copy of nclex-physical assess

7/28/2019 Copy of NCLEX-Physical Assess

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Physical Assessment


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Vital Signs

Blood pressure

Pulse

Temperature

Respiratory rate Oxygen saturation

Pain


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When to Take Vital Signs On admission

Routine schedule

Home health visit

Before and after surgical or invasive procedure

Before and after administration of medications that affect

cardiovascular, respiratory and temperature control

functions

Change in patient condition

Before, during, and after nursing interventions that

influence vital signs

When patient reports symptoms of physical distress


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Nursing Responsibilities

Must know standard range for all vital signs

Must know patients baseline vital signs

Must be able to analyze and interpret

significance of vital sign readings


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Blood Pressure

Systolic ranges 90-140 Diastolic ranges 60-90

Force exerted on the walls of an artery by thepulsing blood under pressure from the heart

Systolic blood pressure- peak of maximumpressure when ventricular ejection occurs

Diastolic blood pressure- minimal pressureexerted against the arterial walls, occurs duringventricular relaxation


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Hypertension

Pre-hypertension

Diastolic blood pressure 80-89 or systolic

blood pressure 120-139 on 2 or more visits

Pathophysiology hypertension Thickening and loss of elasticity of arterial

walls

Peripheral vascular resistance increases

Heart pumps against greater resistance

Blood flow to vital organs decreases


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Hypotension

Systolic blood pressure less than 90 mm Hg Occurs with

Dilation of vascular bed

Loss of blood volume Failure of heart muscle to pump adequately

Orthostatic hypotension

Occurs when a person with a normal blood

pressure has symptoms when rising to an uprightposition


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Pulse

Pulse range 60-100 beats/min

Electrical impulses originate in sinoatrial node of heart

Impulse travels through heart muscle to stimulate

cardiac contraction

Approximately 60-70 ml of blood enters aorta with each

ventricular contraction (stroke volume)

With each stroke volume, walls of aorta distend, creating

a pulse wave that travels rapidly toward the distal ends

of the arteries

Pulse is palpable bounding of the blood flow to the

peripheral artery


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Pulse Sites


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Character of the Pulse

Rate

Rhythm

Strength

Equality


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Pulse and Blood Pressure

Increased HR- less time for heart to fill and

blood pressure decreases

Decreased HR- filling time is increased andblood pressure rises


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Temperature

Temperature range 36- 38 C

(96.8- 100.4 F)

Average oral: 37.5 C (98.6 F)

Average rectal: 37.5 C (99.6 F)

Average axillary: 36.5 C (97.6 F)

Heat produced- Heat lost = Body temperature

Surface temperature fluctuates depending on blood flow to theskin and the amount of heat lost

Skin Oral

Axillae


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Core Temperature

Measurement of body temperature is aimed atobtaining measurement of core body tissues

Core temperature= temperature of deep tissues

Rectum Tympanic membrane

Esophagus

Pulmonary artery

Urinary bladder


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Respirations

Normal Range 12-20 breaths per minute

Assess rate, depth, rhythm

Ventilation: the movement of gases in and out

of the lungs

Diffusion: movement of oxygen and carbon

dioxide between the alveoli and the red blood

cells Perfusion: distribution of red blood cells to

and from the pulmonary capillaries


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Physiological Control of Breathing

Breathing regulated by Respiratory Center in

brainstem

Ventilation- regulated by levels of CO2, O2 and

hydrogen ion concentration in arterial blood

Elevation of CO2 causes the respiratory controlsystem in the brain to increase rate and depth of

breathing which removes excess CO2


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Smokers

Smoker have hypercarbia, chemoreceptors in

carotid artery and aorta become sensitive of

hypoxemia and signal brain to increase rate and

depth of respirations.


