Download - Physical assessment
![Page 1: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/1.jpg)
Physical Assessment
Acute Care Nursing Program 2005
![Page 2: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/2.jpg)
Outline
Assessment Process Respiratory Assessment Cardiac Assessment Neurological Assessment Abdominal Assessment Neurovascular Assessment
![Page 3: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/3.jpg)
Assessment Process
Inspection Palpation Percussion Auscultation
Gather information – base line Record trends
![Page 4: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/4.jpg)
Respiratory Assessment
Inspection Palpation Percussion Auscultation
![Page 5: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/5.jpg)
Respiratory Assessment
Inspection General
appearance, colour
Scaring Symmetry Shape Position of trachea Work of breathing
Rate Rhythm Cough –
productive?
![Page 6: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/6.jpg)
Respiratory Assessment
Palpation Chest excursion Tactile and vocal fremitus
![Page 7: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/7.jpg)
![Page 8: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/8.jpg)
Respiratory Assessment
Percussion Normal – resonant, hollow sound Solid - dull Percussion is done in the intercostal
spaces Percussion is done both on the
posterior chest and lateral chest
![Page 9: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/9.jpg)
![Page 10: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/10.jpg)
Respiratory Assessment
Auscultation Systematic approach Note adventitious (extra)
Crackles Wheeze Friction rub
![Page 11: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/11.jpg)
Respiratory Assessment
![Page 12: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/12.jpg)
Cardiac Assessment
Inspection Palpation (Percussion) Auscultation
![Page 13: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/13.jpg)
Cardiac Assessment
Inspection JVP Oedema Colour
![Page 14: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/14.jpg)
Cardiac Assessment
Palpation Pulse Oedema Capillary refill Blood pressure
![Page 15: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/15.jpg)
Cardiac Assessment
Auscultation Normal
S1 S2
Abnormal S2 split S3 S4
![Page 16: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/16.jpg)
![Page 17: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/17.jpg)
Cardiac Assessment
![Page 18: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/18.jpg)
Neurological Assessment
Glasgow Coma Scale Cranial Nerves
![Page 19: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/19.jpg)
Glasgow Coma Scale
Assess neurological status Assessment of best response
Eyes Verbal Motor
![Page 20: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/20.jpg)
Glasgow Coma ScaleScor
eBest Eye Best Verbal Best
Motor6 ----------- ----------- Obeys5 ---------- Orientated Localises
pain4 Spontaneou
sConfused Withdraws
3 To speech Inappropriate Flexion
2 To Pain Incomprehensible
Extension
1 None None None
![Page 21: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/21.jpg)
Cranial Nerves
12 cranial nerves 3rd – 12th within brainstem
(Midbrain, Pons, Medulla)
![Page 22: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/22.jpg)
Cranial NerveFunction: Sensory Smell
Assessment: Recognition of
odor
IOlfactory
![Page 23: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/23.jpg)
Cranial NerveFunction: Sensory Information
from the retina
Assessment: Visual acuity
IIOptic
![Page 24: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/24.jpg)
Cranial NerveFunction: Motor Four of the six
extra-ocular muscles
Assessment: Response to
light Moves eye Elevates upper
eyelid
IIIOculomotor
![Page 25: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/25.jpg)
Cranial NerveFunction: Motor Controls the
oblique eye muscle
Assessment: Moves eye
right, left, up and down
IVTrochlear
![Page 26: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/26.jpg)
Cranial NerveFunction: Mixed Three sensory
Corneal Reflex One motor
Assessment: Normal facial
sensation Blinks Clenches teeth
VTrigeminal
![Page 27: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/27.jpg)
Cranial NerveFunction: Motor Lateral rectus
muscle of eye
Assessment: Moves eye
laterally
VIAbducens
![Page 28: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/28.jpg)
Cranial NerveFunction: Mixed Sensory
Tongue Motor
Eyelids
Assessment: Elevates
eyebrows Puffs checks Recognizes
tastes
VIIFacial
![Page 29: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/29.jpg)
Cranial NerveFunction: Sensory Hearing
Assessment: Whisper in
each ear
VIIIVestibulocochle
ar
![Page 30: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/30.jpg)
Cranial NerveFunction: Mixed Sensory
Taste buds Motor
Gag reflex
Assessment: Taste testing Test gag
IXGlossopharynge
al
![Page 31: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/31.jpg)
Cranial NerveFunction: Mixed Motor branches
to the pharyngeal and laryngeal muscles
Viscera of the thorax and abdomen
Assessment: Same as IX
XVagus
![Page 32: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/32.jpg)
Cranial NerveFunction: Motor Innervates the
sternocleidomastoid and trapezius muscles
Assessment: Shrugs shoulders
XIAccessory
![Page 33: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/33.jpg)
Cranial NerveFunction: Motor Tongue
muscles
Assessment: Sticks out
tongue
XIIHypoglossal
![Page 34: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/34.jpg)
Abdominal Assessment
Inspection Auscultation Percussion Palpation
![Page 35: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/35.jpg)
![Page 36: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/36.jpg)
![Page 37: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/37.jpg)
Abdominal Assessment
Inspection Asymmetry Engorged veins Intestinal movements Lesions Scars Swelling
![Page 38: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/38.jpg)
![Page 39: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/39.jpg)
Abdominal Assessment
Auscultation Systematic Bowel sounds
![Page 40: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/40.jpg)
Abdominal Assessment
Percussion All four quadrants
Tympanic- air filled structures Dull – solid structures
Bowel Liver Bladder
![Page 41: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/41.jpg)
![Page 42: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/42.jpg)
![Page 43: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/43.jpg)
Abdominal Assessment
Palpation Light and Deep
Tenderness, guarding, rigidity Define organs Kehr’s sign McBurney’s point Murphy’s sign
![Page 44: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/44.jpg)
Neurovascular Assessment
Colour Temperature Capillary Refill Peripheral Pulses Swelling Movement Sensation
![Page 45: Physical assessment](https://reader036.vdocuments.us/reader036/viewer/2022062513/5562b908d8b42a595e8b481d/html5/thumbnails/45.jpg)
References A Practical guide to clinical assessment
http://medicine.ucsd.edu/clinicalmed/ Smith SF, Duell DJ & Martin BC, 2005,
Clinical Nursing Skills, Prentice Hall, New Jersey.