Chapter 13 Physical Assessment Copyright 2013 Wolters Kluwer

Question • Is the following statement true or false? The first step of the

Answer False. The first step of the nursing process is assessment. Copyright © 2013

Physical Assessment • First step of the nursing process – Assessment • Physical assessment

Overview of Physical Assessment • Purposes – To evaluate the client’s current physical condition

Overview of Physical Assessment: Four Basic Physical Assessment Techniques • Inspection – Examining particular

Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) • Percussion – Striking

Inspection and Percussion Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) • Palpation – Lightly

Palpation Techniques Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) • Auscultation – Used

Auscultation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • What is lightly touching or applying pressure to the body using fingertips,

Answer c. Palpation involves lightly applying pressure to the body using fingertips, back of

Overview of Physical Assessment • Equipment – Items needed for a basic physical assessment

Overview of Physical Assessment (cont’d) • Environment – Special examination room or at bedside

Overview of Physical Assessment (cont’d) • Environment (cont’d) – Padded, adjustable or bed –

Performing a Physical Assessment: Basic Activities During a Physical Assessment • Gather general data

Assessment of Height and Weight Copyright © 2013 Wolters Kluwer Health | Lippincott Williams

Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) • Drape and

Client Is Prepared for Examination Copyright © 2013 Wolters Kluwer Health | Lippincott Williams

Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) • Select a

Data Collection: 6 General Areas for Data Collection • Head and neck – Mental

Pupil Size Assessment Guide Copyright © 2013 Wolters Kluwer Health | Lippincott Williams &

Weber Test Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Rinne Test Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • When preparing a client for the Rinne Test, which of the following

Answer b. Tuning fork A tuning fork is required to conduct the Rinne test

Data Collection: Six General Areas for Data Collection (cont’d) • Head and neck (cont’d)

Data Collection: Six General Areas for Data Collection (cont’d) • Chest and spine –

Data Collection: Six General Areas for Data Collection (cont’d) • Chest and spine (cont’d)

Question • Which of the following sounds is not a normal lung sound? a.

Answer d. Wheezing is an adventitious lung sound; it is not normal. Tracheal sound,

Data Collection: Six General Areas for Data Collection (cont’d) • Extremities – Assessment of:

Criteria for Estimating Pitting Edema Copyright © 2013 Wolters Kluwer Health | Lippincott Williams

Data Collection: Six General Areas for Data Collection (cont’d) • Abdomen – Bowel sounds:

Nursing Implications • Assessment findings: basis for identifying health problems – Clients o Reveal

Nursing Implications (cont’d) • Nursing diagnoses – Readiness for enhanced knowledge – Ineffective health

General Gerontologic Considerations • Explain purpose of each procedure • Consider alterations: hearing, vision,

