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Physical Assessment

By Thelma Cook,2014-10-17 14:12
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Physical Assessment

Physical Assessment

    Week Two

    Wanda Dooley

;Last Week

    ;Equipment and positions for physical exam

    ;Parts of health assessment (subjective and objective)

    ;Subjective = CC, PMH, ROS, etc.

    ;Objective begins with General Survey and proceeds with head-to-toe exam (Box 28-1) ;HEENT, chest landmarks, breath sounds

    ;Lots of terminology

    Heart Terminology

    ;Same order for techniques (Inspection, Palpation, Percussion, Auscultation) ;Precordium - area on chest overlying the heart

    ;Heart lies behind and just left of sternum (usually)

    ;A small portion of right atrium extends to right of sternum

    ;Upper portion of heart (atria) is called the base and points posteriorly ;Lower portion of heart (ventricles) is the apex and points anteriorly apex of left ventricle touches chest wall near 5th ICS at MCL

    ;PMI: where apex of left ventricle touches anterior chest wall near LMCL at 4th to 5th ICS; Usually felt just below left nipple

    Heart Terminology

    ;Lift or heave: overly forceful ventricular contraction that can be felt on precordium with palm

    ;S (lub) - produced by closure of mitral and tricuspid valves (A-V valves) 1

    ;Valve closure is almost simultaneous, so only one sound is heard

    ;S (dub) - produced by closure of aortic and pulmonic valves (semilunar valves) 2

    ;Valve closure may be less simultaneous, so sometimes hear physiological splitting of S (split S) 22

    Heart Terminology

    ;Heart sounds can be auscultated anywhere over precordium, but are heard best at defined listening points (auscultory landmarks)

    ;Murmur turbulent sound made as blood flows across a stiff valve, leaks across an an incompetent valve; or leaks through a septal defect

    ;Most murmurs are d/t valve disease; some are from septal defects

Systole - contraction of the ventricles; Normally silent interval that begins with S and 1;ends with S2

    ;Diastole - period when ventricles are relaxed; Normally silent period that starts with with S and ends with S(Figure 28-62 and Table 28-9) 21

    ;S ventricular gallop; fainter sound, right after S; heard best with pt on L side (lub 32

    dub eeh or Ken-tuck-y)

    ;S3 is normal in children and young adults, but is abnormal in older adults and may indicate heart failure

    ;S atrial gallop; heard right before S1 (ta lub dub or Ten-ne-see 4

Auscultory Landmarks

    ;Review anatomy*

    ;Aortic area - 2nd ICS, RSB

    ;Pulmonic area - 2nd ICS, LSB

    ;Erb’s point – midway b/w pulmonic & tricuspid

    ;Tricuspid area - 5th ICS, LSB

    ;Mitral area - 5th ICS, LMCL (aka PMI, apex)

    ;Always Phone Early To Mother

    ;See table 29-9, p. 591 and figure 29-59, p. 590

    Auscultory Landmarks

    Cardiovascular Assessment

    ;Inspect and palpate precordium

    ;Auscultate all four (or five) anatomic sites with diaphragm and then with bell

    ;Begin auscultation by checking heart rate and rhythm

    ;Listen 30-60 seconds over apex, then check other sites

    ;Carotid arteries - palpate VERY carefully and only one at a time; auscultate with bell ;Jugular veins - inspect for distention in semi-fowler’s position

    ;Peripheral pulses - palpate on both sides of body simultaneously (except carotids) Central Vessel Assessment

    ;Central Vessels

    ;Usually assessed during examination of neck

    ;Carotid arteries provide oxygenation to the head and neck, and are the only source of oxygen for the brain

    ;Carotid pulses correlate well with central aortic blood pressure, so when BP is so low that peripheral pulses are weak or not palpable, carotid arteries are still be palpable ;Palpate, auscultate - if bruit heard, palpate for thrill

    ;Jugular veins drain blood from head to SVC (which carries blood to right side of heart) ;External jugulars are visible; internal jugulars are deeper and lie along the carotids ;Normally, external jugular veins distend and become visible when a person lies down, but are flat and not visible when a person is upright

    ;Nurses can assess right sided heart function by palpating and visualizing external jugular veins - bilateral JVD may indicate right sided heart failure

    CV and PV Assessment

    ;Scale for measuring peripheral pulse volume

    ;+0 = absent or not discernible

    ;+1 = thready, weak, difficult to feel

    ;+2 = normal, detected readily, obliterated by strong pressure

    ;+3 = bounding, difficult to obliterate

    ;Reasons for using specific pulse points: radial, temporal, carotid, apical, brachial, femoral, popliteal, posterior tibial, pedal; know where each pulse is located PV Assessment

