Physical Assessment
Physical Assessment
Physical Assessment
Nursing Process
SOAPIER
Positioning
Positions used during nursing assessment,
medical examinations, and during diagnostic
procedures:
Dorsal recumbent
Supine
Sims
Prone
Lithotomy
Genupectoral
Assessment Techniques
Inspection - critical observation
Take time to observe with eyes, ears, nose
Use good lighting
Look at color, shape, symmetry, position
Odors from skin, breath, wound
Develop and use nursing instincts
Assessment Techniques
Palpation - light and deep touch
Back of hand to assess skin temperature
Fingers to assess texture, moisture, areas of
tenderness
Assess size, shape, and consistency of
lesions
See Box 28-4, p. 529 to describe
characteristics of masses
Assessment Techniques
Percussion - sounds produced by striking
body surface
Produces different notes depending on
underlying mass (dull, resonant, flat, tympani)
Used to determine size and shape of
underlying structures by establishing their
borders and indicates if tissue is air-filled,
fluid-filled, or solid
See table 28-4, page 530 for percussion
notes
Assessment Techniques
Auscultation - listening to sounds produced by
the body
Direct auscultation sounds are audible without stethoscope
Indirect auscultation uses stethoscope
PRACTICE
In practice, you often will do focused PE examine only the pertinent parts
PRIORITIZE (ABCs, Maslow)
General Survey
General appearance, gait, nutrition status (NOT
to be confused with nutrition history), state of
dress, body build, obvious disability, speech
patterns, affect (mood), hygiene, body odor,
posture, race, gender, height, weight, vital signs
Height up to age 2 is recumbent
Add head circumference if child is less than 2 years
old
Integumentary System
Integument includes skin, hair, and nails
Integumentary System
Hair - texture, distribution, scalp, critters
Nails - inspect and palpate
Why palpate?
Cyanosis - is it true or d/t cold?
Blanch test (aka capillary refill or CFT): delayed return
of color indicates poor arterial circulation
Clubbing - loss of normal angle between nail and nail
bed d/t chronic oxygen deprivation
HEENT
Head - inspection and palpation
Size, shape, symmetry
Eyes
Visual acuity (Snellen for distance, Rosenbaum for
near vision)
Visual fields - assess peripheral vision
EOMs - checks 6 ocular movements; tests CN 3, 4,
and 6
Pupil response to light and accommodation;
Pupils constrict o light, and also to accommodate for
near vision (dilate for dimness and distance)
Direct and consensual pupil response
Corneal light reflex - checks eye alignment
Fundoscopic exam - ophthalmoscope
Terminology - myopia, presbyopia, ptosis, etc
Ears
Inspection and palpation
Inspect size, shape, position, discharge, lesions
Palpate for tenderness, any lesions
Lungs
Inspect, Palpate, Percuss (normal note is
resonance), Auscultate (normal is clear
and equal bilaterally)
Auscultate using diagram
Respiratory Terminology
Eupnea
Tachypnea
Bradypnea
Apnea
Hyperventilation
Hypoventilation
Dyspnea
Breath Sounds
Auscultate using diaphragm, use a
systematic approach, compare each
side to the other, document when and
where sounds are heard
Normal breath sounds:
bronchovesicular, bronchial, and
vesicular
Abnormal breath sounds are called
adventitious sounds
Breath Sounds
Stridor - may be heard without stethoscope,
shrill harsh sound on inspiration d/t laryngeal
obstruction
Wheeze - may be heard with or without
stethoscope (document which), high-pitched
squeaky musical sound; usually not changed
by coughing; Document if heard on
inspiration, expiration, or both; May clear with
cough
Noise is caused by air moving through narrowed
or partially obstructed airway
Heard in asthma or FBA
Breath Sounds
Crackles - heard only with stethoscope
(formerly called rales): fine, medium, coarse
short crackling sounds (think hair); May clear
with cough
Most commonly heard in bases; easier to hear on
inspiration (but occurs in both inspiration and
expiration)
Breath Sounds
Gurgles - heard only with stethoscope
(formerly called rhonchi): Low pitched,
coarse wheezy or whistling sound usually more pronounced during
expiration when air moves through thick
secretions or narrowed airways
sounds like a moan or snore; best
heard on expiration (but occur both in
and out)
Any Questions?