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Physical assesstment
Is a process by which a nurse obtains a data that describes a persons responses to actual or potential health problems which is analyzed to form pertinent diagnosis. Is a head to toe review of each body system that offers objective information about the client and allows the nurse to make clinical judgment.
1. INSPECTION
It is the use of ones senses of vision and smell to consciously observe the patient. It is also known as concentrated watching. It is a close, careful scrutiny; first of the individual as a whole and then of each body system.
2. PALPATION
It is the act of touching a patient in a therapeutic manner to elicit specific information. It follows and often confirms points you noted during inspection.
Palpation applies your sense of touch to assess these factors Texture Temperature Moisture Organ location and size Any swelling, vibration or pulsation Rigidity or spasticity Crepitation Presence of lumps or masses Presence of tenderness or pain.
A. LIGHT PALPATION
- it is superficial, delicate and gentle. - finger pads are used to gain information of the patients skin surface to a depth of approximately - 1 inch below the surface. - reveals information on skin texture and moisture; overt large or superficial masses; and fluid, muscle guarding and superficial tenderness.
B. DEEP PALPATION
-it can reveal information about the position of organs and masses, as well as their size, shape, mobility, consistency, and areas of discomfort. -uses the hands to explore the bodys internal structure to a depth of 1 to 2 inches or more. -most often used for the abdominal and male and female reproductive assessments.
PERCUSSION
It is the technique of striking or tapping the persons skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size and density of the underlying organ. These sounds also are diagnostic of normal and abnormal findings. The thorax and abdomen are the most frequently percussed location.
Four types of percussion techniques IMMEDIATE OR DIRECT PERCUSSION The striking hand directly contacts the body wall. This produces a sound and is used in percussing the infants thorax or the adults sinus areas. II. MEDIATE OR INDIRECT PERCUSSION It is used more often and involves both hands. The striking hand contacts the stationary hand fixed on the persons skin. This yields a sound and a subtle vibration. I.
I. Flatness (dull) bone and muscle II. Dullness (thud-like) liver, spleen, heart III. Resonance (hollow) air-filled lung / normal lung IV. Hyperresonance emphysematous lung V. Tympany stomach filled with gas (air)
4. AUSCULTATION
It is the act of active listening to the body organs to gather information on patients clinical status. includes listening to sounds that are voluntarily and involuntarily produced by the body such as the heart and blood vessels and the lungs and abdomen. Auscultated sounds should be analyzed in relation to their relative intensity, pitch, duration, quality, and location.
Nursing responsibilities
Nursing responsibilities
BEFORE
Always dress in clean professional manner, make sure you have your name pin or workplace identification. Remove all bracelets, necklaces, or earrings that can interfere during the physical assessment. Be sure your hair will not fall forward and obstruct your vision or touch to the patient. Ensure that all necessary equipment is ready for use and within reach. Introduce yourself to the patient. Enlist the patients cooperation by explaining what you are about to do, where it will be done, and how it may feel. Explain to the patient why you may be spending a long time performing one particular skill. Do medical hand washing . Position the patient as dictated by the body system being assessed. Warm all instruments prior to their use .
Nursing responsibilities
DURING Conduct the assessment in a systematic fashion every time. While performing each step in the physical assessment process, you may need to inform the patient of what to expect, where to expect it, and how it should feel. Avoid making crude or negative remarks, be cognizant of your facial expression when dealing with malodorous and dirty patients or with disturbing findings. Proceed from the least invasive to the most invasive procedure for each body system. If the patient complains of fatigue, continue the assessment later.
Nursing responsibilities
AFTER Provide recognition to the patient when the physical assessment concluded; inform the patient what will happen next. Place patient in a comfortable position. Do after care. Do medical hand washing. Document assessment findings in the appropriate section ofthe patient record.
1. FLASHLIGHT OR PENLIGHT
To assist in viewing of the pharynx and cervix or to determine the reaction of the pupils of the eye.
3. NASAL SEPTUM
To permit visualization of the lower and middle turbinates; usually a penlight is used for illumination.
4. OPHTHALMOSCOPE
A lighted instrument to visualize the interior of the eye
5. OTOSCOPE
A lighted instrument to visualize the eardrum and external auditory canal (a nasal speculum may be attached to the Otoscope to inspect nasal cavities).
7. TUNING FORK
A two-prolonged metal instrument used to test hearing acuity and vibratory sense.
8. COTTON APPLICATORS
To obtain specimens.
9. GLOVES
To protect the nurse
10. LUBRICANT
to ease the insertion of instruments (ex.Vaginal Speculum)
The skin
Skin
First line of defense Composed of the superficial epidermis and the dermis.