    ;Assess for peripheral edema, document location and grade

    ;Assess capillary refill time (blanch test, capillary fill time, CFT) - should be <3 seconds

    ;Assess peripheral perfusion (blood flow) - color, temperature, edema, hair pattern, skin changes, phlebitis, CFT

    ;Homan’s sign – pain in calf with passive dorsiflexion of foot

    Assessment of Abdomen

    ;Four quadrants and nine regions: p. 592-593: figures 28-73, 74, and 75 ;Also still use landmarks from thorax

    ;Other landmarks: umbilicus, costal margins, xiphoid process, symphysis pubis, midline

    ;Know where organs are located (box 28-29 and 28-30)

    Abdominal Landmarks

    Abdomen

    ;Change from usual order of techniques (IPPA); For abdomen inspect and auscultate BEFORE touching

    ;Inspect - masses, distention, pulsations, scars, contour

    ;Auscultate

    ;Bowel Sounds: use flat diaphragm in all 4 quadrants of abdomen frequency of BS is

    R/T time of last meal (loudest when patient is hungry)

    ;Vessels: use bell over aorta, renal arteries, and ileac arteries to assess for bruits Abdominal Vessels

    Bowel Sounds

    ;Active (normal) BS: gurgle every 5-10 seconds (document as + BS or active BS) ;Hypoactive BS: quiet, infrequent gurgles about once/min; indicates decreased motility ;Hyperactive BS - frequent, loud gurgles about every 3 seconds; aka borborygmi - indicates increased motility

    ;Absent BS requires listening for 3 to 5 minutes; Indicates absence of bowel activity

Abdomen

    ;Percussion and palpation - learned with practice; Used to assess size and shape of organs or masses and to assess pain (ex. RLQ rebound tenderness)

    ;Most commonly palpated abdominal organs by nurses: bladder and uterus; nurses also palpate for pain/tenderness

    ;Need to know where underlying organs are

    Genitalia, Rectum, Anus

    ;Inspect - hair, critters, lesions, swelling, lumps/masses, discharge, hemorrhoids, prolapse

    ;Pubic hair development in girls, and pubic hair plus external genital development in boys is part of the Tanner Staging Scale for sexual maturation

    ;Palpate - inguinal lymph nodes and femoral pulses, check for hernia ;Testicular exam - testes should be smooth and symmetrical; Always instruct male clients aged 15 and beyond to do TSE monthly (See Teaching box on p. 988) Genitalia, Rectum, Anus

    ;Assess sexual orientation, knowledge of STDs, HIV, contraception, safer sex (risk factors)

    ;Chapter 38 covers sexual health

    ;Digital rectal exam (DRE) - may be done to examine prostate, assess for impaction, obtain stool specimen

    ;Positions - lithotomy, genupectoral, Sims, dorsal recumbent

    ;In most practice settings, nurses perform only inspection of the external genitals and inguinal area, but DRE is done frequently by nurses in geriatric settings Musculoskeletal System

    ;Muscles, bones, and joints

    ;Thoroughness of exam depends on client’s age, as well as presenting complaint

    ;Inspection, palpation, ROM

    ;Inspect muscle size/bulk, contractures, tremors, skeletal deformities, joints (swelling, redness, warmth)

    ;Palpate muscle tone, strength

    ;ROM assess range and strength

    ;See Box 28-35, p. 601 on testing and grading muscle strength

    ;WNL = 35 (5-strongest, 3-weaker but still wnl)

    Musculoskeletal System

    ;Much of patient’s movement was assessed during previous portions of the exam

    ;Always compare left to right, if both sides are involved, you need to evaluated compared with yourself or other normal people

    ;MS assessment is a good time to assess osteoporosis risk factors and do teaching on exercise and calcium intake, preventing sports injuries, etc.

;Lifespan Considerations

    ;Examine for scoliosis in people over 12 years (10-12 yrs)

    ;Palpate clavicles of newborn and assess hips for dislocation

    ;Wide variation in normal age-related muscle mass loss; assess risk of falls; safety teaching due to loss of reaction time and decreased muscle strength; maintenance of mobility and prevention of decreased mobility

Neurologic System

    ;Thorough neuro exam takes 1 to 3 hours, so routine screening is done to see who warrants more intensive exam

    ;Includes: mental status exam, cranial nerves, reflexes, motor function, and sensory function

    ;Parts of the neuro exam are done in conjunction with the rest of the assessment Mental Status

    ;Observed throughout the entire assessment

    ;General appearance, dress, hygiene, movement, behavior, facial expression, speech, affect

    ;General cerebral functions include intellectual (cognitive) as well as emotional (affective) functions

