test Universal precautions Send specimens promptly

Specific Nursing Implications Electrolytes:

Note diet, food and fluid intake Note s/s that could affect fluid

balance (N/V/D) Chest X-Ray:

Transport Remove metal objects Stand clear

Specific Nursing Implications Arterial Blood

Gases Anticoagulants? Time drawn Check site for

bleeding Pressure Sample on ICE STAT to lab

Physical Assessment:Pediatric Principles Assess:

coping ability previous

knowledge readiness

Encourage questions

Explain at developmental level

Physical Assessment:Pediatric Principles Use concrete

terms Small amounts of

info at a time Simple & clear

explanations Only offer choices

that are available Honest

praise/rewards

Physical Assessment Methods

Inspection Palpation Auscultation Percussion

Equipment Stethoscope Pen light Blood Pressure Cuff Thermometer Watch with second hand

Inspection

Assessment process during which the nurse observes the client

Inspection Initial contact and ongoing Use olfaction, touch General appearance, body language Systematic unhurried approach Expose part, respect privacy Examine: color, size, shape, position,

symmetry (compare like areas) Know “normals” Observe “normals/abnormals”

Palpation

The use of the hands and the sense of touch to gather data

Palpation Detects texture, shape, temp,

movement, pain, moisture Short fingernails, warm hands Gentle approach Light palpation first, if pain - STOP! Palpate tender areas last Three types:

Light palpation (1/2 inch) Deep palpation (1 inch) Bimanual deep palpation (2 hands)

Auscultation The act of

listening to sounds within the body to evaluate the condition of body organs

(stethoscope)

Auscultation Stethoscope: bell for low pitch sounds (cardiac

sounds) Diaphragm for high pitch sounds (bowel,

breath, normal cardiac) 4 characteristics of sounds

Frequency/pitch: # vibrations per second

Loudness: soft, medium, loud Quality: types; gurgling, blowing Duration: short, medium, long (specify)

Auscultation Quiet environment Know landmarks Know “normals” PRACTICE! PRACTICE! PRACTICE! Requires concentration, practice,

and application of knowledge

Percussion Tapping of

various body organs and structures to produce vibration and sound.

Documentation - Purpose Communication Quality Assurance Legal Reimbursement Research Planning Client Care

Education Statistics Accrediting/Licensure Historical Document

Principles of Documentation Timing Confidentiality Permanence Signature Accuracy Sequence Appropriateness

Completeness Standard Terminology Brevity Legibility Legal Awareness

Learning OutcomesThe student will be able to:1. State the purposes of the physical exam.2. Name the necessary equipment need to

perform a physical exam.3. Describe the four basic techniques used in

physical examination.4. Describe guidelines for preparing a client and

the environment for a physical examination.5. What are the components of a general survey?