Ch21- Physical Assessment.ppt

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Chapter 21 Physical Assessment Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terms Associated with Speech Disorders  Aphasia  The person knows what he or she want...

Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Chapter 21 Physical Assessment Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terms Associated with Speech Disorders  Aphasia  The person knows what he or she wants to say, but cannot say it  Dysphasia  The person has difficulty coordinating and organizing words into sentences Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terminology Related to Eye Assessment  Anisocoria  Pupils of different sizes  Ptosis  Drooping of the eyelids  Consensual reflex  Stimulation of one pupil with light, causing both pupils to constrict rapidly, simultaneously, and equally Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terminology Related to Eye Assessment (cont.)  Accommodation response  When focusing on distant object, both pupils dilate to allow in more light to see better at distance; when focusing on close object, pupils constrict because less light is needed to see up close  PERLA  Pupils equal and reactive to light and accommodation Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Multiple Choice Question What eye response does the nurse assess by briefly shining a penlight in one eye of a patient and observing both pupils’ response? A. Aniscoria B. Ptosis C. Consensual reflex D. Accommodation response Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Answer C. Consensual reflex Rationale: Aniscoria is assessed by directly observing the pupils for equal size. Ptosis is assessed by observing the eyelid for drooping. Accommodation response is assessed by holding a finger in front of the patient’s face and slowly increasing and then decreasing the distance between the finger and the patient’s face while observing for dilation and then constriction of pupils. Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition True/False Question An ophthalmoscope is used for assessment of pupil constriction. A. True B. False Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Answer B. False Rationale: A penlight is used to assess pupil constriction of the eyes and to examine the oral and nasal mucous membranes. An otoscope is used to inspect the lining of the nose, tympanic membranes, and ear canals. An ophthalmoscope is used to assess the internal structures of the eyes. Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terms Related to Lung Assessment  Adventitious breath sounds: Abnormal breath sounds (rales, rhonchi, wheezes, stridor, pleural friction rub)  Auscultation: Listening to sounds produced by the body with or without a stethoscope  Bradypnea: An abnormally slow respiratory rate  Eupnea: A normal rate and pattern, with equal depth, of respirations  Tachypnea: A rapid rate of breathing Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terms Related to Lung Assessment (cont.)  Wheezes: Continuous, melodious, musical, or whistling breath sounds due to constriction of the airway  Orthopnea: Being unable to breathe supine, and having to sit up to breathe  Crackles/Rales: Crackling, popping breath sounds caused by air moving over secretions or alveoli opening up; they can be fine or coarse and do not clear with coughing Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terms Related to Lung Assessment (cont.)  Rhonchi: Breath sounds that may sound like soft snoring, rattling, gurgling, or lowpitched wheezes; they are a deeper, more rumbling sound than rales/crackles and may clear with coughing; they are caused by secretions or partial occlusion of the airways  Excursion: Chest expansion, which should be equal on both sides Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Terms Related to Lung Assessment (cont.)  Pleural friction rub: A grating, creaking breath sound due to inflamed, edematous pleural surfaces rubbing together  Stridor: A shrill, high-pitched, harsh, crowing sound made when trying to breathe; it is caused by a foreign body, swelling, or bronchial spasms and is lifethreatening Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Purposes of a Physical Assessment  Establish patient’s current condition; used as a baseline for comparing later changes  Identify problems the patient has or may have the potential to develop  Evaluate the effectiveness of nursing interventions  Monitor for changes in body function  Detect body systems that need further assessment or testing Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Levels of Physical Assessments  Comprehensive health assessment: An in-depth assessment of the whole person, including physical, mental, emotional, cultural, and spiritual aspects of a patient’s health  Focused assessment: An examination and interview regarding a specific body system  Initial head-to-toe shift assessment: A quick overall assessment of patient’s condition to establish a baseline Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Multiple Choice Question Which of the following type of assessment would a nurse perform on a patient who is having problems breathing due to COPD? A. Comprehensive health assessment B. Focused assessment C. Initial head-to-toe shift assessment D. None of the above Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Answer B. Focused assessment Rationale: A focused assessment is performed when time constraints allow you to check only one system or only the systems related to the patient’s disease process. Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition When to Perform a Physical Assessment  On admission: Comprehensive and in-depth; the Joint Commission requires an RN to complete an admission assessment on each patient  At the beginning of each shift: Shorter and more focused  When the patient condition changes  When evaluating the effectiveness of nursing care  Whenever things do not feel right Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Fostering Rapport and Communication SMILE! Exhibit an open and a relaxed posture. Greet the patient using his/her surname. Introduce yourself and explain your intent. Provide for privacy. Be professional, sincere, and nonjudgmental. Demonstrate active listening. Be attentive to the patient’s responses and needs.  