Physical Assessment PDF

 Includes a complete health history and physical examination and forms a baseline database. :  Focuses on a limited or short-term problem  Focuses on evaluating a client’s progress.  rapid collection of data,often during the provision of lifesaving measures.  inspection, palpation, percussi...

 Includes a complete health history and physical examination and forms a baseline database. :  Focuses on a limited or short-term problem  Focuses on evaluating a client’s progress.  rapid collection of data,often during the provision of lifesaving measures.  inspection, palpation, percussion, and auscultation Inspection  The first assessment technique, which uses vision and smell Palpation  Uses the sense of touch  Assess texture, temperature, and moisture of the skin, as well as organ location and size and symmetry Percussion  Provides information related to the presence of air, fluid, or solid masses as well as organ size, shape, and position Auscultation:  Involves listening with a stethoscope Cyanosis:  Check lips and tongue  conjunctivae for pallor. Jaundice:  Check oral mucous membranes for a yellow color check the sclera  Poor turgor occurs in severe dehydration or extreme weight loss  To test skin turgor, pinch a large fold of skin and assess the ability of the skin to return to its place when released. Accumulation of fluid in the interstitial space Types Localized edema Causes traumatic injury from accidents or surgery, local inflammatory processes, or burns. Generalized edema (anasarca) An excessive accumulation of fluid in the interstitial space. 1 + (2mm)  Slight pitting, no visible distortion, disappears rapidly 2 + (4mm )  A somewhat deeper pit than in 1+  no readily detectable distortion  disappears in 10 to 15 seconds 3 + (6mm)  Noticeably deep pit that may last more than a minute; dependent extremity looks fuller and swollen 4 + (8mm)  Very deep pit that lasts as long as 2 to 5 minutes; dependent extremity is grossly distorted Fine crackles  High-pitched crackling (discontinuous sounds)  heard during the end of inspiration.  Not cleared by cough.  May be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases Coarse crackles  Low-pitched  bubbling that start early in inspiration and extend into the first part of expiration.  Not cleared by cough.  condition is worse than fine crackles  be heard in terminally ill clients with diminished gag reflex.  heard in pulmonary edema and pulmonary fibrosis. Wheeze (also called sibilant wheeze)  High-pitched, musical sound  Heard more commonly during expiration, but may also be heard during inspiration.  Heard in narrowed airway diseases such as asthma Rhonchi (also called sonorous wheeze)  Heard in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis  Low-pitched,  Actually sounds like snoring.  Heard primarily during expiration, but may also be heard during inspiration.  Coughing may clear. Pleural friction rub  A superficial, low-pitched sound.  Sounds like two surfaces rubbing together.  Heard throughout inspiration and expiration.  Loudest over the lower anterolateral surface. Not cleared by cough.  Heard in individuals with pleurisy (inflammation of the pleural surfaces) and pleuritis  Palpate the apical impulse at the 4th or 5th interspace, medial to the midclavicular line pulse deficit  difference between apical and radial pulse 5 Locations to hear to heart sound 2nd RICS (aortic) 2nd LICS (pulmonic) 3rd LICS (Erb’s point) 4th LICS (tricuspid) 5th LMCL (mitral)  inspection, auscultation, percussion, palpation. Absent sounds: Auscultate for 5 minutes before determining that sound absent Common Postural Abnormalities Lordosis (Swayback): Increased lumbar curvature Kyphosis (Hunchback): Exaggeration of the posterior curvature of the thoracic spine Scoliosis: Lateral spinal curvature Cranial Nerve Testing for meningitis  positive Brudzinski’s sign  Kernig’s sign  used in exam of neurological function for balance.  when a patient is able to stand with feet together and eyes open, but sways or falls with eyes closed HEARING LOSS TEST Rinne's and Weber's are tuning fork tests (512 Hz tuning fork) used to screen for conductive and sensorineural hearing loss.  detect the location and nature of the hearing loss. In conductive hearing loss,  the sound should lateralize to the affected side sensorineural hearing loss,  the sound lateralizes to the contralateral side