Basic Physical Assessment

Head-to-toe assessment Major body systems assessment

Purpose
Gather baseline data Supplement, confirm, or refute data in nursing hx

Confirm and identify nursing diagnosis

Make clinical judgments about changing status Evaluate the physiological outcomes of care

Health History
Provides baseline subjective information Guides and directs your physical assessment Family history Life patterns Sociocultural history Spiritual health Mental reactions Emotional reactions

Identifies
Strengths Actual or potential health problems Support system Teaching needs Discharge and referral needs

Use of effective communications skills

PHYSICAL ASSESSMENT
Validates the patients complaints related to health

Assists in formulating nursing diagnoses and interventions

Monitors current health problems

Obtains baseline information for future assessments

Assessment techniques
Inspection Palpation
Percussion Auscultation

Always first!!!

Assessment techniques

Palpation
Temperature
Texture Moisture Organ size and location Rigidity or spasticity

Crepitation, Vibration
Position Size Presence of lumps or masses

Tenderness, or pain

Assessment techniques

Percussion
Assess underlying structures for location, size, density of underlying organs. Direct sinus tenderness Indirect- lung percussion Blunt percussionorgan tenderness (CVA tenderness)

Assessment techniques

Percussion sounds
Flatness bone or muscle
Dullness heart, liver, spleen

Resonance air filled lungs (hollow)

Hyperresonance emphysematous lung
(hyperinflated)

Tympany air-filled stomach (drumlike)

Assessment techniques

Auscultation
Listening to sounds produced by the body:
Heart Blood vessels Lungs Abdomen Instrument: stethoscope

Diaphragm
Bell

high pitched sounds

low pitched sounds

Assessment techniques

Auscultation
Avoid Interruptions Start with a general inspection first Proceed for specific observation of the system Examine the unaffected area or parts first Examine external parts first, then internal Compare one side to the other side Proceed from head to toe

Expose only the part being examined

Eyes - PERRLA
Shine light through pupil onto retina Cranial nerve III stimulated
Observe for pupillary constriction Observe for accomodation

Pupils: black, round, regular, equal in size, 3-7 mm

PERRLA = Pupils equal, round, reactive to light, accommodation

Pupils
Cloudy pupil: cataracts Dilated pupil: glaucoma, trauma, neurologic disorder Constricted pupil: drug use Pinpoint pupil: opioid intoxication

Great vessels of the neck

Jugular veins Empty unoxugenated blood directly into the
superior vena cava, which empties into the right side of the heart

Carotid arteries
Reflects cardiac systole and is timed with S1, Palpate only one at a time Carotid artery pulse correlates with first heart sound

Assessment
Position client supine Then head elevated at 45 degrees

INSPECTION: Lifts, heaves PMI (assess location)

General Reference Lines

Sternal Line Midclavicular Line
Apical /PMI left 5 th iCS midclavicular line

Axillary Line

Heart Auscultatory Sites

When auscultating sounds, place the stethoscpe over the four different site All physicians take money- APTM Aortic, Pulmonic, Trisuspic, Mitral The sites are identified by the names of heart valves but they are not located directly over the valves. Rather, these sites are located along the pathway blood takes as it flows throught the hearts chambers and valves.

Heart
Review: heart is in the center of the chest, behind and to left of the sternum Base is at top, apex is the bottom tip Apex touches anterior chest wall at 5th intercostal space medial to left midclavicular line Heart pumps blood through 4 chambers Events on left side occurs just before those on right Valves open and close, pressures within rise and fall and chambers contract as blood flows though each chamber

Cardiac Cycle
Systole: ventricles contract and eject blood from left ventricle into aorta and from right ventricle into pulmonary system

Diastole: ventricles relax and atria contract to move blood into ventricles and fill coronary arteries Diahragm of the stethoscpe for highpitched sounds heart sounds Bell- for low pitched sounds bruits, murmurs

Heart Sounds
S1: Lub: mitral valve closure

S2:

Dub:

Aortic valve closure

Heart Sounds S1 & S2

S1:
Closure of mitral and tricuspid valves (M1 before T1)

S2:
Closure of aortic and pulmonic valves

Correlates with the carotid pulse Can be split but not often

May have a split sound (A2 before P2)

Heart Sounds
S1 loudest at the apex (tricuspid), this sound corresponds to the closure of M1& T1 May be split. S2 loudest at the base (aortic), Physiologic S2 splitting- heard best at pulmonic area during peak inspiration S2 splitting when the pulmonic valve closes later than the aortic valve normal during inspiration Fixed split ASHD no variation with insp.

