Introduction to the Physical Assessment

Introduction to the Physical Assessment Madeline Gervase MSN,CCRN,FNP,RN Assessment  Systematic & continuous collection, validation, and communication of client data  Nursing process  Initial and ongoing  Medical vs Nursing  Essential components Purposes of Assessment Obtain Baseline Date regarding functional abilities  Supplement, confirm, or refute date obtained in nursing history  Obtain data that helps establish nursing diagnoses and plan care  Evaluate physiologic outcomes of health care and thus client progress  Screen for presence of risk factors  Types of Assessment Initial  Focused  Emergency  Ongoing  Types of Data  Objective  Data  Subjective  Data “signs”  info perceived by the senses  Ex: T 101, moist skin “symptoms”  info perceived only by affected person  Ex: feeling nervous, tired Characteristics of Data  Complete  Factual & Accurate  Relevant Problems r/t Data Collection  Organization  Omission  Irrelevant or Duplicate Data  Misinterpretatio n  Too little data  Documentation Why is a health history taken? Patterns of wellness/illness  Physical & Behavioral risk factors  Deviations from norm  Nurse as a resource  Functional Health Patterns       Health Perception/ Management Nutritional-Metabolic Elimination Activity-Exercise SexualityReproduction Sleep-Rest      Sensory-Perceptual Cognitive Role-Relationship Coping-Stress Tolerance Value-Belief Nursing Health History   Chief Complaint Present Problem         Usual health status Chronological story Impact on functioning Medications Past Medical History Family History Personal & Social History Review of Systems or Functional Patterns Client Profile – UK Clinical Setting     Biographical Data Chief Complaint History of Present Illness Current Medications    Current Treatments Past Illnesses or Past Hospitalizations Allergies General Survey – Clinical Setting         Age/Sex/Race Mental Status Behavior Mood Appearance Body Type Posture Body Mechanics  Speech    Use of language Thought Process Reliability as historian   Height/Weight Vital Signs Explanation- Affect/Mood  Affect – observable behaviors which indicate the feelings or emotional status of the client. Mood – term which refers to the client’s emotional state as described by the client.  Documentation Terms  Affect       Mood          Broad Restricted Blunted Flat Labile  Appropriate Inappropriate Depressed Anxiety Agitated Elated Manic Euphoric Euthymic (normal) irritable General Principles - History  Explain purpose  Communication techniques  Utilization of data sources  Document  Avoid interruptions or tiring the client  Consider client’s developmental level Developmental Principles  Pediatric  Geriatric Parent/child interactions  Integrate child  Respect adolescent, give choices  Do not stereotype  Assess and accommodate:  sensory & physical functioning  Psychosocial Considerations History  Avoid stereotypes  Healthcare beliefs  Language differences  Eye contact  Non-judgmental  Stressors/Coping Mechanisms Cultural Awareness Considerations Time Orientation  Activity Orientation  Human Nature Orientation  Human-Nature Orientation  Relational Orientation   Seidel, 2003, pp. 43. History - Biographical Data Name  Race  Age  Gender  Marital status  Birthplace, date  Address  Source of medical care  Insurance coverage  Past Health History Previous hosp. & surgeries  Allergies  Illnesses & Accidents  Immunizations  Medications  Habits/Lifestyle  ADLs  Client’s Family History  Blood relatives  Significant others Health history   Family as resource Stressors in family  Present Illness/Health Concerns Onset  Duration  Location, quality, and intensity  Precipitating factors  Relief factors  Client’s expectations  Subjective and Objective data  PQRST – Characterize Symptoms      Precipitating factors Quality Radiation Severity Temporal Factors OLD CARTS –         Onset Location Duration Character Aggravating factors Relieving factors Temporal factors Severity Reasons for Seeking Healthcare  Chief complaint  Why?  