Physical Assessment

Acute Care Nursing Program 2005

Outline

Assessment Process Respiratory Assessment Cardiac Assessment Neurological Assessment Abdominal Assessment Neurovascular Assessment

Assessment Process

Inspection Palpation Percussion Auscultation

Gather information – base line Record trends

Respiratory Assessment

Inspection Palpation Percussion Auscultation

Respiratory Assessment

Inspection General

appearance, colour

Scaring Symmetry Shape Position of trachea Work of breathing

Rate Rhythm Cough –

productive?

Respiratory Assessment

Palpation Chest excursion Tactile and vocal fremitus

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

Respiratory Assessment

Auscultation Systematic approach Note adventitious (extra)

Crackles Wheeze Friction rub

Respiratory Assessment

Cardiac Assessment

Inspection Palpation (Percussion) Auscultation

Cardiac Assessment

Inspection JVP Oedema Colour

Cardiac Assessment

Palpation Pulse Oedema Capillary refill Blood pressure

Cardiac Assessment

Auscultation Normal

S1 S2

Abnormal S2 split S3 S4

Cardiac Assessment

Neurological Assessment

Glasgow Coma Scale Cranial Nerves

Glasgow Coma Scale

Assess neurological status Assessment of best response

Eyes Verbal Motor

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

Cranial Nerves

12 cranial nerves 3rd – 12th within brainstem

(Midbrain, Pons, Medulla)

Cranial NerveFunction: Sensory Smell

Assessment: Recognition of

odor

IOlfactory

Cranial NerveFunction: Sensory Information

from the retina

Assessment: Visual acuity

IIOptic

Cranial NerveFunction: Motor Four of the six

extra-ocular muscles

Assessment: Response to

light Moves eye Elevates upper

eyelid

IIIOculomotor

Cranial NerveFunction: Motor Controls the

oblique eye muscle

Assessment: Moves eye

right, left, up and down

IVTrochlear

Cranial NerveFunction: Mixed Three sensory

Corneal Reflex One motor

Assessment: Normal facial

sensation Blinks Clenches teeth

VTrigeminal

Cranial NerveFunction: Motor Lateral rectus

muscle of eye

Assessment: Moves eye

laterally

VIAbducens

Cranial NerveFunction: Mixed Sensory

Tongue Motor

Eyelids

Assessment: Elevates

eyebrows Puffs checks Recognizes

tastes

VIIFacial

Cranial NerveFunction: Sensory Hearing

Assessment: Whisper in

each ear

VIIIVestibulocochle

ar

Cranial NerveFunction: Mixed Sensory

Taste buds Motor

Gag reflex

Assessment: Taste testing Test gag

IXGlossopharynge

al

Cranial NerveFunction: Mixed Motor branches

to the pharyngeal and laryngeal muscles

Viscera of the thorax and abdomen

Assessment: Same as IX

XVagus

Cranial NerveFunction: Motor Innervates the

sternocleidomastoid and trapezius muscles

Assessment: Shrugs shoulders

XIAccessory

Cranial NerveFunction: Motor Tongue

muscles

Assessment: Sticks out

tongue

XIIHypoglossal

Abdominal Assessment

Inspection Auscultation Percussion Palpation

Abdominal Assessment

Inspection Asymmetry Engorged veins Intestinal movements Lesions Scars Swelling

Abdominal Assessment

Auscultation Systematic Bowel sounds

Abdominal Assessment

Percussion All four quadrants

Tympanic- air filled structures Dull – solid structures

Bowel Liver Bladder

Abdominal Assessment

Palpation Light and Deep

Tenderness, guarding, rigidity Define organs Kehr’s sign McBurney’s point Murphy’s sign

Neurovascular Assessment

Colour Temperature Capillary Refill Peripheral Pulses Swelling Movement Sensation

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.