Extra Heart Sounds- S3

a low-pitch vibration in early diastole immediately after S2

Rapid ventricular filling: ventricular gallop May be a cardinal sign of CHF in adults
May be normal in children, and patients with high cardiac output (athletes) Pathological in adults: CHF, HTN, CAD

S1 -- S2-S3
Sounds like: Ken--tuc-ky

Extra Heart Sounds- S4

Soft, low-pitched sound in late diastole immediately before S1 Atria contract and eject blood into resistant ventricles (slow ventricular contraction): atrial gallop May be physiological in infants and small children Common in HTN pts S4-S1 S2 Sounds like Ten-nes--see

Heart Sounds
Normal (Lub-dub, Lub-dub) S1 Lub (Closure of AV Valves at start of systole)

S2 Dub (Closure of pulmonic and aortic valves upon end diastole)

3rd Heart Sound Middle 3rd of diastole 4th Heart Sound Atrial

S1
S4 MT

Systole Systole S2
A P

S2
S3 S4

Diastole
MT

S1
AP

Peripheral Pulses
Apply firm pressure with pads of index and middle finger on pulse site without occluding pulse Measure strength of pulse and equality Assess carotid, radial, and pedal Also assess brachial, posterior tibial, and dorsalis pedis

Peripheral Pulses
Apply firm pressure with pads of index and middle finger on pulse site without occluding pulse Measure strength of pulse and equality Assess carotid, radial, and pedal Also assess brachial, posterior tibial, and dorsalis pedis Documentation of Pulses

Grading
0 = Absent, not palpable 1+- Diminished, barely palpable

2+- Easily palpable, normal pulse

3+ - Full pulse, increased 4+ - Strong, bounding, cannot be obliterated

Lower Extremities
Pedal pulses Foot strength bilaterally

Homans Sign
Capillary refill (see next slide) Edema Pain

Capillary Refill
Should test fingers and toes Press down on nail to compress capillaries

Color goes white, then release

Color should return briskly; < 3 seconds Document sluggish if > 3 seconds

Assessing for Edema

Depress pretibial area & medial malleolus for 5 seconds Grade pitting edema
1+ to 4+

Lungs Anatomy and Landmarks

Lungs are paired but not symmetrical (see next slide) right lung = 3 lobes RUL, RML, RLL left lung=2 lobes LUL , LLL Lung border locations: Apices 1 inch above the clavicles Bases located at the level of the 6th rib (T10)

Lateral chest extend from the apex of the axilla to the 7th or 8th rib.

Lungs
Inspection
Color, Size and shape of chest, any deformities or lesions Resp. rate and depth Pattern of respiration regular rhythm Abnormal patterns Hyperventilation-fast rate and deep breathing Tachypnea >28 vs. bradypnea <10 Stertorous -death rattle seen in comatose patient

Lungs
Inspection Check size, shape, symmetry
Altered shape ex., COPD, barrel chest
Altered symmetry ex., kyphosis (hunchback), scoliosis (S)

Altered breathing ex., rib fractures, pneumothorax

Altered color ex., hypoxia Retractions from airway obstruction, respiratory distress Scars from lung surgery, trauma

Looking at related structures

Skin: cyanosis, pallor Nails: Clubbing
Spongy nail matrix and nail angle of greater than 160 degrees Associated with congenital heart disease

AP Diameter Anterior Posterior Diameter

The diameter of the chest from front to back should half the width of the chest.

AP-Transverse/Lateral diameter= 1:2;

Transverse/Lateral should twice as wide as front to back

Barrel chest emphesyma pts (alveoli lost its eleasticity so lung tissue
does not recoil back to normal COPD / Emphysema classically produces the "Barrel Chest Deformity" Lungs are overinflated, and pushing the chest wall out

Pectus carinatum (Pigeon chest) sternum protrudes out beyond the

front of the abdomen may be related to Rickkets

Pectus excavatum (funnel chest) sternum pushed in; depressed on all or

part of the sternum

Normal Breath Sounds

Bronchial over trachea Bronchiovescular over main bronchi Vesicular over lesser bronchi, bronchioles, and lobes

Adventitious/Abnormal Breath Sounds

Note whether the sound occur during inhalation or exhalation, or both.

