This document outlines the process and assessments for several body systems including respiratory, cardiac, neurological, abdominal, and neurovascular. It describes the steps in the assessment process as inspection, palpation, percussion, and auscultation. For each body system, it lists the specific points to examine, techniques to use, and normal and abnormal findings to note during the physical assessment of a patient in an acute care setting.

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

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

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

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

37. Abdominal Assessment Inspection Asymmetry Engorged veins Intestinal movements Lesions Scars Swelling

39. Abdominal Assessment Auscultation Systematic Bowel sounds

40. Abdominal Assessment Percussion All four quadrants Tympanic- air filled structures Dull – solid structures Bowel Liver Bladder

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.