Be aware of cultural influences.  Use touch purposefully and judiciously.        Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition 6 Techniques Used for Physical Assessment       Interview Inspection (observation) Percussion Auscultation Palpation Olfaction Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Signs vs. Symptoms  Signs: Use of the four senses (vision, hearing, olfaction, and touch), which produces objective and measurable evidence of illness or injury  Symptoms: Evidence of illness or injury that is verbalized by the patient; the findings are subjective, which means not directly observable or measurable Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information Obtained in the Patient History  Personal identity and demographics  Details regarding the patient’s current condition  Medical history, including current medications  Social history  Food and drug allergies  Height and normal weight  Expectations for hospitalization Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Data Detected by Inspection/Observation  Skin and mucous membrane color  Respiratory effort and rate of respirations  Level of consciousness; response to simple commands  Whether the patient makes eye contact  Affect (smiling, frowning, blunted, obtunded)  Pupil response  Facial symmetry  Signs of pain: grimacing, holding or rubbing an area of the body Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Data Detected by Inspection/Observation (cont.)  Posture; body alignment; movement and range of motion of all joints and extremities; contractures; tremors  Skin turgor  Intact or impaired skin integrity (incisions, open wounds); stage pressure ulcers  Edema  Size and location of external body parts  Distention of the abdomen  Response time of capillary refill  Signs of anxiety, nervousness, fear: being wide-eyed; picking at things; jiggling, tapping, or bouncing of extremities Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Data Detected by Inspection/Observation (cont.)  Drainage from orifices, drains, tubes, lesions, or wounds  Patency and function of tubes, IVs, oxygen, Foley catheters, and NG tubes  Reading results of a thermometer, pulse oximeter, sphygmomanometer, FSBS, telemetry strip, scales, measuring tape, or IV or feeding pumps  Written results of laboratory or radiological tests Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Percussion  Involves tapping with the tips of the fingers over specific body parts to:  Elicit sounds that can help locate and determine the size of structures beneath the surface  Identify whether the structure is solid or hollow  Detect areas containing air or fluid Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Sounds Heard With Auscultation  Heart sounds  Breath sounds  Bowel sounds  Murmurs: Abnormal heart valve sounds  Bruits: Rushing of blood through a vessel Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition        Data Detected by Palpation Skin temperature Skin moisture/texture Skin turgor Growths on or below the skin Edema Size and location of body parts Distention of the bladder or abdomen Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Data Detected by Palpation (cont.)  Firmness versus softness of tissue  Location and strength of pulses; PMI  Strength of hand grips and foot flexion Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Olfaction Detects: Infection Acetone breath in ketoacidosis Alcohol Blood Ammonia Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Assessment Findings Relative to Specific Health Conditions  Cheilosis: Usually related to vitamin B deficiency  Angioedema: Associated with anaphylaxis, a life-threatening allergic response  Retractions: Indicate acute respiratory distress Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Assessment Findings Relative to Specific Health Conditions  Stridor: Indicates a life-threatening upper airway obstruction  Paresthesia: Indicates a loss of nerve function, such as in diabetes or stroke  Pitting edema: Indicates excess fluid shifting; may be related to many conditions Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Systems Assessed in an Initial Head-to-Toe Shift Assessment      Neurological Cardiovascular Respiratory Integumentary Gastrointestinal Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Systems Assessed in an Initial Head-to-Toe Shift  Genitourinary Assessment (cont.) Concepts, Connections, & Skills, Second Edition  Muscular  Skeletal  The immune system (briefly) Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Additional Specific Assessments Made in an Initial Head-to-Toe Shift Assessment Vital signs, including pain and SpO Concepts, Connections, & Skills, Second Edition        2 Appearance Speech Safety risk factors Tubes and equipment Comfort or complaints Needs Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Assessment Findings by System        Neurological Cardiovascular Respiratory Gastrointestinal Urinary Integumentary Musculoskeletal Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Components of a Basic Neurological Examination Vital signs Concepts, Connections, & Skills, Second Edition         Level of consciousness Orientation to the four spheres Pupil size, equality, and reaction to light Facial symmetry Speech clarity and appropriateness Response to simple commands Movement, strength, and bilateral equality of the four extremities Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Cardiovascular Assessments  Heart sounds: S1 and S2, heart rate, rhythm, strength  Radial pulse: rate, rhythm, strength  Apical-radial pulses: same rate?  BP  Neck vein distention  Chest pain or pain of the left jaw, shoulder, or arm (females—also left back pain) Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Cardiovascular Assessments (cont.)  