Physical Assessment

• Disease


  Disturbance of a structure or function of the body; a pathologic condition of the body
• Disease


  • Recognized by a set of signs and symptoms
  • Nurses do not make a medical diagnosis
  • Nurses assess signs and symptoms to formulate a nursing diagnosis
• Signs


  Objective data as perceived- observed by the examiner
• Symptoms


  Subjective data- what the patient says
• Infection


  Caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites that produce tissue damage
• Inflammation


  Protective response of the body tissues to irritation, injury, or invasion by disease-producing organisms

  
• Signs of inflammation


  • Swelling, pain, warmth, and redness of the affected area

  
• Acute disease


  Begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment
• Chronic disease


  Develops slowly and persists over a long period, often for a person's lifetime
• Exacerbation


  Recurrence of symptoms many times recovery not to pre-exacerbation levels
• Risk factors do not necessarily mean that a person will develop a disease condition, only that the chances of disease are increased
• Categories of risk factors

  • Genetic and physiologic
  • Age
  • Environment
  • Lifestyle
• Inflammation defense


  • Erythema (redness)
  • Edema (swelling)
  • Increased blood flow to area
  • Capillary walls more permeable
  • Damaged tissue enables WBC and plasma to move to affected area
  • WBC digest microorganism
  • Pain
  • Loss of function
  • Imposes a period of rest

  
• Assessment


  Process of making an evaluation or appraisal of the patient's condition
• Medical assessment


  • Physical examination is conducted by the health care provider
  • Nurse is often expected to carry out certain functions
• Nurse's role in medical assessment

  • Explain what will occur
  • Equipment and supplies
  • Preparing the exam room
  • Assisting with equipment
  • Preparing the patient
  • Collecting specimens
• Nursing assessment


  • Performing the nursing physical assessment
  • Use of the senses of touch, smell, sight, and hearing
  • Always wash your hands
  • Documentation of the interview utilizing facility forms
  • Telephone consultation
• Items needed for nursing physical assessment

  • Penlight
  • Stethoscope
  • Blood pressure cuff
  • Thermometer
  • Gloves
  • Tongue blade
• Head-to-toe assessment: General appearance


  • General observation of client
  • Evaluate behavior, mood, affect
  • Assess posture and body structure
  • Hygiene, grooming, dress, and odors
  • Check height, weight, and BMI
  • Gait – use of assistive devices
  • Vital signs
• Common postural abnormalities


  • Kyphosis
  • Lordosis
  • Scoliosis
• Physical assessment techniques


  • Inspection
  • Percussion
  • Palpation
  • Auscultation
• Inspection


  Visual examination
• Palpation


  Sense of touch, use fingertips- more sensitive
• Auscultation


  Listening to sounds produced, use the ears, direct (use unaided ear), indirect (use stethoscope)
• Initiating the nurse-patient relationship


  • Introduce yourself and state name, position, and purpose of the interview
  • Give an estimate of time
  • Ask if the patient has any questions and answer them appropriately
  • Communicate trust and confidentiality
  • Convey competence and professionalism
• The interview

  • Project relaxed, unhurried manner
  • Conduct in a quiet, private, well-lighted setting
  • Convey feelings of compassion and concern
  • Determine by what name the patient wishes to be addressed
  • Nurse should have an accepting posture, relaxed, eye level, and pleasant facial expression
• Nursing health history


  • Initial step in assessment process
  • Information on patient's wellness, changes in life patterns, sociocultural role, and mental and emotional reaction to illness
• Biographic data


  • DOB
  • Gender
  • Address
  • Religious practices
  • Occupation
• Reasons for seeking health care

  • Chief complaint
  • Document information in patient's own words
• Health history


  • Present illness or health concerns
  • Habits and lifestyles, medicines, allergies, etc.
  • Past health history, surgeries, past hospitalization
• Family history


  • Immediate and blood relatives
  • Includes health or cause of death, as well as history of illness
  • Provides information about family structure, interaction, and function
• Environmental history


  Provides data about patient's home environment
• Psychosocial and cultural history

  • Data about primary language, cultural groups, educational background, attention span, and developmental stage
  • Coping skills and family support
  • Identify major beliefs, values, and behaviors when treating patient
• Review of systems (ROS)


  Systematic method for collecting data on all body systems
• When to perform a physical assessment


  • Perform assessment as soon after admission as possible
  • Initial assessment is done by an RN
  • Ongoing assessment is the responsibility of LPN and RN
• Nursing physical assessment


  • Normally admission assessment- RN completes
  • Head-to-toe, health history, information pertaining to level of functioning, systemic and thorough
  • Beginning of each shift
  • Helps to identify changes
• Focused assessment


  • Concentrated on a particular part of the body
  • Done during shift where signs and symptoms assessed to determine intervention
• Focused assessment


  • Based on complaints by client, nurse's observations, and client's presenting problem
  • Used to evaluate nursing interventions and medical therapies
• Neurologic assessment


  • Level of consciousness (LOC)
  • Orientation x 3 (time, place, and person)
  • Orientation X 4 (time, place, person, and purpose)
  • PERRLA-pupils-equally-round-reactive-light-accommodation
  • Normal eye constrict quickly when light is applied
  • Accommodation - Pt. follows finger when it is brought in toward the directly between the eyes
  • Pupils- direct and consensual response
• Focused assessment


  Concentrated on a particular part of the body