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Overview of Physical Assessment • Purposes – To evaluate the client’s current physical condition – To detect early signs of health problems – To establish baseline for future comparisons – To evaluate client’s responses to medical and nursing interventions Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Physical Assessment: Four Basic Physical Assessment Techniques • Inspection – Examining particular body parts – Looking for specific normal and abnormal characteristics – Using special instruments to inspect parts of the body inaccessible to ordinary visual inspection techniques Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) • Percussion – Striking or tapping the body with fingertips to produce vibratory sounds – Quality of sounds determines location, size, and density of underlying structures; variation in sound could mean possible pathologic change – Pain: possible disease process or tissue injury Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) • Palpation – Lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand – Deep palpation – Information: normal tissue and unusual masses; bilateral structures; skin temperature and moisture Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) • Auscultation – Used for assessing the heart, lungs, and abdomen – Soft sounds, loud sounds – Nurses: practice auscultation repeatedly to gain proficiency; to ensure accuracy, eliminate or reduce environmental noise Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • What is lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand called? a. Inspection b. Percussion c. Palpation d. Auscultation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer c. Palpation involves lightly applying pressure to the body using fingertips, back of the hand, or palm of the hand. Inspection is looking for specific normal and abnormal characteristics. Percussion is striking or tapping the body with fingertips to produce vibratory sounds. Auscultation is listening to the sounds of the heart, lungs, and abdomen with a stethoscope. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Physical Assessment (cont’d) • Environment – Special examination room or at bedside – Easy access to a restroom; a door or curtain to ensure privacy – Adequate warmth – Lined receptacle for soiled articles – Adequate lighting Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Physical Assessment (cont’d) • Environment (cont’d) – Padded, adjustable or bed – Sufficient room for movement around client – Facilities for hand hygiene – Clean counter or surface for placing examination equipment Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Performing a Physical Assessment: Basic Activities During a Physical Assessment • Gather general data during first contact with client – Physical appearance; gait; coordinated movement; use of ambulatory aids; mood and emotional tone – Preliminary data o Vital signs, weight, height, documentation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) • Drape and position the client – Ensure that client is covered with a drape (sheet of soft cloth or paper) – Begin examination with the client standing or sitting Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) • Select a systematic approach for collecting data – Head-to-toe approach: Advantages – Body systems approach: Advantages; disadvantages • Examining the client: Outline procedure for performing a physical assessment Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Collection: 6 General Areas for Data Collection • Head and neck – Mental status assessment – Eyes: accommodation; Snellen eye chart; Jaeger chart; extraocular movements – Ears: cerumen; Weber test; Rinne test; audiometry – Nose: abnormalities; smelling acuity Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • When preparing a client for the Rinne Test, which of the following equipment should the nurse keep ready? a. Stethoscope b. Tuning fork c. Snellen chart d. Jaeger chart Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer b. Tuning fork A tuning fork is required to conduct the Rinne test to determine hearing impairment. A stethoscope is used to listen to lung, heart, and abdominal sounds. A Snellen chart and a Jaeger chart are tools for assessing far and near vision respectively. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Collection: Six General Areas for Data Collection (cont’d) • Head and neck (cont’d) – Mouth and oral mucous membrane o Unusual breath odors o Assessment of taste – Facial skin: alterations in skin – Hair, scalp – Neck Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Collection: Six General Areas for Data Collection (cont’d) • Chest and spine – Skin turgor – Assess chest shape and movement; chest expansion – Spine: lordosis, kyphosis, scoliosis – Breasts – Heart sounds: S 1, S 2, S 3, S 4 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Collection: Six General Areas for Data Collection (cont’d) • Chest and spine (cont’d) – Lung sounds o Normal § Tracheal sounds § Bronchial sounds § Bronchovesicular sounds § Vesicular sounds Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Collection: Six General Areas for Data Collection (cont’d) • Chest and spine (cont’d) – Lung sounds (cont’d) o Adventitious lung sounds § Crackles § Gurgles § Wheezes § Rubs Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer d. Wheezing is an adventitious lung sound; it is not normal. Tracheal sound, bronchial sound, and vesicular sound are normal lung sounds. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Collection: Six General Areas for Data Collection (cont’d) • Extremities – Assessment of: o Capillary refill o Muscle strength o Fingernails and toenails o Edema: measurement o Skin sensation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Data Collection: Six General Areas for Data Collection (cont’d) • Abdomen – Bowel sounds: hyperactive, hypoactive, absent – Abdominal girth measurement – Genitalia • Anus and rectum – Client positioning; trauma; hemorrhoids Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Implications • Assessment findings: basis for identifying health problems – Clients o Reveal situations that caused health failure o Ask for more information Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Implications (cont’d) • Nursing diagnoses – Readiness for enhanced knowledge – Ineffective health maintenance – Effective or ineffective therapeutic regimen management – Deficient knowledge; noncompliance – Health-seeking behaviors Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

General Gerontologic Considerations • Explain purpose of each procedure • Consider alterations: hearing, vision, mobility • Ask appropriate questions • Make appropriate adjustments: physical limitations • Older women: modifications in preprocedure positioning Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins