Download - Physical assessment
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Assessment
Diagnosis
PlanningImplementation
Evaluation
HEALTHCARE PROCESS
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It is the FIRST STEP of the Health Care Process. The following are its key components: Health Interview Physical Examination Laboratory or Diagnostic Examination Records Review
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A systematic way of collecting objective data from a client using the four examination techniques in order to assess or identify current health status. Different Approaches: Cephalocaudal Proximodistal Mediolateral Outer to Inner /External to Internal
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Obtain physical data about the client’s functional abilities Supplement, confirm, or refute data obtained in the client’s health history Obtain data that will help the nurse establish diagnoses and plan the client’s care. Evaluate the physiologic outcomes of health care and thus the progress of a patient’s health problem To identify areas for health promotion and disease prevention
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METHODS OF EXAMINATION
I.P.P.A. Technique
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Assess moisture, color and texture of the body surfaces, as well as shape, position, size, color, and symmetry of the body.
Visual examination of the patient done in a methodical, deliberate, purposeful, and systematic manner.
INSPECTION
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Assess temperature; turgor; texture; moisture; vibrations; position, size, shape, consistency and mobility of organ or masses; distention; pulsation; and the presence of pain upon pressure(tenderness)
The use of hand to touch and feel the patient’s skin, organs, mass, and other delineated structures in the body
PALPATIONExamination of the body using the sense of touch.
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Palmar surfaces of the examiner's fingertips and finger pads are used for discriminatory sensation, such as texture, vibration, presence of fluid, or size and consistency of a mass
The dorsum, or back of the hand, is used to assess surface temperature.
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Light palpation, light pressure is applied by placing the fingers together and depressing the skin and underlying structures about 1/2 inch (1 cm).
Use to check muscle tone and to assess for tenderness
LIGHT PALPATION
Place the hand with fingers together parallel to the skin surface or area being palpated, while moving the hand in circle.
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Deep palpation is used with caution because pressure can damage internal organs. The skin and underlying structures are depressed about 1 inch (2 cm).
To identify abdominal organs and abdominal masses.
Two – handed deep palpation
place the fingers of one hand
on top of those of the other.
The top hand applies pressure
while the lower hand remains
relaxed to perceive the tactile
sensation.
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Deep Palpation using lower hand to support the body while the upper hand palpates the organ
Deep Palpation is done with two hands
(bimanually) or one hand.
Usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed
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PERCUSSION
Striking of the body surface with short, sharp strokes in order to elicit palpable vibrations and characteristic sound.
It is used to determine the location, size, shape, It is used to determine the location, size, shape, and density of underlying structures; to detect and density of underlying structures; to detect the presence of air or fluid in a body space; and the presence of air or fluid in a body space; and to elicit tenderness.to elicit tenderness.
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DIRECT PERCUSSION - Using one hand to strike the surface of the body
Jing Salaria, RN,MD
TYPES OF PERCUSSION
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INDIRECT PERCUSSIONUsing the finger of the one hand to tap the finger of the other hand.
Jing Salaria, RN,MD
plexor strikes the finger of the examiner’s other hand, which is in contact with the body surface being percussed (pleximeter- the middle finger of the nondominant hand).
TYPES OF PERCUSSION
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Percussion is used to access the location, shape, size, and density of tissues. (Left) The non-dominant hand is placed directly on the area to be percussed, and the middle finger is placed firmly on the body surface. (Right) The tip of the middle finger of the dominant hand strikes the joint of the middle finger of the opposite hand
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AAUSCULTATIONUSCULTATION
Listening to sounds produced within the body.
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Stethoscope bell and diaphragm. Use the diaphragm of the stethoscope to detect high-pitched sounds. The diaphragm should be at least 1.5 inches wide for adults and smaller for children. Hold the diaphragm firmly against the body part being auscultated. Use the bell of the stethoscope to detect low-pitched sounds. The bell should be at least 1 inch wide. Hold the bell lightly against the body part being auscultated.
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Introduce self to the client. Verify his identity. Explain the purpose why such procedure is necessary and how he could cooperate (i.e. positioning). Help him put on a clean gown and offer a bedpan or a urinal to empty his bladder. Ensure privacy by closing the doors or pulling the curtains around him. Invite a relative or a significant other to stay with the client, as necessary.