Color of skin, mucous membranes, nail beds  Temperature of the extremities  Edema of the extremities  Capillary refill time in the extremities  If present:  Telemetry: intact lead wires, rhythm  Antiembolism stockings  Sequential compression devices Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Respiratory Assessments  Color of the skin, mucous membranes, and nail beds  Respiratory rate, depth, pattern, and effort  Respiratory effort  Cough, sputum  SpO2 (oxygen saturation)  Supplemental oxygen: liter flow, delivery device, and humidification  Auscultation of breath sounds  Equal chest excursion  Tracheostomy Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Various Respiratory Patterns  Eupnea: Normal rate (12 to 20), depth, and pattern  Tachypynea: Increased rate greater than 20  Bradypnea: An abnormally slow rate, less than 12  Kussmaul: An abnormally deep and rapid rate  Biots: Breaths of equal depth with periods of apnea Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Respiratory Patterns (cont.)  Apnea: A temporary absence of breathing  Cheyne-Stokes: Cyclical breathing, beginning with a shallow breath and gradually increasing in depth with each additional breath until a peak is reached; then gradually decreasing in depth with each breath until breath is barely discernable; then a period of apnea before the cycle begins again Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Abnormal Breath Sounds Rales Rhonchi Wheezes Pleural rub Stridor (can usually be heard without the use of a stethoscope)  Absence or decreased breath sounds      Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Gastrointestinal Assessments  Shape of the abdomen  Auscultation of bowel sounds  Palpation of the abdomen for softness/firmness and pain  Last BM  Reports of nausea, vomiting, flatulence, indigestion  Incision, dressing, binder, ostomy, PEG, NG tube, drain  NPO, type diet, tolerance of diet, IV fluids Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Urinary Assessments  Bladder palpable?  Last time the patient voided  Burning, frequency, difficulty starting the urine stream  Foley catheter: intact, secured to leg, patent, and color and clarity of the urine  Intake/output Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Integumentary Assessments Color Temperature Moisture Turgor Integrity: if immobile, assess pressure points  Lesions, wounds, scars, rash, ecchymosis  Other breachment of first line of defense: IV or SL site      Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Musculoskeletal Assessments  Movement and range-of-motion of joints and extremities  Strength of hand grips and foot flexion  Ability to stand and walk; balance  Continuous passive motion machine  Splints, casts, traction, over-the-bed trapeze bar  Walker, cane use Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition True/False Question Abnormal findings in a physical assessment should be reassessed within at least a 4-hour window, and sooner depending on the severity of the finding. A. True B. False Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Answer A. True Rationale: When assessment findings are outside the normal range for the specific patient, they are considered to be abnormal. Abnormal findings in a physical assessment should be reassessed within at least a 4-hour window or sooner depending on the severity of the finding. Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Patient Teaching Related to Needs Assessment Oxygen and circulatory Nutritional and fluid Safety and security Psychosocial and cultural Elimination Rest and activity Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence  Note: Adaptations in assessment technique may be necessary due to the age, size, and condition of the patient.  First assessments:  VS, SpO2, and pain  Affect Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence  Head         (cont.) Level of consciousness Pupils Conjunctiva and sclera Supplemental oxygen? NG tube? Oral mucosa and lips Oral/nasal airway device? Speech Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence (cont.)  Neck  Neck vein distention?  Tracheostomy ?  C-collar? Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence  Chest (cont.)  Heart sounds: AP rate and characteristics  Breath sounds  Respiratory effort  Respiration characteristics  Chest excursion  Chest tube  Telemetry  Incision, dressing  Any discomforts? Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence (cont.)  Arms  Apical-radial pulse strength the same?  Color and temperature of both hands  Edema of the hands  Bilateral equality of radial pulses  Capillary refill time for both hands  Strength of the hand grips  IV or saline lock  Skin integrity of the elbows Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence (cont.)  Abdomen            Shape Bowel sounds Soft or firm Pain with or without palpation? Last BM and voiding Bladder distention Skin turgor and common skin conditions Nausea or other discomforts? Incision, dressing, binder, drain tube Ostomy Any discomforts? Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence (cont.)  Perineum  Foley  Incontinent? Bed dry? Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence (cont.) Lower extremities  Movement and range of motion  Color and temperature of feet  Capillary refill time for each foot  Edema  Bilateral equality of pedal pulses  Strength of dorsal/plantar flexion  Skin integrity of heels  TEDs, SCDs, cast, traction, Ace wrap Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence (cont.)  Back and buttocks  Skin integrity  Incontinent? Bed dry? Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence (cont.)  Comfort and needs  Reposition comfortably with pillow support if needed  Correct the body alignment  Straighten wrinkled sheets in bed linens  Offer fluid if not NPO  Assess toileting needs  Inquire about any other needs Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Head-to-Toe Sequence (cont.)  Safety  Bed low and wheels locked  Rails up if needed  Call light within reach Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information in the Connection Features      Clinical Connection Knowledge People and Places Anatomy and Physiology Post Conference Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information in the Safety Features  Why are the particular safety features so important that they are highlighted as safety issues?  What could happen if those safety guidelines are not followed? Copyright F.A. Davis © 2015 Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information in the Skills Procedures  Review the steps of each of the skills procedures.  Make sure you understand why the steps are important.  What could happen if each of the steps are not followed or are followed out of order? Copyright F.A. Davis © 2015