Physical assessment
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Physical assessment

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Presentation to participants of the 'Acute Care Nursing Program' - Canberra Hospital, 2005

Presentation to participants of the 'Acute Care Nursing Program' - Canberra Hospital, 2005

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  • Inspection: Observe the patient of skin colour and texture; check for lesions, scars of hair disruption Palpation: Information by using hands and finger to palpate. A light or deep palpation depending on the area being palpated. Used to assess organ position, size and consistency, fluid accumulation, pain and masses. Percussion: Produces sound waves by using the fingers as a hammer. Vibration is produced by the impact of the fingers striking against underlying tissue. Sound or tone is usually determined by the body area or organ percussed. Auscultation: Listening using a stethoscope. Place stethoscope on bare skin to listen for the characteristics of sound waves. The bell of the stethoscope is used to detect low-pitch sounds, the diaphragm to detect high-pitched sounds. Notice vibrations in intensity, pitch, duration and quality.
  • Pulse – pulse deficit listen to apex and feel radial – if there is a difference this indicates a pulse deficit
  • S1 – tricuspid and mitral valve closure S2 – pulmonic and aortic valve closure
  • S2 split – A2 = aortic valve closure, P2 = pulmonic valve closure. On inspiration, venous return to the heart is impeded and pulmonic valve closure is delayed resulting in a split sound. Can be normal in some people. Get patient to hold breath to hear this better S3 – left ventricular failure: and is caused by blood from the left atrium slamming into an already overfilled ventricle during early diastolic filling S4 - left ventricular hypertrophy: blood trying to enter a stiff, non-compliant left ventricle during atrial contraction
  • Recognition of an odour such as coffee or toothpaste
  • Ability to read newsprint
  • Motor nerve: controls four out of the six extra-ocular muscles, raise eyelids and controls the constrictor pupillar and ciliary muscles of the eyeball.
  • Assessment: Clenches teeth with no lateral jaw deviation
  • Recognises tastes such as sugar salt
  • Ability to stick tongue out in a midline without deviation
  • Cullen's sign – bluish colour around the umbilicus seen in hemorrhagic pancreases Grey turner’s sign – bruising in the flanks associated with retroperitoneal bleeding.
  • Caput Medusae – head of medusa a mythical snake-haired person. Associated with
  • Start in (L) lilac fossa region Bowel sounds – timing, frequency, etc… Renal arteries – bruits, abnormal pathological flow of blood resulting in a swishing sound or murmur. Note timings such as, occurrence with other cycles and location. All are specific
  • Liver, start high on ribs and work down Bladder – only when full, otherwise is small within pelvis
  • Liver, start high on ribs and work down Bladder – only when full, otherwise is small within pelvis
  • Liver, start high on ribs and work down Bladder – only when full, otherwise is small within pelvis
  • Kehr’s sign – referred pain to shoulder in splenic injury (occurs in approx 50% of cases) McBuney’s point – located 1/3 distacnce from the anterior superior iliac spine to the umbilicus. Tenderness associated with appendicitis Murphy's sign – on inspiration, pain associated with palpation of the RUQ, indicative of choecystitis.

Transcript

  • 1. Physical Assessment Acute Care Nursing Program 2005
  • 2. Outline
    • Assessment Process
    • Respiratory Assessment
    • Cardiac Assessment
    • Neurological Assessment
    • Abdominal Assessment
    • Neurovascular Assessment
  • 3. Assessment Process
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
    • Gather information – base line
    • Record trends
  • 4. Respiratory Assessment
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
  • 5. Respiratory Assessment
    • Inspection
      • General appearance, colour
      • Scaring
      • Symmetry
      • Shape
      • Position of trachea
      • Work of breathing
      • Rate
      • Rhythm
      • Cough – productive?
  • 6. Respiratory Assessment
    • Palpation
      • Chest excursion
      • Tactile and vocal fremitus
  • 7.  
  • 8. 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
  • 9.  
  • 10. Respiratory Assessment
    • Auscultation
      • Systematic approach
      • Note adventitious (extra)
        • Crackles
        • Wheeze
        • Friction rub
  • 11. Respiratory Assessment
  • 12. Cardiac Assessment
    • Inspection
    • Palpation
    • (Percussion)
    • Auscultation
  • 13. Cardiac Assessment
    • Inspection
      • JVP
      • Oedema
      • Colour
  • 14. Cardiac Assessment
    • Palpation
      • Pulse
      • Oedema
      • Capillary refill
      • Blood pressure
  • 15. Cardiac Assessment
    • Auscultation
      • Normal
        • S1
        • S2
      • Abnormal
        • S2 split
        • S3
        • S4
  • 16.  
  • 17. Cardiac Assessment
  • 18. Neurological Assessment
    • Glasgow Coma Scale
    • Cranial Nerves
  • 19. Glasgow Coma Scale
    • Assess neurological status
    • Assessment of best response
      • Eyes
      • Verbal
      • Motor
  • 20. Glasgow Coma Scale None None None 1 Extension Incomprehensible To Pain 2 Flexion Inappropriate To speech 3 Withdraws Confused Spontaneous 4 Localises pain Orientated ---------- 5 Obeys ----------- ----------- 6 Best Motor Best Verbal Best Eye Score
  • 21. Cranial Nerves
    • 12 cranial nerves
    • 3 rd – 12 th within brainstem (Midbrain, Pons, Medulla)
  • 22. Cranial Nerve
    • Function:
    • Sensory
    • Smell
    • Assessment:
    • Recognition of odor
    I Olfactory
  • 23. Cranial Nerve
    • Function:
    • Sensory
    • Information from the retina
    • Assessment:
    • Visual acuity
    II Optic
  • 24. Cranial Nerve
    • Function:
    • Motor
    • Four of the six extra-ocular muscles
    • Assessment:
    • Response to light
    • Moves eye
    • Elevates upper eyelid
    III Oculomotor
  • 25. Cranial Nerve
    • Function:
    • Motor
    • Controls the oblique eye muscle
    • Assessment:
    • Moves eye right, left, up and down
    IV Trochlear
  • 26. Cranial Nerve
    • Function:
    • Mixed
    • Three sensory
      • Corneal Reflex
    • One motor
    • Assessment:
    • Normal facial sensation
    • Blinks
    • Clenches teeth
    V Trigeminal
  • 27. Cranial Nerve
    • Function:
    • Motor
    • Lateral rectus muscle of eye
    • Assessment:
    • Moves eye laterally
    VI Abducens
  • 28. Cranial Nerve
    • Function:
    • Mixed
    • Sensory
      • Tongue
    • Motor
      • Eyelids
    • Assessment:
    • Elevates eyebrows
    • Puffs checks
    • Recognizes tastes
    VII Facial
  • 29. Cranial Nerve
    • Function:
    • Sensory
    • Hearing
    • Assessment:
    • Whisper in each ear
    VIII Vestibulocochlear
  • 30. Cranial Nerve
    • Function:
    • Mixed
    • Sensory
      • Taste buds
    • Motor
      • Gag reflex
    • Assessment:
    • Taste testing
    • Test gag
    IX Glossopharyngeal
  • 31. Cranial Nerve
    • Function:
    • Mixed
    • Motor branches to the pharyngeal and laryngeal muscles
    • Viscera of the thorax and abdomen
    • Assessment:
    • Same as IX
    X Vagus
  • 32. Cranial Nerve
    • Function:
    • Motor
    • Innervates the sternocleidomastoid and trapezius muscles
    • Assessment:
    • Shrugs shoulders
    XI Accessory
  • 33. Cranial Nerve
    • Function:
    • Motor
    • Tongue muscles
    • Assessment:
    • Sticks out tongue
    XII Hypoglossal
  • 34. Abdominal Assessment
    • Inspection
    • Auscultation
    • Percussion
    • Palpation
  • 35.  
  • 36.  
  • 37. Abdominal Assessment
    • Inspection
      • Asymmetry
      • Engorged veins
      • Intestinal movements
      • Lesions
      • Scars
      • Swelling
  • 38.  
  • 39. Abdominal Assessment
    • Auscultation
      • Systematic
      • Bowel sounds
  • 40. Abdominal Assessment
    • Percussion
      • All four quadrants
        • Tympanic- air filled structures
        • Dull – solid structures
      • Bowel
      • Liver
      • Bladder
  • 41.  
  • 42.  
  • 43. Abdominal Assessment
    • Palpation
      • Light and Deep
        • Tenderness, guarding, rigidity
      • Define organs
      • Kehr’s sign
      • McBurney’s point
      • Murphy’s sign
  • 44. Neurovascular Assessment
    • Colour
    • Temperature
    • Capillary Refill
    • Peripheral Pulses
    • Swelling
    • Movement
    • Sensation
  • 45. 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.