Physical assessment

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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.
  • Physical assessment

    1. 1. Physical Assessment Acute Care Nursing Program 2005
    2. 2. Outline <ul><li>Assessment Process </li></ul><ul><li>Respiratory Assessment </li></ul><ul><li>Cardiac Assessment </li></ul><ul><li>Neurological Assessment </li></ul><ul><li>Abdominal Assessment </li></ul><ul><li>Neurovascular Assessment </li></ul>
    3. 3. Assessment Process <ul><li>Inspection </li></ul><ul><li>Palpation </li></ul><ul><li>Percussion </li></ul><ul><li>Auscultation </li></ul><ul><li>Gather information – base line </li></ul><ul><li>Record trends </li></ul>
    4. 4. Respiratory Assessment <ul><li>Inspection </li></ul><ul><li>Palpation </li></ul><ul><li>Percussion </li></ul><ul><li>Auscultation </li></ul>
    5. 5. Respiratory Assessment <ul><li>Inspection </li></ul><ul><ul><li>General appearance, colour </li></ul></ul><ul><ul><li>Scaring </li></ul></ul><ul><ul><li>Symmetry </li></ul></ul><ul><ul><li>Shape </li></ul></ul><ul><ul><li>Position of trachea </li></ul></ul><ul><ul><li>Work of breathing </li></ul></ul><ul><ul><li>Rate </li></ul></ul><ul><ul><li>Rhythm </li></ul></ul><ul><ul><li>Cough – productive? </li></ul></ul>
    6. 6. Respiratory Assessment <ul><li>Palpation </li></ul><ul><ul><li>Chest excursion </li></ul></ul><ul><ul><li>Tactile and vocal fremitus </li></ul></ul>
    7. 8. Respiratory Assessment <ul><li>Percussion </li></ul><ul><ul><li>Normal – resonant, hollow sound </li></ul></ul><ul><ul><li>Solid - dull </li></ul></ul><ul><ul><li>Percussion is done in the intercostal spaces </li></ul></ul><ul><ul><li>Percussion is done both on the posterior chest and lateral chest </li></ul></ul>
    8. 10. Respiratory Assessment <ul><li>Auscultation </li></ul><ul><ul><li>Systematic approach </li></ul></ul><ul><ul><li>Note adventitious (extra) </li></ul></ul><ul><ul><ul><li>Crackles </li></ul></ul></ul><ul><ul><ul><li>Wheeze </li></ul></ul></ul><ul><ul><ul><li>Friction rub </li></ul></ul></ul>
    9. 11. Respiratory Assessment
    10. 12. Cardiac Assessment <ul><li>Inspection </li></ul><ul><li>Palpation </li></ul><ul><li>(Percussion) </li></ul><ul><li>Auscultation </li></ul>
    11. 13. Cardiac Assessment <ul><li>Inspection </li></ul><ul><ul><li>JVP </li></ul></ul><ul><ul><li>Oedema </li></ul></ul><ul><ul><li>Colour </li></ul></ul>
    12. 14. Cardiac Assessment <ul><li>Palpation </li></ul><ul><ul><li>Pulse </li></ul></ul><ul><ul><li>Oedema </li></ul></ul><ul><ul><li>Capillary refill </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul>
    13. 15. Cardiac Assessment <ul><li>Auscultation </li></ul><ul><ul><li>Normal </li></ul></ul><ul><ul><ul><li>S1 </li></ul></ul></ul><ul><ul><ul><li>S2 </li></ul></ul></ul><ul><ul><li>Abnormal </li></ul></ul><ul><ul><ul><li>S2 split </li></ul></ul></ul><ul><ul><ul><li>S3 </li></ul></ul></ul><ul><ul><ul><li>S4 </li></ul></ul></ul>
    14. 17. Cardiac Assessment
    15. 18. Neurological Assessment <ul><li>Glasgow Coma Scale </li></ul><ul><li>Cranial Nerves </li></ul>
    16. 19. Glasgow Coma Scale <ul><li>Assess neurological status </li></ul><ul><li>Assessment of best response </li></ul><ul><ul><li>Eyes </li></ul></ul><ul><ul><li>Verbal </li></ul></ul><ul><ul><li>Motor </li></ul></ul>
    17. 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
    18. 21. Cranial Nerves <ul><li>12 cranial nerves </li></ul><ul><li>3 rd – 12 th within brainstem (Midbrain, Pons, Medulla) </li></ul>
    19. 22. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Sensory </li></ul><ul><li>Smell </li></ul><ul><li>Assessment: </li></ul><ul><li>Recognition of odor </li></ul>I Olfactory
    20. 23. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Sensory </li></ul><ul><li>Information from the retina </li></ul><ul><li>Assessment: </li></ul><ul><li>Visual acuity </li></ul>II Optic
    21. 24. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Motor </li></ul><ul><li>Four of the six extra-ocular muscles </li></ul><ul><li>Assessment: </li></ul><ul><li>Response to light </li></ul><ul><li>Moves eye </li></ul><ul><li>Elevates upper eyelid </li></ul>III Oculomotor