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Provide adequate lighting. Gather the equipment:
height chart, weighing scale, Snellen’s chart, penlight, card board, sterile gloves, tongue depressor, 4x4 Gauze, tuning fork, stethoscope, wrist watch, tape measure, marker/pencil, record sheet & waste receptacle.
Ensure the examination table is at a comfortable working height. Perform hand hygiene.
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Materials Needed
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Position and drape the client
appropriately
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STANDING = assessment of posture, gait & balance
DORSAL RECUMBENT= used in patient having difficulty maintaining supine position
SITTING = used to take vital signs
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SUPINE
SIM’s = assessment of rectum and vagina
PRONE = assessment of hip and posterior thorax
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LITHOTOMY = assessment of female rectum and vagina.(for a brief period only)
KNEE-CHEST= assessment of rectal area (for briefperiod only)
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SALIENT POINTS:
Subjective data should be documented in patient’s own words.
Objective data should be specific. No generalizations and judgmental phrases
Data gathered in the nursing health history may be confirmed or refuted by the nurse during the interview or the physical assessment
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PROCEDUREI. Obtain vital signs & anthropometric measurement
(height/weight).
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PROCEDUREI. Obtain vital signs & anthropometric measurement
(height/weight).
NOTE: Given: IBW= A-B where, A= ht. in cm -100
B= (A) x 0.10 C= (IBW) x 0.10
N Range = IBW-C (Lower Limit) = IBW+C (Upper Limit)
BMI= wt. in kg/ ht. in (m)2
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BMI Interpretation
<18 = Underweight18-24 = Normal
>25 = Obese
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Example computation
A = 134.62 -100 = 34.62
B = 34.62 x 0.10 = 3.46
IBW = 34.62 – 3.46 = 31.16
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Example computation
To get the normal range: C = 31.16 x0.10 = 3.12
Upper limit = 31.16 + 3.12 = 34.28Lower limit = 31.16 – 3.12 = 28.04
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Example computation
BMI = 55 / (1.346)2 = 29.7 30
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II. Assess the General Appearance:A. Body build, height and weight in relation to age, lifestyle and healthB. Posture and GaitC. Over-all hygiene and groomingD. Body and breath odorE. Signs of distressF. Mood / AffectG. Quantity, Quality & Organization of SpeechH. Relevance & Organization of Thoughts
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Scoliosis Kyphosis Lordosis
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ASSESSMENT OF THE INTEGUMENTARY SYSTEM
• Skin• Nails • Hair• Scalp
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Part 1. Anatomical Parts of the Skin
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1. SKIN COLOR
Normal• Varies from light
to deep brown, from ruddy pink to light pink
Deviations from Normal• Pallor• Cyanosis• Jaundice• Erythema
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2. Skin Color UniformityNormal• Generally uniform
except in areas exposed to sun; areas of lighter pigmentation in dark skinned
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2. Skin Color Uniformity
Deviations • Hyperpigmentation
Birthmarks – abnormal distribution of the melanin
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2. Skin Color Uniformity
Deviations • Hypopigmentation
Vitiligo due to destruction of melanocytes in the area
Albinism – complete or partial lack of melanin
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3. Assess for Edema• Excessive accumulation of fluid in body tissues • Note the degree to which the skin remains
indented or pitted when pressed by a finger Edema scale
1+ = barely detectable2+ = indentation of less than 5 mm3+ = indentation of 5 to 10 mm4+ = indentation of more than 10 mm
ANASARCA
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4. Inspect, palpate, and describe skin lesions
• According to type/structure, color, number, distribution, locationTYPES:Primary skin lesions – abscess, ulcer, tumor,
and open woundSecondary skin lesion crusts, kelloids,
scars, etc.
