Physical assessment
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Presentation to participants of the 'Acute Care Nursing Program' - Canberra Hospital, 2005
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Physical assessment
- 1. Physical Assessment Acute Care Nursing Program 2005
- 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
Editor's Notes
- 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.