Physical Assessment PDF

PHYSICAL ASSESSMENT urposes: 1. To obtain baseline data aboutthe client's functional abilities. 2. To supplement, confirm, or refute data obtained in the nursing history. 3. Toobtain data that will help establish nursing diagnoses and plan ofcare. 4. To evaluate the physiologic outco...

PHYSICAL ASSESSMENT urposes: 1. To obtain baseline data aboutthe client's functional abilities. 2. To supplement, confirm, or refute data obtained in the nursing history. 3. Toobtain data that will help establish nursing diagnoses and plan ofcare. 4. To evaluate the physiologic outcomes of health care and thus the progress of a client's health problem. lethods of Examination: - 1. Inspection is the visual examination, using the sense of sight. - 2. Palpation is the examination of the body using the sense of touch. - 3. Percussion involves tapping the body with fingertips to evaluate the size, borders and consistency of body organsand to discover fluid in body cavities. - 4. Auscultation is the process of listening to sounds produced within the body. quipment: 1. Wrist watch with second hand 2. Thermometer Sphygmomanometer 3. 4. Stethoscope 5. Otoscope 6. Snellen chart 7. Penlight 8. Safety pin 9. Percussion hammer 10. Tape measure 11. Tongue depressor 12. Gloves 13. Cotton applicator 14. Millimeter / Centimeter ruler 15. Gauze square 16. Pencil 17. Wisps of cotton 18. Test tubes of hot and cold water (optional) Dcedure: 1. Wash hands. Reducestransmisson of microorganisms. 2. Prepare all materials needed. Ensures smooth flowof the procedures. 3. Prepare suitable environment: eliminate drafts, control room temperature. Suitable environment promotes client's comfort and prevents chilling. Explain procedure to the client. Promotes cOoperation. 4. by allowing the opportunity to empty the bowel or bladder. 5. Provide for client's comfort neral Survey 1. Note relevant observation appearance:hygiene, groomingfor presence of make-up,type of clothes Physical mood and and self-care practices. Grooming may reflect activity level prior to examination, client's preferences. May alsO affect culture, lifestyle, economic status, and personal 19  Posture, position and gait, noting alignment of shoulders and hips while client stands and sits (slumped,erect or bent posture) May reveal musculoskeletal problem, mood or presenceof pain. skin Skin: color, lesion. Changes in color can be indicative of pathological alterations. Centain lesions can be identified by a characteistic pattem offeatures. Hair, obsenve the color distribution,quantity.thickness, texture and lubrication. Changes in hair distribution. mayreflect hononal changes,changes trom aging, poor nutrition or uso of certan hir products, Nails. Changes may indicate inadequate nutrition or grooming practices, nervous habts or systematic diseases. Client behaviour, facial expression. Behaviours may relect specific physical abnormalties. Level of consciousness. Influences ability tocooperate. 2. Check client's: Height and weight, if sudden gain or loss in weight has occurred. Weight of 15% to 20% above standard indicates excess body fat. however, fluid ratention is one factor that must be ruled out. Temperature, Pulse, Respiration and Blood Pressure. Vital signs provide impotant infomation regarding physiological changes in relation to oxygenation and circulation. 3. Assess for pain 4. Assess affect and mood, note if verbal and nonverbal expressions match and were appropriate to the situation Assessment of the Head Inspection 1. Assist the client to a sitting position. 2. Inspectand palpate thehead for the following: size/circumference, deformities, lesions,swelling. mass (describeexact location), condition and distribution of hair, presence of pediculosis and dandruff. Palpation 3. Palpate head for any deformities, swelling, etc. Assessment of the Eye 4. Inspect position of eyes, color and for the following changes: redness, yelowish discoloration, discharges, excessive tearing, sweling. Asymmeticalpositioning or eye movement may reflect trauma or tumor arowth. 5. down lowerlids slightly and note the inner parts for its color. Pull Changes of color of conjunction may be due to local infection or symptomatic of another abnomality. 6. Inspect pupil for size, shape and reaction to light. Note iris for its color. Nomal pupils are round, clear and equal in size and shape. Differences in color may be congenital. 