Continuous sounds Wheezes Rhonchi

Discontinuous sounds Crackles (Rales) Fine Course *Atelectic crackles Pleural friction rub

Wheeze & Rhonchi Continuous Sound

Wheeze
high-pitched musical sounds heard first when a patient exhales

Partial blockage in airflow

Severe blockage wheezes also heard when patient inhales Asthma, CHF, or foreign body obstruction, tumors

Rhonchi
low pitched snoring, rattling sound heard primarily when the pt exhales may also be heard on inhalation disappears with coughing

Uncleared secretions, bronchitis, pneumonia,

Crackles Discontinuous Sound Crackles (Rales) -Caused by collapsed or fluid-filled alveoli popping open.
FINE Crackles
usually heard in the lung bases; CHF, Pneumonia, restrictive diseases pulm fibrosis, asbestosis, atelectasis (early CHF)

COURSE Crackles
during inhalation and may be present in exhalation Sounds like bubbling or gurgling as air moves through secretions in the larger airways COPD, pulm edema

Crackles Discontinuous Sound

Crackles (Rales) -Caused by collapsed or fluid-filled

alveoli popping open.

Atelectic crackles
common in elderly, disappears after several deep breaths

Pleural friction rub pericarditis

fluid in the pericardial space due to inflamed pleura pain on deep inspiration.

Pulmonary Edema
Accumulation of fluid in the air sacks (aveoli) of the lungs

Abnormal Breath Sounds

Diminished breath sounds
Obese, muscular chest wall poor inspiratory effort pleural effusion

Absent breath sounds

Missing lung/lobe airway obstruction, pneumothorax

Lungs - Palpation
Crepitus SQ air pockets = abnormal
Indicates subcutaneous air in the chest Feels like puffed rice cereal crackling under the skin and indicates air is leaking from the airways or lungs due to chest tube or open wound

Tactile fremitus increased fluid accumulation = abnormal

A palpable vibration that is caused by the transmission of air through the broncho pulmunary system
Decreased fremitus over areas where pleural fluid collects (effusion, and pneumothorax, atelectasis, emphysema) Increased fremitus abnormally seen in areas in which alveoli are filled with fluid and exudate, occurs with consolidation of lung tissue (pneumonia). You will feel more vibration.

Objective Data
Respiratory
Rate: 18 resp/min Depth: deep, even, shallow Effort: labored, unlabored

Breath Sounds Describe: clear, rhonchi, inspiratory/expiratory wheezes, crackles Location: all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat.

Cough: present/not present

Describe: productive, moist, nonproductive

Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.

 Position, Turn, Cough, Deep breathe

Interventions

O2 Method: nc, venti mask, rebreathing mask Flow rate: 2L/min; 3l/min Humidity: yes/no Pulse Oximeter: continuous, spot monitoring Incentive Spirometer: in use, n/a Time used: 10 am, 11 am, 1 pm, 3 pm Volume: 500 cc, 500 cc, 600 cc, 800 cc Oropharyngeal Suctioning: Describe- moderate amount thick tan secretions

Med List: Albuterol inhaler, Prednisone, Theophylline

Abdomen
Sounds, masses, tenderness Divide into four quadrants: RUQ, RLQ, LUQ, LLQ Inspect then auscultate Bowel sounds: absent, hypoactive, hyperactive Listen continuously for 5 minutes to determine absence Palpate and/or percuss after listening Abdomen should be soft, non-tender, nondistended

Abdomen
RUQ liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of colon, ascending /transverse colon, right kidney LUQ stomach, spleen, body of pancreas, left kidney, splenic flexure of colon, transverse/descending colon RLQ cecum, appendix, right ovary, tube, ureter, and spermatic cord

Midline aorta, uterus, bladder Epigastric, umbilical, suprapubic

Different Sequence of Assessment

Inspect Auscultate Percuss Palpate Note the abdominal shape and contour. The abdomen should be flat to rounded in people of average weight. A protruding abdomen may be due to obesity, pregnancy, ascites, or abdominal distention. A slender person may have a slightly concave abdomen

Procedure:
Have patient empty bladder Position patient supine with knees slightly flexed

Abdomen - Inspection
Lesions benign, scars from sx or trauma, striae, etc. Distention - can be from fluid, air, mass, or obstruction Pulsations - or movement of abdominal wall from peristalsis, pulsations and respiratory movement Peristalsis usually cant be seen. If seen, slight wavelike motions. Visible rippling waves may indicate bowel obstruction reported immediately. In thin pts, abdominal aortic pulsations may be seen in the epigastric area. Marked pulsations may indicate HTN, Aortic insuff, AAA, or other condition causing widening pulse pressure (see next slide)

Aneurysm
Note vascular sounds presence of bruits over aorta, renal, iliac, femoral Normally no bruits noted Abdominal aortic aneurysm surg emerg.-tx immed to prevent hemorrhage, shock, and death

If you see bounding pulsation on abd wall, feel for pulsations, and measure (greater than 6 cm- most likely aneurysm) report.

Auscultation of Bowel Sounds

Absent
no BS for 5 min

Hypoactive
less than 5/min

Active
5-30 per min

Hyperactive
> 30 /min

Abdomen - procedure
BOWEL SOUNDS VENOUS HUMS RENAL BRUITS INGUINAL BRUITS

Use diaphragm of stethoscope lightly on skin to prevent stimulating bowel sounds Start in RLQ (BS often present here) then proceed all four quadrants Listen for 3-5 minutes Note character and frequency of BS

Bowel Sounds
Normal BS are high-pitched, gurgling noises caused be air mixing with fluid
during peristalsis. The noises vary in frequency and pitch, and intensity. They are loudest before meal times. Normal BS 5-30 per minute

Borborygmus, or stomach growling are the loud, gurgling, splashing

bowel sound heard over the large intesting as gas passes through it.

Hyperactive BS - > 30 /min loud, high pitch, tinkling that occur

frequently may occur with diarrhea, constipation, and laxative use

Hypoactive < 5 per min; - occur infrequently assoc. with bowel

obstruction, ileus, peritonitis, and indicate diminished peristalsis. (paralytic ileus, use of narc meds can decrease peristalsis)

Absent, no BS for 5 minutes.

Be sure to allow enough time for listing in each quadrant before you decide that bowel sounds are absent. If NGT to suction, turn off suction as to not obscure or mimic sounds

Percussion

To assess -Density of abdominal contents -Locate organs -Screen for abnormal fluid or masses

Tympany predominantly over the abdomen gas-filled Dull over organs in the abdominal cavity (liver, spleen) CVA tenderness Costovertebral Angle CVA tenderness positive in pyelonephritis

Abdomen - Palpate
Palpate all four quadrants: To check for muscle resistance or rigidity; masses, fluid, tenderness. To palpate, put finger of one hand close together and make gentle rotating movements as you depress inch (1.3 cm) Light palpation depress 1 cm:Relaxation; Tenderness; Masses Palpate areas of pain and tenderness last Normal: the abd should be soft and nontender. As you palpate, note any

Abnormal findings: tenderness, masses, and rigidity

Palpation
Light Palpation TENDERNESS, MASSES, RIGIDITY
Deep Palpation Deep palpation depress 5-8 cm; thats about 2-3 inches. In obese, patient, put one hand over the other and push down.

Palpate the entire abd on a clockwise direction and not any: Tenderness; Masse s; Enlarged organs

Normally Palpable Structures

Know what is underneath so you can determine what can be expected from normal to abnormal Ex. suprapubic distention, full bladder or tumor? Sigmoid colon, stool can be palpated there

Liver should not be able to palpate liver way below the rib = enlarged

Rebound Tenderness
Use when found abdominal pain or tenderness Hold hand at 90 deg angle & push slowly & deeply Lift hand quickly Norm. response is no pain on release of pressure

Perform at end

ABDOMEN (summary)
INSPECT-SKIN, PULSATION AUSCULTATE FOR BOWEL SOUNDS IN 4 QUADRANTS FOR 2-5 MIN & DETERMINE IF AUDIBLE, ABSENT, HYPOACTIVE, HYPERACTIVE PERCUSS FOR TYMPANY & LIVER DULLNESS PALPATE LIGHTLY FOR TENDERNESS, MASSES, RIGIDITY

References
ASSESSMENT OF HEAD & NECK http://e-

courses.cerritos.edu/rsantiago/My%20Webs/ASSE SSMENT%20OF%20HEAD%20&%20NECK_SP% 2004.ppt Health History and Physical Assessment http://ecourses.cerritos.edu/rsantiago/My%20Webs/Power Point%20Presentations.htm

Physical Assessment http://webteach.mc.uky.edu/nursing/nur869/webque sts/lab1/Presentationphysical%20assessment.ppt

References
Rachel S. Natividad, RN,MSN: Assessment of the Abdomen
http://ecourses.cerritos.edu/rsantiago/My%20Webs/ASSESSMENT%20OF%20THE%20 ABDOMEN%20N212_n251%20SP04.ppt

Rachel S. Natividad, RN,MSN: Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system http://ecourses.cerritos.edu/rsantiago/My%20Webs/Cardiovascular% 20Assessment%20_N212_N251%20SP04.ppt Rachel S. Natividad, RN, MSN:The Respiratory System, Thorax and Lungs http://ecourses.cerritos.edu/rsantiago/My%20Webs/Resp%20Assess %20N212_251%20SP04.ppt