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Physical assesstment Head to toe

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.

Importance of physical assessment


To early detect and treat diseases and disorders. To identify actual and potential health problems. To establish a data based from which the subsequent phases of the nursing evolve. To assess the clients impact of activity and exercise on the clients overall level of health. To assess the clients routine exercise pattern and observe how the clients body system response to activity and exercise. To establish the client-nurse relationship. To obtain information about the clients health including, physiologic, psychological, socio-cultural, cognitive, developmental and spiritual aspects. To identify the clients strength and weaknesses.

Purpose of physical assesstment


To supplement, confirm or refute data obtained in the nursing history. To confirm and identify nursing diagnosis. To make clinical judgments about a clients changing health status and management. To evaluate the physiological outcome of care. To obtain and gather data about the clients health basis of data for future assessment. An excellent way to evaluate an individuals current health status.

Four basic techniques in physical assessment

Four basic techniques in physical assestment

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.

Four basic techniques in physical assestment

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.

Two distinct types of palpation

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.

Two distinct types of palpation

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.

Four basic techniques in physical assestment


3.

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.

Four types of percussion techniques III. DIRECT FIST PERCUSSION


It is used to assess the presence of tenderness in internal organs, such as the liver or the kidneys. The presence of pain in conjunction with direct fist percussion indicated inflammation of that organ or a strike of too high in intensity.

IV. INDIRECT FIST PERCUSSION


Its purpose is the same as direct fist percussion. In fact, the indirect method is preferred over the direct method. It is because in this methods, the non dominant hand absorbs some of the force of the striking hand. The resulting intensity should be sufficient force to produce pain in the patient if organ inflammation is present .

Percussion elicits five types of sounds

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)

Four basic techniques in physical assestment

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.

Two types of auscultation


A) DIRECT OR IMMEDIATE AUSCULTATION
It is the process of listening with the unaided ear. This can include listening to the patient from some distance away or placing the ear directly on the patients skin surface. And example is the wheezing that is audible to the unassisted ear in a person having a severe asthmatic attack.

B) INDIRECT OR MEDIATE AUSCULTATION


It is the use of stethoscope, which transmits the sounds to the nurses ear.

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.

Materials and Instruments of Physical Treatment

Materials and Instruments of Physical Treatment

1. FLASHLIGHT OR PENLIGHT
 To assist in viewing of the pharynx and cervix or to determine the reaction of the pupils of the eye.

Materials and Instruments of Physical Treatment

2. LARYNGEAL OR DENTAL MIRROR


 To observe the pharynx and oral cavity

Materials and Instruments of Physical Treatment

3. NASAL SEPTUM
 To permit visualization of the lower and middle turbinates; usually a penlight is used for illumination.

Materials and Instruments of Physical Treatment

4. OPHTHALMOSCOPE
 A lighted instrument to visualize the interior of the eye

Materials and Instruments of Physical Treatment

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).

Materials and Instruments of Physical Treatment

6. PERCUSSION (REFLEX) HAMMER


 An instrument with a rubber head to test reflexes

Materials and Instruments of Physical Treatment

7. TUNING FORK
 A two-prolonged metal instrument used to test hearing acuity and vibratory sense.

Materials and Instruments of Physical Treatment

8. COTTON APPLICATORS
 To obtain specimens.

Materials and Instruments of Physical Treatment

9. GLOVES
 To protect the nurse

Materials and Instruments of Physical Treatment

10. LUBRICANT
 to ease the insertion of instruments (ex.Vaginal Speculum)

Materials and Instruments of Physical Treatment

11. TONGUE BLADES (DEPRESSORS)


 To depress the tongue during assessment of the mouth and pharynx

Various positioning of the patient

Various positioning of the patient


 DORSAL RECUMBENT  Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface. Supine (horizontal recumbent)  Back-lying position with legs extended; with or without pillow under the head  SITTING  -A seated position. The back is unsupported and legs hanging freely.  LITHOTOMY  Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table.  SIMS  Side-lying position with the lowermost leg flexed at the hip and knee, upper arm flexed at the shoulder and elbow.  PRONE  Lies on the abdomen with head turned to the side, with or without a small pillow.

Various positioning of the patient

Assessment of body parts

The skin

Skin
 First line of defense  Composed of the superficial epidermis and the dermis.

SKIN DISCOLORATIONS
S PALLOR (PALE)

-result of inadequate circulating blood or hemoglobin.


-cause: anemia

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.

II. ELEVATED LESIONS


    Papule - circumscribed solid skin elevations less than 1cm Plaque - larger than 1cm Nodule - solid hard mass with circumscribed border that extends deeper into the dermis and 0.5-2cm in size. Tumor - solid hard mass with irregular border that may extend through the subcutaneous tissue larger than 2cm.

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.

