Purposes of a physical assessment
To evaluate the clients current physical condition, to detect early signs of developing health problems, to establish a baseline for future comparison, to evaluate the clients responses to medical and nursing intervention.
Four assessment technique
Inspection, percussion, palpatation, auscultation. ,
percussion technique
Involves striking or tapping part of the clients body producing vibratory sound. Quality of sound aids in determining the location, size, and density, of underlying structure. Least used.
Palpatation
Lightly tapping the body or applying pressure to the body part that is being examined.
Light palpatation
Uses fingertips, back of palm hand.
Deep palpatation
Depressing tissue approximately 1 inch with the forefingers of one or both hands.
Purposes of palpatation
Provides information about size shape, consistency, and mobility of normal tissue and unusual masses. Symmetry or asymmetry of bilateral structure. Skin temperature or moisture. Tenderness.
Auscultation techniques
Listening to body sounds. Frequently used. Most often used to asses the heart, lungs, and abdomen. Softer sounds a stethoscope is used to eliminate noise and hear clearer. Loud sounds those that are audible with gross hearing. Gi area with hyperactivity,
Body system approach (physical exam)
Collecting data according to functional systems of the body. Involves examining the structure in each system seperatly.
Macule
Flat round colored nonpalpable area. Freckles.
Papule
Elevated. Palpable solid . Wart.
Vesicle
Elevated, round, filled with serum. Blisters.
Wheal
Elevated, irregular border, no free fluid. Hives.
Pustules
Elevated, raised border, filled with pus. Boild
Nodule
Elevated, solid mass, deeper, and firmer than a papule. Enlarged lymph node.
Cyst
Encapsulated, round fluid filled or solid mass beneath the skin. Tissue growth.
Pallor
Pale regardless of race. anemia, blood loss.
Erythmea
Red. Superficial burns, local inflammation.
Flushed
Pink. Fever, hypertension.
Ecchymosis
Purple. Trauma to soft tissues.
Cyanosis
Blue. Low tissue oxygenation.
Jaundice
Yellow. Liver or kidney disease, destruction of red blood cells.
Tan
Brown. Ethnic variation, sun exposure, pregnancy. Addisons disease.wrote
Spine lordosis
Exaggerated natural lumbar curve of the spine.
Spine kyphosis
An increased thoracic cure.
Spine scoliosis
Pronunced curvature of spine.
lung sounds crackles(rales)
Intermittent, high pitched, popping, and heard in distant areas of the lungs, heard primarily during inspiration.
Lung sounds gurgles (ronchi)
Low pitched, continous bubbling, heard more on expiration
Lung sounds wheezes
Whistling/squeaking sounds. Unaltered by cough. May be audible to ear
Lung sounds rubs
Grafting, leathery sounds.
1 plus edema
Slightly indentation 2 mm normal contours
2 plus edema
Deeper pit after depressing 4mm fairly normal contour
3 plus edema
Deep pit 6mm swelling is obvious to the eye
4 plus edema
Deep pit 8mm very obvious swelling
5 plus edema
No pitting skin palpates as firm skin surface shiny warm and moist.
Pain assessment
Location duration quality rating intervention effectiveness of intervention.
Dorsal recumbent
Catheter insertion vaginal rectal exam inspection
Lithotomy
Ob delivery cytoscopic exam pelvic exam
Sims
Rectal vagina exam supp insertion enema administration
Knee-chest
Rectal and lower intestinal examination
Modified standing
Prostate gland exam rectal gland cyst removal