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Physical assessment


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Physical assessment

  1. 1. HEALTHCARE PROCESS Assessment Diagnosis Evaluation Implementation Planning
  2. 2. It is the FIRST STEP of the Health Care Process. The following are its key components:  Health Interview  Physical Examination  Laboratory or Diagnostic Examination  Records Review
  3. 3. A systematic way of collecting objective data from a client using the four examination techniques in order to assess or identify current health status. Different Approaches:  Cephalocaudal  Proximodistal  Mediolateral  Outer to Inner /External to Internal
  4. 4.  Obtain physical data about the client’s functional abilities  Supplement, confirm, or refute data obtained in the client’s health history  Obtain data that will help the nurse establish diagnoses and plan the client’s care.  Evaluate the physiologic outcomes of health care and thus the progress of a patient’s health problem  To identify areas for health promotion and disease prevention
  6. 6. INSPECTION Visual examination of the patient done in a methodical, deliberate, purposeful, and systematic manner. Assess moisture, color and texture of the body surfaces, as well as shape, position, size, color, and symmetry of the body.
  7. 7. PALPATION Examination of the body using the sense of touch. The use of hand to touch and feel the patient’s skin, organs, mass, and other delineated structures in the body Assess temperature; turgor; texture; moisture; vibrations; position, size, shape, consistency and mobility of organ or masses; distention; pulsation; and the presence of pain upon pressure(tenderness)
  8. 8. Palmar surfaces of the examiner's fingertips and finger pads are used for discriminatory sensation, such as texture, vibration, presence of fluid, or size and consistency of a mass The dorsum, or back of the hand, is used to assess surface temperature.
  9. 9. LIGHT PALPATION Place the hand with fingers together parallel to the skin surface or area being palpated, while moving the hand in circle. Light palpation, light pressure is applied by placing the fingers together and depressing the skin and underlying structures about 1/2 inch (1 cm). Use to check muscle tone and to assess for tenderness
  10. 10. Deep palpation is used with caution because pressure can damage internal organs. The skin and underlying structures are depressed about 1 inch (2 cm). To identify abdominal organs and abdominal masses. Two – handed deep palpation place the fingers of one hand on top of those of the other. The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensation.
  11. 11. Deep Palpation is done with two hands (bimanually) or one hand. Usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed Deep Palpation using lower hand to support the body while the upper hand palpates the organ
  12. 12. PERCUSSION Striking of the body surface with short, sharp strokes in order to elicit palpable vibrations and characteristic sound. It is used to determine the location, size, shape, and density of underlying structures; to detect the presence of air or fluid in a body space; and to elicit tenderness.
  13. 13. TYPES OF PERCUSSION DIRECT PERCUSSION - Using one hand to strike the surface of the body Jing Salaria, RN,MD
  14. 14. TYPES OF PERCUSSION INDIRECT PERCUSSION Using the finger of the one hand to tap the finger of the other hand. plexor strikes the finger of the examiner’s other hand, which is in contact with the body surface being percussed (pleximeter- the middle finger of the nondominant hand). Jing Salaria, RN,MD
  15. 15. Percussion is used to access the location, shape, size, and density of tissues. (Left) The non-dominant hand is placed directly on the area to be percussed, and the middle finger is placed firmly on the body surface. (Right) The tip of the middle finger of the dominant hand strikes the joint of the middle finger of the opposite hand
  16. 16. AUSCULTATION Listening to sounds produced within the body.
  17. 17. Stethoscope bell and diaphragm. Use the diaphragm of the stethoscope to detect high-pitched sounds. The diaphragm should be at least 1.5 inches wide for adults and smaller for children. Hold the diaphragm firmly against the body part being auscultated. Use the bell of the stethoscope to detect low-pitched sounds. The bell should be at least 1 inch wide. Hold the bell lightly against the body part being auscultated.
  18. 18.  Introduce self to the client. Verify his identity. Explain the purpose why such procedure is necessary and how he could cooperate (i.e. positioning).  Help him put on a clean gown and offer a bedpan or a urinal to empty his bladder.  Ensure privacy by closing the doors or pulling the curtains around him.  Invite a relative or a significant other to stay with the client, as necessary.