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Purposes of Physical Assessment

Routine screening to promote wellness

behaviors and preventive health measures

Determine the clients eligibility for health

insurance, new job, military service Patients admission to hospital or long-term

care facility


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Uses of Physical Assessment

Gather baseline data

Supplement, confirm, or refute data obtained

in the nursing history

Confirm and identify nursing diagnoses

Make clinical judgments about a clients

changing health status and management

Evaluate the physiological outcomes of care


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Types of Data

Subjective data

Patients perception about their health

problems

Objective data Observations or measurements made by the

data collector
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Sources of Data

Client

Family and significantothers

Health care team

members Medical records

Other records-educational, military,

and employmentrecords


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Nursing Health History

Objectives

Identify patterns of health and illness

Identify risk patterns for physical and behavioralhealth problems

Identify variations from normal

Identify available resources for adaptation


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Biographical information

Address, occupation, working status, marital

status, source of health care, types of insurance

Reason for seeking care

Clients perception of reasons for seeking health

care

Helps identify potential needs for education,counseling, or referral to community resources


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Patient Expectations Acknowledges what is important to the patient

Treatments and outcomes

Plan for returning home

Relief of pain and other symptoms


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Present Illness or Health Concerns

Determine when symptoms began, whether

they began suddenly or gradually, and

whether they are always present or come andgo, duration of symptoms, intensity


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Health History

Data on the clients health care experience and

current health habits

Medical problems

Hospitalizations

Surgeries

Complete list of medications- prescribed, OTC

including herbals

Allergies- medications, foods, latex, contact agents

Habits and lifestyle patterns- alcohol, tobacco,

caffeine, recreational drugs

Patterns of sleep, exercise, and nutrition


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Family History

To determine whether the client is at risk forillnesses of a genetic of familial nature and toidentify areas of health promotion and illness

prevention

Ex. Cancer, CAD, sickle cell anemia, stroke,diabetes, hypertension

Also provides information regarding family

structure, interaction, and function


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Environmental History

Provides data about clients home and working

environment with an emphasis on determining

the clients safety Function of utilities, layout of rooms in the

house, presence of barriers or risks for client

injury

Identifies exposure to pollutants in theworkplace, existence of high crime, available

resources


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Psychosocial History

Reveals clients support system, ways to cope

with stress, recent deaths

Spiritual health Beliefs about life, their source for guidance in

acting on beliefs, relationship with family in

exercising their faith, rituals and religious

practices


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Review of Systems

Systematic method for collecting data on all

body systems


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Preparation for Assessment

Preparing the client

Explain what will be done, what the client should

expect to feel, and how the client can cooperate

Allow patient to empty bowel/bladder

Provide privacy

Provide adequate lighting

Try to keep patient warm and covered- eliminate

drafts, control room temperature, provide warmblankets


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Preparation for Assessment

Help patient assume positions during

assessment

Pace assessment according to the clients

physical and emotional tolerance Use a relaxed voice tone and facial

expressions to put client at ease

Encourage patient to ask questions

Have family member or third person present

during assessment of genitalia


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Children and Adolescents

Focus is on growth and development, sensory screening, dentalexamination, and behavioral assessment

Gain childs trust- talk and play with the child first

Perform parts of the examination that can be done visually before

actually touching the child Children feel safer during an examination if you move to the

periphery and then to the central part of the body

Parents may feel they are being judged- offer support duringexamination

Call children by their preferred name and address parents as Mr.and/or Mrs.

Open-ended questions allow parents to share more

Adolescents have a right to confidentiality


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Older Adults

Allow extra time

Plan the history and examination, taking into account the

older adults energy level, physical limitations, pace and

adaptability

Take advantage of natural opportunities for assessment

(ex. During bathing, grooming)

Sequence examination to keep position changes to a

minimum

Be sure an examination includes review of mental status


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Cultural Considerations

Use open-ended questions

Communicate respect through proper used of distance,attention, eye contact, tone, and loudness of voice

Use a professional interpreter Allow time for responses

Work with the established family hierarchy

Develop knowledge of words that are offensive to the

culture Use gender-congruent providers to perform the physical

assessment


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Assessment Techniques

Inspection

Palpation

Percussion

Auscultation

Olfaction


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Inspection

Visual examination of body parts

Inspect size, shape, color, symmetry,

position, and the presence of abnormalities

Compare with opposite side of the bodyAsk patient for further information regarding

abnormalities


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Palpation

Can make sensitive measurements of specific physicalsigns, including resistance, resilience, roughness,texture, temperature, and mobility