    ;Language - aphasia is a defect d/t disease or injury of the cerebral cortex that interferes with clients ability to express himself and/or comprehend others (verbal, written, or both) (do not confuse with aphagia)

    ;Aphagia is a GI problem

    ;Aphasia is a speech or communication problem

    Mental Status

    ;LOC and orientation - normal response is A&O x3 (person, place, time) ;LOC is a continuum from comatose to fully alert

    ;Glasgow coma scale: alert person scores 15, comatose person scores < 7 ;Tests eye response, verbal response, and motor response

    ;GCS is in Table 28-10, p. 613

    ;Attention span and calculation - tests ability to concentrate: serial 7’s or serial 3’s

    ;Memory - immediate recall (lists); Recent memory (how did client get to clinic), remote (recall an event from 5+ years ago)

    Mental Status

    ;Are thought processes logical and organized?

    ;Suicide or homicide ideation requires immediate reporting (this is one of the few times it is legally ok to break patient confidentiality - to protect the patient or another from harm)

    ;MMSE - Mini Mental Status Exam

    Cranial Nerves

    ;Table 28-11, p. 614: On Old Olympia’s Towering Top A Finn And German Viewed Some Hops

    ;CN’s aren’t usually assessed in isolation - are done with rest of exam (the vision exam

    tests 4 different cranial nerves)

    ;Visual acuity tests CN 2 (also visual fields)

    ;Checking EOMs tests CN 3, 4, and 6

    ;Pupil response tests CN 3

    ;Some cranial nerves are sensory nerves, some are motor nerves, some are both ;Some Say Mind Matters, Some Say Body Matters, But Some Say Big Brains Matter Most

    Cranial Nerves

    ;Olfactory aromas

    ;Optic - visual acuity (Snellen) & visual fields

    ;Oculomotor - pupil response, EOMs

    ;Trochlear EOMs

    ;Trigeminal - sensation to cornea and side of face (feel wisp of cotton); muscles of chewing (clench teeth)

    ;Abducens - EOMs

    Cranial Nerves

    ;Facial - expression (smile, frown), taste on anterior tongue (sugar, lemon juice) ;Auditory vestibular branch = balance (Romberg test); cochlear branch = hearing (whisper test, tuning fork tests)

    ;- Romberg: evaluates balance - stand with feet together, arms at sides, ask pt to close eyes and you observe - a little sway is normal

    ;Glossopharyngeal - swallow and gag (gag, move tongue side to side & up and down) and taste on posterior tongue

    Cranial Nerves

    ;Vagus - throat sensation and vocal cords (assessed with CN 9 - gag, swallow, listen to voice quality)

    ;Spinal Accessory - head movement (turn head against resistance) and shoulder shrug (shrug against resistance)

    ;Hypoglossal - tongue protrusion (assessed with CN 9 and 10 - stick out tongue and move side to side)

    Reflexes

    ;Reflex is an automatic response to a stimulus (not voluntary or conscious) ;Deep tendon reflex (DTR) is activated when a tendon is stimulated (tapped) and its associated muscle contracts

    ;The quality of a reflex varies among individuals and varies with age (less intense with age)

    ;Graded on a scale from 0 to 4, normal DTR = 2 (Box 28-36, p. 605) Reflexes

    ;Different DTRs test different levels of the spinal cord

    ;RNs check DTRs in ER, ICU, and L&D

    ;Plantar or Babinski reflex - normal response to is to curl the toes downward ;Infants spread the toes apart - called a positive Babinski

    ;A positive Babinski is abnormal at any other age

    Babinski Plantar Reflex

    Motor Function

    ;Evaluates proprioception and cerebellar function

    ;Proprioceptors are sensory nerve terminals in the muscles, joints, tendons, and internal ear that provide information about movements and the position of the body; Pts with a proprioception defect must watch their own leg or arm movements to see where their limbs are

    ;Cerebellum helps control posture, helps make body movements smooth and coordinated, controls skeletal muscles to maintain equilibrium (DWI tests assess cerebellar function)

    Motor Function

    ;Gross motor function and balance

    ;Gait, Romberg, stand on one foot, heel-toe walking, toe walking, heel walking ;Only done as needed: usually do Romberg plus one other

    ;Fine motor function

    ;Finger to nose with eyes closed, heel down shin, rapid alternating movements: hands on thighs, finger between nose and examiner’s finger, thumb to fingers. Done only as

    needed

    Sensory Function

    ;Patient’s eyes are closed for all tests

    ;Light touch sensation

;Sharp/dull

    ;Warm/cold

    ;Kinesthetic sense (position sense)

    ;Tactile discrimination (one point vs two points) ;Stereognosis keys, coins, paper clips, letters on palm

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