  19. 19.  Provide adequate lighting.  Gather the equipment: height chart, weighing scale, Snellen’s chart, penlight, card board, sterile gloves, tongue depressor, 4x4 Gauze, tuning fork, stethoscope, wrist watch, tape measure, marker/pencil, record sheet & waste receptacle.  Ensure the examination table is at a comfortable working height. Perform hand hygiene.
  20. 20. Materials Needed
  21. 21. Position and drape the client appropriately 
  22. 22. STANDING = assessment of posture, gait & balance SITTING = used to take vital signs DORSAL RECUMBENT = used in patient having difficulty maintaining supine position
  23. 23. SUPINE SIM’s = assessment of rectum and vagina PRONE = assessment of hip and posterior thorax
  24. 24. LITHOTOMY = assessment of female rectum and vagina. (for a brief period only) KNEE-CHEST = assessment of rectal area (for brief period only)
  25. 25. SALIENT POINTS:  Subjective data should be documented in patient’s own words.  Objective data should be specific. generalizations and judgmental phrases No  Data gathered in the nursing health history may be confirmed or refuted by the nurse during the interview or the physical assessment
  26. 26. PROCEDURE I. Obtain vital signs & anthropometric measurement (height/weight).
  27. 27. PROCEDURE I. Obtain vital signs & anthropometric measurement (height/weight). NOTE: Given: IBW= A-B where, A= ht. in cm -100 B= (A) x 0.10 C= (IBW) x 0.10 N Range = IBW-C (Lower Limit) = IBW+C (Upper Limit) BMI= wt. in kg/ ht. in (m)2
  28. 28. BMI Interpretation <18 = Underweight 18-24 = Normal >25 = Obese
  29. 29. Example computation A = 134.62 -100 = 34.62 B = 34.62 x 0.10 = 3.46 IBW = 34.62 – 3.46 = 31.16
  30. 30. Example computation To get the normal range: C = 31.16 x0.10 = 3.12 Upper limit = 31.16 + 3.12 = 34.28 Lower limit = 31.16 – 3.12 = 28.04
  31. 31. Example computation BMI = 55 / (1.346)2 = 29.7  30
  32. 32. II. Assess the General Appearance: A. Body build, height and weight in relation to age, lifestyle and health B. Posture and Gait C. Over-all hygiene and grooming D. Body and breath odor E. Signs of distress F. Mood / Affect G. Quantity, Quality & Organization of Speech H. Relevance & Organization of Thoughts
  33. 33. Scoliosis Kyphosis Lordosis
  34. 34. ASSESSMENT OF THE INTEGUMENTARY SYSTEM • Skin • Nails • Hair • Scalp
  35. 35. Part 1. Anatomical Parts of the Skin
  36. 36. 1. SKIN COLOR Normal Deviations from Normal • Varies from light • Pallor to deep brown, • Cyanosis from ruddy pink • Jaundice to light pink • Erythema
  37. 37. 2. Skin Color Uniformity Normal • Generally uniform except in areas exposed to sun; areas of lighter pigmentation in dark skinned
  38. 38. 2. Skin Color Uniformity Deviations • Hyperpigmentation  Birthmarks – abnormal distribution of the melanin
  39. 39. 2. Skin Color Uniformity Deviations • Hypopigmentation  Vitiligo due to destruction of melanocytes in the area  Albinism – complete or partial lack of melanin
  40. 40. 3. Assess for Edema • Excessive accumulation of fluid in body tissues • Note the degree to which the skin remains indented or pitted when pressed by a finger Edema scale 1+ = barely detectable 2+ = indentation of less than 5 mm 3+ = indentation of 5 to 10 mm 4+ = indentation of more than 10 mm ANASARCA
  41. 41. 4. Inspect, palpate, and describe skin lesions • According to type/structure, color, number, distribution, location TYPES: Primary skin lesions – abscess, ulcer, tumor, and open wound Secondary skin lesion  crusts, kelloids, scars, etc.