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Primary and Secondary Primary and Secondary LesionsLesions
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PRIMARY SKIN LESIONS
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PRIMARY SKIN LESIONSPRIMARY SKIN LESIONS
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PRIMARY SKIN LESIONSPRIMARY SKIN LESIONS
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Cyst
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5. Observe and palpate skin moisture
• Done by touching or palpating the skin of the extremities
NormalNormal MoistMoist
DeviationsDeviations Excessively dryExcessively dry
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6. Palpate skin temperature
Normal• Uniform; within
normal range
Deviations• Generalized or localized;
hyperthermic or hypothermic
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7. Palpate Skin Turgor• Refers to fullness or elasticity• Indicative of status of hydration of the body.• Assessed by pinching the skin on an extremity.
NormalNormal When pinched, skin When pinched, skin
springs back to springs back to previous state in less previous state in less than than 3 seconds3 seconds
DeviationsDeviations Skins stays pinched or Skins stays pinched or
indented or moves back indented or moves back slowly.slowly.
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Note that this is not as valid in elderly people as in Note that this is not as valid in elderly people as in younger people because skin elasticity decreases younger people because skin elasticity decreases with age; thus, other parameters should be used, with age; thus, other parameters should be used, such as: I&O, daily weightsuch as: I&O, daily weight
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Let’s have a break…
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1. Inspect fingernail plate shape, curvature & angle
Normal– Colorless and a
convex curve.
– Angle between nail and nail bed: usually 160o
Deviations from Normal• Concave
• Clubbed fingernails (>180O) due to chronic tissue hypoxia
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Examples of Nail Abnormalities
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2. Inspect and palpate finger & toenail bed color
Normal• Highly vascular and
pink in light skinned; dark skinned may be brown or black
Deviations from N• Bluish or purplish
tinges; • Pale
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3. Inspect tissues surrounding nails
Normal• Intact epidermis
Deviations from N• Hangnails (paronychia =
ingrown nail)• Inflammation of
surrounding tissues
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4. Perform Blanch Test/Capillary refill test
Normal• Prompt return or pink
or usual color, less than 2-4 seconds
Deviations • Delayed return of pink
or usual color, usually >4 seconds
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(Skull and Face)
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Part 3. Structures of the Skull
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1. Inspect skull size, shape, proportion & symmetry
Normal• Round and is of normal
size or head circumference Normocephalic • In proportion w/ gross
body structure • Frontal, parietal and
occipital prominences;• Smooth skull contour
Deviations from Normal• Disproportionate• Asymmetric prominences• Increased head circumference
• Square-head• Bulging / depressed bone
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2. Palpate skull nodules or masses & depression
Normal• Smooth, uniform
consistency; absence of nodules/masses or depression
Deviations from Normal• Sebaceous cysts; local
deformities from trauma; masses; nodules
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3. Inspect facial featuresNormal• Symmetric facial
features;• Eye brow hair equally
distributed • palpebral fissures equal
in size; • symmetric nasolabial
folds
Deviations from N• Asymmetric features• Increased facial hair; thinning
of eyebrows; exopthalmos; moon face;
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4. Inspect eyes for edema and hollowness
Normal• No edema, eyes not
sunken
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4. Inspect eyes for edema and hollowness
Sunken eyes, cheeks and temples (indicative of dehydration, starvation, and illness)
Deviations• Periorbital edema
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5. Inspect symmetry of facial movements
Normal• Symmetric facial
movements
Deviations• Asymmetric facial
movements, drooping of lower eyelid and mouth; involuntary facial movement
Raise or lower both Raise or lower both eyebrowseyebrows
Blink both eyesBlink both eyesClose both eyes tightlyClose both eyes tightlySmile and show the Smile and show the
teethteethFrownFrownPuff the cheeksPuff the cheeks
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Assessing the Hair
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1. Evenness of growth of hair over scalp
Normal• Evenly distributed
Deviations from Normal• Patches of hair loss, i.e.
alopecia
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2. Hair thickness or thinnessNormal• Thick Hair
Deviations from Normal• Very thin hair (hypothyroidism)
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3. Hair Texture and Oiliness3. Hair Texture and Oiliness
NormalNormal Silky, resilient hairSilky, resilient hair
Deviations from NormalDeviations from Normal Brittle hair (poor nutrition)Brittle hair (poor nutrition) excessively oily or dry hairexcessively oily or dry hair
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Normal• No infection/
infestation
Deviations from Normal• Flaking, sores, lice, nits
4. Note presence of 4. Note presence of infection / infestationinfection / infestation