Palpate sensitive areas last Apply pressure slowly, gently, and deliberately,

depressing about 1 cm

Light palpation vs. deep palpation

Light palpation- tender areas

Deep palpation- examine condition of organs


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Percussion

Involves tapping the body with the fingertips toevaluate the size, borders, and consistency of bodyorgans and to discover fluid in body cavities

Nurse strikes the bodys surface with a finger to

create a vibration, and sound waves are heard aspercussion tones arising from vibrations in bodytissues


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Auscultation

Listening to soundsproduced by the body with astethoscope

Place stethoscope directlyon skin- not over clothing


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Characteristics of Sound

Note the following characteristics-

Frequency- number of sound waves generated per

second by a vibrating sound (higher the frequency, the

louder the pitch)

Loudness- amplitude of a sound wave (loud or soft)

Quality- sounds of similar frequency and loudness from

different sources (blowing, gurgling, etc.)

Duration- length of time sound vibrations last (short,

medium, or long)


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Olfaction

Use of sense of smell to

detect abnormalities


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GENERAL SURVEY

Overall appearance

First impression

Vital signs, height, weight, age, body

frame, hygiene, dressPosture, prosthesis, devices (cane, etc)


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INTEGUMENTARY

Color - skin, oral mucous

membranes,nailbeds, ear lobes,

conjunctiva

Turgor - elastic, brisk

Moisture, temperature - dry, warm

Integrity - skin intact, lesions, rashes,

scalp

IV sites Dressings, binders, etc.


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Skin Color Variations

Bluish

Nail beds, lips, mouth, skin

Increased amount deoxygenated hemoglobin

Heart or lung disease, cold

Pallor Face, conjunctivae, nail beds, palms of hands

Reduced amount oxyhemoglobin

Anemia

Loss of pigmentation Patchy area on skin over face, hands, arms


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Skin Color Variations

Yellow-orange

Sclera, mucous membranes, skin

Increased deposit of bilirubin in tissues

Liver disease, destruction of red blood cells

Red (erythema)

Face, area of trauma, sacrum, shoulders

Increased visibility of oxyhemoglobin caused by dilation orincreased blood flow

Fever, trauma, blushing, alcohol intake

Tan-brown

Areas exposed to sun

Increased amount of melanin

Suntan, pregnancy


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Macule

Flat, nonpalpable

change in skin color,

smaller than 1 cm


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Papule

Palpable, circumscribed, , solid elevation in skin,

smaller than 0.5 cm


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Nodule

Elevated solid mass,

deeper and firmer than

papule, 0.5-0.2 cm


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Tumor

Solid mass that may extend deep through

subcutaneous tissue, larger than 1-2 cm
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Wheal