  42. 42. Primary and Secondary Lesions
  46. 46. Cyst
  47. 47. 5. Observe and palpate skin moisture • Done by touching or palpating the skin of the extremities Normal  Moist Deviations  Excessively dry
  48. 48. 6. Palpate skin temperature Normal Deviations • Uniform; within • Generalized or localized; normal range hyperthermic or hypothermic
  49. 49. 7. Palpate Skin Turgor • Refers to fullness or elasticity • Indicative of status of hydration of the body. • Assessed by pinching the skin on an extremity. Normal Deviations  When pinched, skin  Skins stays pinched or springs back to indented or moves back previous state in less than 3 seconds slowly.
  50. 50.  Note that this is not as valid in elderly people as in younger people because skin elasticity decreases with age; thus, other parameters should be used, such as: I&O, daily weight
  51. 51. Let’s have a break…
  52. 52. 1. Inspect fingernail plate shape, curvature & angle Normal – Colorless and a convex curve. Deviations from Normal • Concave • Clubbed fingernails (>180O) due to chronic tissue hypoxia – Angle between nail and nail bed: usually 160o
  53. 53. Examples of Nail Abnormalities
  54. 54. 2. Inspect and palpate finger & toenail bed color Normal • Highly vascular and pink in light skinned; dark skinned may be brown or black Deviations from N • Bluish or purplish tinges; • Pale
  55. 55. 3. Inspect tissues surrounding nails Normal • Intact epidermis Deviations from N • Hangnails (paronychia = ingrown nail) • Inflammation of surrounding tissues
  56. 56. 4. Perform Blanch Test/Capillary refill test Normal • Prompt return or pink or usual color, less than 2-4 seconds Deviations • Delayed return of pink or usual color, usually >4 seconds
  57. 57. (Skull and Face)
  58. 58. Part 3. Structures of the Skull
  59. 59. 1. Inspect skull size, shape, proportion & symmetry Normal Deviations from Normal • Round and is of normal • Disproportionate size or head circumference • Asymmetric prominences Normocephalic • Increased head circumference • In proportion w/ gross body structure • Frontal, parietal and • Square-head occipital prominences; • Bulging / depressed bone • Smooth skull contour
  60. 60. 2. Palpate skull nodules or masses & depression Normal Deviations from Normal • Smooth, uniform • Sebaceous cysts; local consistency; absence deformities from of nodules/masses trauma; masses; or depression nodules
  61. 61. 3. Inspect facial features Normal • Symmetric facial features; • Eye brow hair equally distributed • palpebral fissures equal in size; • symmetric nasolabial folds Deviations from N • Asymmetric features • Increased facial hair; thinning of eyebrows; exopthalmos; moon face;
  62. 62. 4. Inspect eyes for edema and hollowness Normal • No edema, eyes not sunken
  63. 63. 4. Inspect eyes for edema and hollowness Sunken eyes, cheeks and temples (indicative of dehydration, starvation, and illness) Deviations • Periorbital edema
  64. 64. 5. Inspect symmetry of facial movements Normal • Symmetric facial movements Deviations • Asymmetric facial movements, drooping of lower eyelid and mouth; involuntary facial movement Raise or lower both eyebrows Blink both eyes Close both eyes tightly Smile and show the teeth Frown Puff the cheeks
  65. 65. Assessing the Hair
  66. 66. 1. Evenness of growth of hair over scalp Normal • Evenly distributed Deviations from Normal • Patches of hair loss, i.e. alopecia
  67. 67. 2. Hair thickness or thinness Normal • Thick Hair Deviations from Normal • Very thin hair (hypothyroidism)
  68. 68. 3. Hair Texture and Oiliness Normal Deviations from Normal  Silky, resilient hair  Brittle hair (poor nutrition)  excessively oily or dry hair
  69. 69. 4. Note presence of infection / infestation Normal • No infection/ infestation Deviations from Normal • Flaking, sores, lice, nits