SKIN DISCOLORATIONS
S PALLOR (PALE)
Skin
S JAUNDICE (YELLOW-ORANGE) - Resulting from accumulation of bilirubin. - cause: hemolysis, liver disease & cholestasis S CYANOSIS (BLUE) - Increased concentration of deoxyhemoglobin - Cause: heart or lung disease and cold environment
Skin
S ERYTHEMA (REDNESS) - Resulting from some rashes - Cause: fever, direct trauma, blushing and alcohol intake
Skin lesions
The skin normally has no lesions, except for common freckles or age-related changes such as skin-tags, senile keratosis, cherry angiomas and atropic warts. PRIMARY LESIONS
Appear initially in response to some change in internal or external environment of the skin.
SECONDARY LESIONS
Do not appear initially but result from modifications such as chronicity, trauma or infection.
Primary lesions
I. FLAT LESIONS
unelevated changes in color Macule - circumscribed 1mm to 1cm in size Patch - irregularly-shaped and larger than 1cm.
Primary lesions
III. FLUID-FILLED LESIONS
Wheal - irregularly-shaped, reddened, elevated localized collection of edema fluid that varies in size. Vesicle - translucent circumscribed, round or oval elevation of the skin which is filled with serious fluid or blood and smaller than 0.5cm. Bulla - thin-walled blister of the skin or mucous membranes greater then 0.5cm containing clear, serous fluid. Pustule - circumscribed elevation of the skin that varies n size and is similar to a vesicle but filled with pus. Cyst - 1cm or large, elevated, encapsulated in or under the skin lined with epithelium and containing fluid or semisolid material.
Secondary lesions
LOSS OF SKIN SURFACE:
Erosion- wearing away of the superficial epidermis causing a moist, shallow depression. Since erosions do not extend into the dermis, they do not bleed and they heal without scarring. Ulcer- deep, irregularly-shaped area of the skin loss extending into the dermis or subcutaneous tissue which may bleed and may leave a scar. Fissure- a linear crack with sharp edges that extends into the dermis. Excoriation- an injury to a surface of the body caused by trauma, such as scratching, abrasion, or a chemical or thermal burn.
The head
HEAD
S INSPECTION: S PALPATION: For size, shape & symmetry For contour, masses, depressions. S NORMAL S NORMAL FINDINGS: FINDINGS: The normal skull is The head should be smooth, and round (normocephalic) without masses or and symmetrical. depressions, non tender
HAIR
S INSPECTION: For color, evenness of growth over the scalp, presence of parasites, amount of body hair.
S NORMAL FINDINGS:
Can be black, brown or burgundy depending on the race, evenly distributed covers the whole scalp (no evidences of Alopecia), no parasites, and the amount is variable.
S PALPATION: Thickness or thinness texture and oiliness. S NORMAL FINDINGS: Maybe thick or thin, coarse or smooth neither brittle nor dry.
SCALP
S INSPECTION:
For Color, oiliness, presence of scars, lice and dandruff.
S PALPATION:
For lesions or masses tenderness.
S NORMAL FINDINGS:
Lighter in color than the complexion, can be moist or oily,no scars noted, free from lice, nits and dandruff.
S NORMAL FINDINGS:
NO lesions should be noted, neither tenderness nor masses
FOREHEAD
S INSPECTION:
For symmetry, skin appearance,presence of rushes, scars or pimples.
S PALPATION:
For masses, lumps and tenderness
S NORMAL FINDINGS:
Symmetrical, light to dark brown, no rushes, scars and pimples.
S NORMAL FINDINGS:
Non-tender, no lumps and absence of masses
FACE
S INSPECTION:
For shape and symmetry, presence of scars, pimples or acne
S PALPATION:
For any swelling, masses, lumps, and the four sinuses (sphenoidal sinuses, frontal sinuses, ethmoid sinuses and maxillary sinuses).
S NORMAL FINDINGS:
The shape of the face can be oval, round, or slightly square, the face is symmetrical, absence of scars, pimples or acne. There should be no edema, disproportionate structures, or involuntary movements.
S NORMAL FINDINGS:
No lumps and swelling of the face, absence of masses and there is no pain felt during palpation of face
Snellen chart
EYES
S INSPECTION: For symmetry S NORMAL FINDINGS: Symmetrical or evenly placed and inline with each other. Non protruding and equal palpebral fissure.
EYEBROWS
S INSPECTION:
For hair distribution and alignment and skin quality and movement, presence of pimples, dandruff and color of the hair.
S PALPATION: For the presence of lumps, pain and nodules. S NORMAL FINDINGS: No lumps, no nodules and no pain felt during palpation
S NORMAL FINDINGS: Hair evenly distributed; skin intact. Eyebrows symmetrically aligned; equal movement, absence of pimples and dandruff, maybe black brown or blond depending on race.
2.
Middle
3 ossicles ( malleus, incus, stapes; decrease magnitude of sound) Eustachian tube
3.
Inner ear
Cochlea Vestibule Semicircular canal
To straighten the ear canal of adult - pull pinna up and backwards To straighten the ear canal of child - pull pinna down and backwards
head. positive abnormal finding -sound is heard better in impaired ear (bone conductive hearing loss) -sound is heard better in normal ear (sensorineural hearing loss)
Webers test
Rinnes test
S PALPATION: Presence of pain, tenderness, and lumps. S NORMAL FINDINGS: They should feel firm (not tender) and movement produce pain.