Quotes  Specify  Clarify Resources  Home and outside environment  Community resources  Financial  Family & significant others  Consider Basic Human Needs Medical Diagnostic Data  Medical Nursing Diagnosis  Nursing Implications r/t Medical Diagnosis vs Contributions of Lab Data Verifies data  Provides baseline information  Evaluates outcomes  Identifies problems missed in history and assessment  Test: Complete Blood Count (CBC)  Analysis of peripheral venous blood specimen  Main components: RBC = red blood cell count (erythrocytes)  WBC = white blood cell count (leukocytes)  Hgb = hemoglobin  Hct = hematocrit  Test: Urinalysis (UA) Analysis of a urine specimen  Screens for:     urinary infection renal disease diabetes mellitus Urinalysis  Main  components pH4.6 - 8.0  Proteinup to 10mg/100ml  Specific gravity-1.003 - 1.030  Glucosenegative  Ketonesnegative  Bloodup to 2 RBCs Test: Electrolytes (lytes, e-) Inorganic substances in the body that conduct electrical current  Usage:   Assess fluid balance Electrolytes  Main  Components: sodium potassium chloride calcium phosphate magnesium Na+  K+  Cl Ca P  Mg Test: Chest X-Ray (CXR, PA Chest, PA & LAT Chest) Radiographic exam of the thorax  Visualizes respiratory & cardiac function  Identifies & follows progression/ remission of dx process  Test: Arterial Blood Gas (ABG)   Assesses the adequacy of ventilation and oxygenation via arterial blood Use: measures respiratory and metabolic (renal) disturbances Arterial Blood Gases  Main  Components: pH  PaCO2  PaO2  HCO3  SaO2 General Nursing Implications  Assess client’s readiness to learn  Explain procedure to client  Assist client in dealing with the test  Provide privacy  Prepare client for test  Universal precautions  Send specimens promptly Specific Nursing Implications  Electrolytes:  Note diet, food and fluid intake  Note s/s that could affect fluid balance (N/V/D)  Chest  X-Ray: Transport  Remove metal objects  Stand clear Specific Nursing Implications  Arterial Gases  Blood Anticoagulants?  Time drawn  Check site for bleeding  Pressure  Sample on ICE  STAT to lab Physical Assessment: Pediatric Principles  Assess:    coping ability previous knowledge readiness Encourage questions  Explain at developmental level  Physical Assessment: Pediatric Principles Use concrete terms  Small amounts of info at a time  Simple & clear explanations  Only offer choices that are available  Honest praise/rewards  Physical Assessment Methods  Inspection  Palpation  Auscultation  Percussion Equipment Stethoscope  Pen light  Blood Pressure Cuff  Thermometer  Watch with second hand  Inspection  Assessment process during which the nurse observes the client Inspection  Initial contact and ongoing  Use olfaction, touch  General appearance, body language  Systematic unhurried approach  Expose part, respect privacy  Examine: color, size, shape, position, symmetry (compare like areas)  Know “normals”  Observe “normals/abnormals” Palpation  The use of the hands and the sense of touch to gather data Palpation  Detects texture, shape, temp, movement, pain, moisture  Short fingernails, warm hands  Gentle approach  Light palpation first, if pain - STOP!  Palpate tender areas last  Three types:  Light palpation (1/2 inch)  Deep palpation (1 inch)  Bimanual deep palpation (2 hands) Auscultation  The act of listening to sounds within the body to evaluate the condition of body organs  (stethoscope) Auscultation  Stethoscope: bell for low pitch sounds (cardiac sounds)  Diaphragm for high pitch sounds (bowel, breath, normal cardiac)  4  characteristics of sounds Frequency/pitch: # vibrations per second  Loudness: soft, medium, loud  Quality: types; gurgling, blowing  Duration: short, medium, long (specify) Auscultation  Quiet environment  Know landmarks  Know “normals”  PRACTICE! PRACTICE! PRACTICE!  Requires concentration, practice, and application of knowledge Percussion  Tapping of various body organs and structures to produce vibration and sound. Documentation - Purpose       Communication Quality Assurance Legal Reimbursement Research Planning Client Care     Education Statistics Accrediting/Licensure Historical Document Principles of Documentation        Timing Confidentiality Permanence Signature Accuracy Sequence Appropriateness      Completeness Standard Terminology Brevity Legibility Legal Awareness Learning Outcomes The student will be able to: 1. 2. 3. 4. 5. State the purposes of the physical exam. Name the necessary equipment need to perform a physical exam. Describe the four basic techniques used in physical examination. Describe guidelines for preparing a client and the environment for a physical examination. What are the components of a general survey?