    22. 25. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Motor </li></ul><ul><li>Controls the oblique eye muscle </li></ul><ul><li>Assessment: </li></ul><ul><li>Moves eye right, left, up and down </li></ul>IV Trochlear
    23. 26. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Mixed </li></ul><ul><li>Three sensory </li></ul><ul><ul><li>Corneal Reflex </li></ul></ul><ul><li>One motor </li></ul><ul><li>Assessment: </li></ul><ul><li>Normal facial sensation </li></ul><ul><li>Blinks </li></ul><ul><li>Clenches teeth </li></ul>V Trigeminal
    24. 27. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Motor </li></ul><ul><li>Lateral rectus muscle of eye </li></ul><ul><li>Assessment: </li></ul><ul><li>Moves eye laterally </li></ul>VI Abducens
    25. 28. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Mixed </li></ul><ul><li>Sensory </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><li>Motor </li></ul><ul><ul><li>Eyelids </li></ul></ul><ul><li>Assessment: </li></ul><ul><li>Elevates eyebrows </li></ul><ul><li>Puffs checks </li></ul><ul><li>Recognizes tastes </li></ul>VII Facial
    26. 29. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Sensory </li></ul><ul><li>Hearing </li></ul><ul><li>Assessment: </li></ul><ul><li>Whisper in each ear </li></ul>VIII Vestibulocochlear
    27. 30. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Mixed </li></ul><ul><li>Sensory </li></ul><ul><ul><li>Taste buds </li></ul></ul><ul><li>Motor </li></ul><ul><ul><li>Gag reflex </li></ul></ul><ul><li>Assessment: </li></ul><ul><li>Taste testing </li></ul><ul><li>Test gag </li></ul>IX Glossopharyngeal
    28. 31. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Mixed </li></ul><ul><li>Motor branches to the pharyngeal and laryngeal muscles </li></ul><ul><li>Viscera of the thorax and abdomen </li></ul><ul><li>Assessment: </li></ul><ul><li>Same as IX </li></ul>X Vagus
    29. 32. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Motor </li></ul><ul><li>Innervates the sternocleidomastoid and trapezius muscles </li></ul><ul><li>Assessment: </li></ul><ul><li>Shrugs shoulders </li></ul>XI Accessory
    30. 33. Cranial Nerve <ul><li>Function: </li></ul><ul><li>Motor </li></ul><ul><li>Tongue muscles </li></ul><ul><li>Assessment: </li></ul><ul><li>Sticks out tongue </li></ul>XII Hypoglossal
    31. 34. Abdominal Assessment <ul><li>Inspection </li></ul><ul><li>Auscultation </li></ul><ul><li>Percussion </li></ul><ul><li>Palpation </li></ul>
    32. 37. Abdominal Assessment <ul><li>Inspection </li></ul><ul><ul><li>Asymmetry </li></ul></ul><ul><ul><li>Engorged veins </li></ul></ul><ul><ul><li>Intestinal movements </li></ul></ul><ul><ul><li>Lesions </li></ul></ul><ul><ul><li>Scars </li></ul></ul><ul><ul><li>Swelling </li></ul></ul>
    33. 39. Abdominal Assessment <ul><li>Auscultation </li></ul><ul><ul><li>Systematic </li></ul></ul><ul><ul><li>Bowel sounds </li></ul></ul>
    34. 40. Abdominal Assessment <ul><li>Percussion </li></ul><ul><ul><li>All four quadrants </li></ul></ul><ul><ul><ul><li>Tympanic- air filled structures </li></ul></ul></ul><ul><ul><ul><li>Dull – solid structures </li></ul></ul></ul><ul><ul><li>Bowel </li></ul></ul><ul><ul><li>Liver </li></ul></ul><ul><ul><li>Bladder </li></ul></ul>
    35. 43. Abdominal Assessment <ul><li>Palpation </li></ul><ul><ul><li>Light and Deep </li></ul></ul><ul><ul><ul><li>Tenderness, guarding, rigidity </li></ul></ul></ul><ul><ul><li>Define organs </li></ul></ul><ul><ul><li>Kehr’s sign </li></ul></ul><ul><ul><li>McBurney’s point </li></ul></ul><ul><ul><li>Murphy’s sign </li></ul></ul>
    36. 44. Neurovascular Assessment <ul><li>Colour </li></ul><ul><li>Temperature </li></ul><ul><li>Capillary Refill </li></ul><ul><li>Peripheral Pulses </li></ul><ul><li>Swelling </li></ul><ul><li>Movement </li></ul><ul><li>Sensation </li></ul>
    37. 45. References <ul><li>A Practical guide to clinical assessment http://medicine.ucsd.edu/clinicalmed/ </li></ul><ul><li>Smith SF, Duell DJ & Martin BC, 2005, Clinical Nursing Skills , Prentice Hall, New Jersey. </li></ul>

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