S NORMAL FINDINGS: The ear matches the flesh color of the rest of the patients skin and should be positioned centrally and in proportion to the head. The top of the ear should cross an imaginary line drawn from the outer canthus of the eye to the occiput with no swelling or thickening. Cerumen should be moist and not obscure the lympanic membrane. There should be no foreign bodies, redness, drainage, deformities, nodules or lesions.
NOSE
S EXTERNAL INSPECTION: Inspect the nose nothing any bleeding, inflammation, or lesions, masses, swelling, and symmetry, discharges and color, sense of smell. S NORMAL FINDINGS: The shape of the external nose can vary greatly among individual. Normally, it is located symmetrically on the midline of the face that is without swelling, bleeding, lesions, or masses. No discharge or flaring and uniform color, there is a sense of smell. S EXTERNAL PALPATION: For tenderness and presence of pain. S NORMAL FINDINGS: Non-tender; absence of pain S INTERNAL INSPECTION: Inspect for nasal septum for deviation, perforation, lesions and bleeding. S NORMAL FINDINGS: The nasal mucosa should be pink or dull red without swelling. The septum is at the midline and without perforation, lesions or bleeding, the small amount of watery discharge is normal.
FRONTAL SINUSES
S INSPECTION:
For any swelling around the eyes
S PERCUSSION: Note any sound S NORMAL FINDINGS: The sound should be flat or dull.
S NORMAL FINDINGS: There is no evidence of swelling around the eyes. S PALPATION: Presence of pain and tenderness S NORMAL FINDINGS: The patient should not feel pain during palpation and no tenderness felt.
MAXILLARY SINUSES
S INSPECTION: For any swelling around the eyes S NORMAL FINDINGS: There is no evidence of swelling around the nose and eyes. S PALPATION: presence of pain and tenderness S NORMAL FINDINGS: The patient should not feel any pain and tenderness during palpation. S PERCUSSION: Note any sound S NORMAL FINDINGS The sound should be flat or dull
The first teeth (central lower incisors) appear at 5 to 8 months after birth. 20 temporary teeth are completed at 2 years old and lost at 6 to 7 years old. It is replaced by 32 permanent teeth including the appearance of wisdom tooth. (3rd molar). The buccal mucosa is best for identification of central cyanosis.
Mouth and pharynx S 3 PAIRS OF SALIVARY GLANDS 1. PAROTID the largest ; empties through the Stensens duct. 2. SUBMANDIBULAR - empties through the wharton duct. 3. SUBLINGUAL located in the floor of the mouth.
Salivary glands
Mouth and pharynx S PHARYNX Is an organ shared by the gastrointestinal system and the respiratory system. S NASOPHARYNX Is where the eustachian tube opens to the middle ear and oropharynx open into the GIT while the laryngopharynx opens to the respiratory system.
Lips
S INSPECTION: For color, texture, cracking, symmetry, lesions and hydration S NORMAL FINDINGS: The lips should be pink, soft moist, smooth texture with no evidence of lesions or inflammation. Not crack and symmetrical. S PALPATION: For any presence of pain, lumps and tenderness. S NORMAL FINDINGS: There is no presence of lumps and pain. It is tender.
gums
S INSPECTION:
For color, texture, swelling, bleeding, retraction form the teeth S NORMAL FINDINGS: The gums should be pink, moist, firm texture, no retraction, no swelling or bleeding. The gum margins at the teeth are tight and well-defined. S PALPATION: For the presence of pain, tenderness and lumps. S NORMAL FINDINGS: There should be no pain felt during palpation, no lumps and non- tender.
teeth
S INSPECTION: For discoloration, numbers of tooth and texture. S NORMAL FINDINGS: The adult normally has 32 teeth, which should be white, straight and smooth edges in proper alignment or evenly placed, clean and free of debris or decay
tongue
S INSPECTION:
For color, texture, surface characteristics, symmetry, presence of lesions, and sense of taste.
S NORMAL FINDINGS:
The tongue is in the midline of the mouth, the dorsal surface should be pink, moist, rough and without lesions. The tongue is symmetrical and moves freely. The strength of the tongue is symmetrical and strong. The ventral surface of the tongue ahs prominent blood vessels and should be moist without lesions, looks smooth and glistening. There is a sense of taste.
tonsils
S INSPECTION: For color, shape, size and discharge S NORMAL FINDINGS: It is pink in color and smooth. Oval in shape. No discharge. Of normal size or not visible, no inflammation, and not swollen.
The 12 cranial nerves S OCULOMOTOR Class: motor Basic function: extraocular eye movement Test: test eye movement and pupillary response to light S TROCHLEAR
Class: motor Basic function: extraocular eye movement Test: test eye movement and pupillary response to light
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FINISH
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