Materials on the skin surface


Crust- dry blood, serum or pus left on the skin surface when vesicles or pustules burst. It can be red-brown, orange, or yellow. Scabs are large crusts that adhere to the skin surface. Scar- flat, irregular area of connective tissue left after a lesion or wound has healed. New scars may be red or purple, while older scars may be white or silvery. Scales- shedding flakes of greasy, keratinized skin tissue. The color varies from whit, gray or solver. While, the texture may range from fine to thick. Keloid- elevated, irregular, darkened area of excess scar tissue caused excessive collagen formation during healing. It extends beyond the site of the original injury and has a higher incidence in people of African descent. Lichenification- rough, thickened, hardened area of the epidermis that resulted from chronic irritation such as scratching or rubbing.

Other skin variations


Petechiae- pinpoint-sized, red or purple spots on the skin resulting from small hemorrhages in the skin layer. Edema- swollen areas from abdominal accumulation of fluid in interstitial spaces of tissues.

Skin malignancies in older adults


Basal cell carcinoma - 0.5-1.0cm crusted lesion that may be flat or raised and may have rolled and somewhat scaly border. There are frequently underlying and widely dilated blood vessels that can be seen within the lesion. Squamous cell carcinoma - 0.5-1.5cm scaly lesions that may be ulcerated or crusted. It appears more frequently, grows more rapidly and occurs more often on the mucosal surfaces and non-exposed areas of the skin as compared to basal cell. Melanoma - 0.5-1.0 am brown, flat lesion that may arise on sunexposed or non-exposed skin. There are varieties of pigmentation, irregular borders, and indistinct margins. Meanwhile, ulceration, recent growth, or recent changes in longstanding mole are ominuous sign.

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

EYES AND VISION


PERRLA -Pupils should be Equal, Round, Reactive to Light and Accomodation. ANISOCORIA - Unequal pupil CONSTRICTION - Normal reaction to light and near accomodation. 3-7 mm in diameter -Normal pupil 20/20 normal vision 20/200 - legal definition of blindness MYOPIA nearsightedness HYPEROPIA- farsightedness PRESBYOPIA - loss of elasticity of the lens due to aging, thus loss ability to see close objects. ASTIGMATISM - an uneven curvature of the cornea that prevents horizontal and vertical rays from focusing on the retina. SNELLEN CHART- test visual acuity

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.

EARS AND HEARING


S 1. DIVIDED INTO 3 PARTS: Outer
Auricle or pinna External canal Tympanic membrane

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

Parts of the ear

EARS AND HEARING


S WEBERS TEST
- Lateralization test that compares right and left ear. 

negative normal finding


-sound is heard in both ears or is localized at the center of the

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

EARS AND HEARING S RINNES TEST


- Compares air conduction with bone conduction.

 positive rinne- normal finding


-air conduction is greater than bone conduction.

 negative rinne- abnormal finding


-bone conduction time is equal to or longer than air conduction (conductive hearing loss)

Rinnes test

EARS AND HEARING


S INSPECTION: For position, color, size, shape, anydeformities, inflammation, or lesions

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 AND PARANASAL SINUSES


S
1. 2. 3. 4. 5.

THE FACIAL SINUSES INCLUDE:


Frontal Supra orbital Ethmoidal Sphenoidal Maxillary

NASAL SPECULUM, PENLIGHT OR OTOSCOPE


-used to visually examine the nose.

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

MOUTH AND PHARYNX

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

The 12 cranial nerves


S OLFACTORY Class : sensory Basic function: smell Test: test smell using non-irritating substances S OPTIC Class: sensory Basic function: sight Test: visual acuity like snellen chart and visual field

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

The 12 cranial nerves


S TRIGEMINAL Class: both Basic function: S- facial sensation M- chewing Test: check pain sensation (dull or sharp stimuli using safety pin, hot and cold using test tube, light touch using wisp of cotton); test corneal reflex; test clenching of teeth.

The 12 cranial nerves


S ABDUCENS Class: motor Basic function: extraocular eye movement Test: test eye movement and pupillary response to light S FACIAL Class: both Basic function: S- taste of anterior 2/3 of the tongue M- facial movement Test: observe facial expressions

The 12 cranial nerves


S ACOUSTIC (VESTIBULOCOCHLEAR)  Class: sensory  Basic function: hearing and sense of balance  Test: assess hearing using rinne and weber test. S GLOSSOPHARYNGEAL  Class: both  Basic function: S- taste of posterior 1/3 of the tongue M- swallowing  Test: listen to patients voice. Ask the patient to say ah and not the movement of soft palate and pharynx. Test gag reflex.

The 12 cranial nerves


S VAGUS Class: both Basic function: innervation of the pharynx, respiratory, cardiac and circulatory system Test: listen to patients voice. Ask the patient to say ah and note movement of the soft palate and pharynx. Test gag reflex.

The 12 cranial nerves S SPINAL ACCESORY


Class: motor Basic function: shoulder and head movement Test: ask the patient to shrug shoulder against your hand. S HYPOGLOSSAL Class: motor Basic function: tongue movement Test: note tongue and ask the patient to stick out tongue

The 12 cranial nerves


S MNEMONICS FOR THE 12 CRANIAL NERVES

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S TO REMEMBER WHETHER THE CN IS MOTOR, SENSORY OR BOTH:

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FINISH
Thank you!

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