Irregularly shaped,

elevated area or

superficial localized

edema, varies in size


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Vesicle

Circumscribed elevation of skin, filled with serous

fluid, smaller than 0.5 cm


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Pustule

Circumscribed elevation

of skin similar to vesicle

but filled with pus,

varies in size


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Ulcer

Deep loss of skin surface that may extend to dermis

and frequently bleeds and scars, varies in size


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Atrophy

Thinning of skin with

loss of normal skin

furrow, with skin

appearing shiny and

translucent, varies insize


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Head & Nails

Inspect and palpate

Hair and scalp

Alopecia

Nails Clubbing

Capillary refill


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Eyes

Eyelids for position and lesions

Conjunctiva- color

Cornea- opacity or scratch

PERRLA

Pupils equal, round, reactive to light and

accomodation

Snellen chart- visual acuity


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Nose

Inspect nares- drainage, patency


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Ear, Mouth, Pharynx

Inspect and palpate

Test auditory acuity

Whispering

Weber

Rinne

Inspect teeth

Tartar

Gingivitis

Dentures

Inspect tonsils, uvula


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Neck

Inspect for JVD

Palpate for lymph nodes

Evaluate ROM

Check swallowing


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NEUROLOGICAL

LOC, behavior, appearance, memory

Speech

Pupils - PERRLA

Pain Sleep


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ABNORMAL LUNG

SOUNDS

Normal Lung Sounds

RESPIRATORY


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RESPIRATORY

Respiratory rate (adult 12-20), rhythm Chest shape, symmetry

Accessory muscle use

Breath sounds - crackles (rales), gurgles,

wheezes (whistling), friction rub (rubbing,

grating sounds) Cough- productive, unproductive, amount and

color of secretions

Oxygenation and color of skin- pale, cyanotic,

mottled,

Respiratory treatment, incentive spirometer

LUNG AUSCULTATION


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LUNG AUSCULTATION

Left to Right Comparison


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CARDIOVASCULAR

Heart sounds- rate and rhythm, regular, irregular,extra sounds, murmur

Pulses- present and equal, strong or bounding, weak

or faint

Edema pitting or nonpitting, localized or anasarca,dependent or independent

JVD

Capillary refill - fingers / toes


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Auscultation

APE to Man

S1

S2

S3

S4

Pericardial

friction rubs

Murmurs


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Grading Intensity of Murmurs

Grade I Barely audible in a quiet roomGrade II Quiet but clearly audible

Grade III Moderately Loud

Grade IV Loud, associated with a thrill

Grade V Very loud, audible withstethoscope off chest, thrilleasily palpable

Grade VI Very loud, audible with

stethoscope off chest;palpable thrill


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S1

Closure of mitral & tricuspid valves

Signals the beginning of systole

Loudest at apex


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S2

Closure of aortic & pulmonic valves

Loudest at the base

S3


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S3

Ken-tuck-y

Occurs early in diastole during the rapid fillingphase

Heard best with bell of stethoscope

Loudest at apex or left lower sternal borderwith person in left lateral position

Pathologic in adults

Decreased compliance of the ventricles

Volume overload

S4


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S4

Ten-se-se

Occurs when atria contract late in diastole Heard immediately before S1

Heard best with bell of stethoscope

Loudest at apex with person in left lateral position

Pathologic Decreased compliance of the ventricle

Systolic overload

Systemic hypertension


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Pericardial Friction Rub

Heard best withdiaphragm of

stethoscope

Have person sitting up

& leaning forward withbreath held

Heard loudest at apex &

left, lower sternal border


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Murmurs

Caused by turbulent blood flow

High flow rate through a normal/abnormal orifice

Forward flow through a constricted or irregular orifice

into a dilated vessel or chamber

Backward or regurgitant flow through an incompetentvalve, septal defect or PDA

Identify timing, loudness, pitch, pattern,

quality, location & radiation


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Location

Describe the area of maximum intensity

Note valve or intercostals spaces


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Pitch

Depends on the pressure and the rate ofblood flow

Described as high, medium or low


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Quality

Described as musical, blowing, harsh orrumbling


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Radiation

May be transmitted downstream in thedirection of blood flow

May be heard in another place on the

precordium, neck, back or axilla


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Jugular Venous Pressure

Jugular veins emptyunoxygenated blooddirectly into the superiorvena cava

Reflect filling pressures& volume changes inright side of heart

Evaluate with patient at45-degree angle


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GASTROINTESTINAL

Diet type, percent Height, weight, body frame Inspect abdomen for symmetry Bowel sounds- present or absent, hyperactive or

hypoactive, audible in all quadrants

Abdomen distended, tender, hard or soft Last bowel movement (LBM) Bowel diversions - ostomy Nausea, vomiting (N/V) Feeding tubes


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Auscultation Bowel Sounds

Bowel sounds

Listen in each

quadrant

Normal: gurgles

every 5-15 sec

Decreased:

obstructions

Increased:

peristalsis


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Light Palpation

Abdominal tenderness

Rigidity

Masses

Peritoneal irritation

l i


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Deep Palpation

Masses

Rebound tenderness

Liver

Spleen

Kidneys

Aorta

GENITOURINARY


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GENITOURINARY

REPRODUCTIVE

I & O

Urine characteristics color, amount,

odor

Urinary diversions - catheter, stents, tubes Urinary difficulties- dysuria, hematuria

Menstruation - reproductive surgeries

Breasts, genitalia, discharges

MUSCULOSKELETAL


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MUSCULOSKELETAL

Motor function

Strength

ROM: MAE x4CSM: circulation, sensation,

movement

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