7. Check visual acuity by having client read newspaper for near vision and snellen chart for far vision. If client has visual acuity or visual Field loss. make adjustments to support self-care measures and teacthing. 8. Test papillary reflexes. To test reaction to light, dim room lights. As client looks straight ahead, use penlight and shine a light on the pupil. Observe papillary response, noting briskness and equality of the reflex. Darkened room nomallyensures brisk response of pupils to light. Pupil that is illuminated constricts. Pupils ineye should constrict equally (consensuallight reflex). Assessment of the Ear 9. Note the client's response to questions and the indications that the client hears normal sound as you make them. For client with obvious hearing impaiment, speak clearty and concisely. 20  10. Inspectthe auricles for color, symmetry and position. Note the level of superior aspect of the auricle if aligned with outer canthus of the eye. Low set ears is associated with congenital abnonalily such as Down syndrome. 11.Using an otoScope, inspect the external ear canal for cerumen, skin lesions, pus and blood. Dry cerumen is grayish-tan in color, or sticky, wet cerumen in various shades of brown. Assessment of the Nose 12. Examine external nose for symmetry, nasal flare, deviation in shape, discharges and perforation witn penlight. discharge and inflammation indicates allergy or infection, Perforation and erosion of the Character of Sputum and puffiness and/or increased vasculanity of the mucOsa can indicate habitual use of tune intranasal cocaine and opioids. Lighty palpate external nose to detemine areas tendemess, masses, and displacements of bone of 13. and cartilaqe. nares and breathe through the opposite 14. Ask client to close mouth, exert pressure on one of the the nares. nares, repeat the procedure. To detenmine patency of 15. Palpate the maxillary and frontal sinusesfor tenderness. Assessment of the mouth, lip, tongue and throat lips for color, texture, hydration, swelling and lesions. 16.Observe its and lesion 17.Inspectgum for color, edema, bleeding site, color Brown or black dental hygiene, presence of dental carries, extraction 18. Inspect teeth for or the presence of caries. discoloration the enamel may indicate staining and penlight for of palate ises, with tongue depressor say "ahh" so that the soft 19. Have client appropriate visualization. uvula for color and size. 20. At the same time, observe in mouth and throat. Inspect one side at inflammation, lesions, edema, exudates 21. Inspect throat for to expose one side of oropharynx, press to avoid qag reflex. Use tongue depressor a time eliciting opens the mouth wide. side while client tilts head and againsttongue on the same color, discharge and size. 22. Inspectthe tonsils for Assessment of the Neck for better to hold the head erect the neck for symmetry, edema, masses or scars. Ask 1. Inspect visualization. It detemines how the thyroid the bulging of the thyroid. note for 2. Ask to extend neck, then swallow, causes bulging of theqland cartilaqes move and whetherswallowing smoothness. Note any areas of and cricoids and index finger for the thyroid gland with the middle 3.Palpate enlargement, masses or nodules. and lungs of time since Assessment of the thorax amount pack-years) determine length (type, duration, and in Assess tobacco use 1. smoking if client quits. respiratory alterations smoke. 2. Ask if client experiences radiation, or secondhand in environment containing pollutants, Determine if client works 3. to infectious diseases factors and/or exposure 4. Review history for risk expansion duning examination. upright. Pronmotes full lung Position client sitting covered 5. front of chest and legs gown from posterior chest, keep retraction of intercostal spaces 6. Remove shape, position of spine, To thorax for expansion. 7. Stood behind client; inspect during expiration and symmetrical of intercostal spaces distress, Ina child shape is during inspiration, bulging any symptoms of respiratory AP chest expansion and 1:2 chest istwice as wide as deep with identify impaired in adult almost circular with AP diameter in 1:1 ratio, chest). 1:1 ratio (barel Chronic Lung Disease results in diameter. 21