Physical Assessment Exam Study Guide Pt 1

PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Nursing Assessment 1. Part of Nursing Process 2. Nurses use physical assessment skills to: a) Obtain baseline data and expand the data base from which subsequent phases of the nursing process can evolve b) To identify and manage a variety of patient problems (actual and potential) c) Evaluate the effectiveness of nursing care d) Enhance the nurse-patient relationship e) Make clinical judgments Gathering Data Subjective data - Said by the client (S) Objective data - Observed by the nurse (O) Document: SOAPIER Assessment Techniques: The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for the abdomen which is Inspect – Auscultation – Percuss – Palpate. A. Inspection – critical observation *always first* 1. Take time to “observe” with eyes, ears, nose (all senses) 2. Use good lighting 3. Look at color, shape, symmetry, position 4. Observe for odors from skin, breath, wound 5. Develop and use nursing instincts 6. Inspection is done alone and in combination with other assessment techniques B. Palpation – light and deep touch 1. Back of hand (dorsal aspect) to assess skin temperature 2. Fingers to assess texture, moisture, areas of tenderness 3. Assess size, shape, and consistency of lesions and organs 4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep C. Percussion – sounds produced by striking body surface 1. Produces different notes depending on underlying mass (dull, resonant, flat, tympanic) 2. Used to determine size and shape of underlying structures by establishing their borders and indicates if tissue is air-filled, fluid-filled, or solid 3. Action is performed in the wrist. D. Auscultation – listening to sounds produced by the body 1. Direct auscultation – sounds are audible without stethoscope 2. Indirect auscultation – uses stethoscope 3. Know how to use stethoscope properly [practice skill] 4. Fine-tune your ears to pick up subtle changes [practice skill] 5. Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill] 6. Flat diaphragm picks up high-pitched respiratory sounds best. 7. Bell picks up low pitched sounds such as heart murmurs. 8. Practice using BOTH diaphragms PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE General Assessment A general survey is an overall review or first impression a nurse has of a person’s well being. This is done head to toe, or cephalo-caudal, lateral to lateral, proximal to distal, and front to back. General surveying is visual observation and encompasses the following. Appearance Body structure/mobility Behavior appears to be reported age; sexual development appropriate; alert & oriented; facial features symmetric; no signs of acute distress weight and height within normal range (refer to Center for Disease Control and Prevention (CDC) Body Mass Index (BMI) [adult] or BMI-for-age and gender forms [children]); body parts equal bilaterally; stands erect, sits comfortably; gait is coordinated; walk is smooth and well balanced; full mobility of joints maintains eye contact with appropriate expressions; comfortable and cooperative; speech clear; clothing appropriate to climate; looks clean and fit; appears clean and well-groomed Deviations from what would generally be considered to be normal or expected should be documented and may require further evaluation or action, including a report and/or referral. Standardized and routine screening such as audiometric screening, scoliosis and vision screening using the Snellen Test are usually discussed in General Survey areas. *************************************************************************************************** Health History A patient history should be done as indicated by the age specific prevention guidelines, usually set forth by Center for Disease Control and Prevention (CDC), American Medical Association, American Association of Pediatrics, and National Association of Pediatric Nurse Practitioners. The Healthy People website (www.healthypeople.gov) provides an excellent source to determine benchmarks for healthy living across the life span. A comprehensive history, including chief complaint or reason for the visit, a complete review of systems, and a complete past family and/or social history should be obtained on the first encounter with a patient, regardless of setting and by a registered nurse. The history should be age and sex appropriate and include all the necessary questions to enable an adequate delivery of services according to prevention guidelines, scope of practice, patient need, visit requirement, and/or request. Usually, completing a provider based Health History and Physical Examination Form will assist in the assessment of the patient’s past and current health and behavior risk status. Certain health problems, which may be identified on a health history, PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE An interval history (including an update of complaints, reason for visit, review of systems and past family and/or social history) should be done. Usually family health histories are completed across three generations looking specifically for patterns in genetic issues that negatively impact quality of life. The health history gives picture of the patient’s current health and behavior risk status. Additional information than what is on a form may be required depending on the specialized service(s) to be provided or if the person presents with special needs or conditions. So a health history maybe may be problem focused, expanded problem focused, detailed, or comprehensive. Regardless, documentation must be completed for each visit and/or assessment. Mental status evaluation may be done while doing health history (see neuro review). *********************************************************************************************** Physical Examination A comprehensive physical examination should be performed according to age specific preventive health guidelines. American Medical Association clinical practice guidelines recognize the following body areas and organ systems for purpose of the examination: ◊ Body Areas: Head (including the face); Neck; Chest (including breasts and axillae); Abdomen; genitalia, groin, buttocks; Back (including spine); and each extremity. ◊ Organ Systems: Constitutional (vital signs, general appearance), Eyes, Ear, Nose, Throat; Cardiovascular; Gastrointestinal; Genitourinary; Musculoskeletal; Dermatological; Neurological; Psychiatric; Hematological/lymphatic/immunological ◊ Integumentary: Both overall body and organ systems should have skin assessments integrated into them. Integument includes skin, hair and nails. Normal and abnormal findings should be recorded on a health history and physical examination form. *********************************************************************************** Measurements Body measurements include length or height, weight, and head circumference for children from birth to 36 months of age. Thereafter, body measurements include height and weight. The assessment of hearing, speech and vision are also measurements of an individual’s function in these areas. The Denver Development Screening Test measures an infant’s and young child’s gross motor, language, fine motor-adaptive and personal-social development milestones. If developmental delay is suspected based on an assessment of a parent’s development/behavior concern or if delays are suspected after a screening of development benchmarks, a written referral is to a physician or pediatric nurse practitioner is imperative. A patient’s measurements can be compared with a standard, expected, or predictable measurement for age and gender. Deviation from standards helps identify significant conditions requiring close monitoring or referral to a physician or pediatric nurse practitioner. The significance of measurements and actions to take when they deviate from normal expectations are age-specific. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE How to measure Height: 1. Obtain height by measuring the recumbent length of children less than 2 years of age and children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used. a) Lay the child flat against the center of the board. The head should be held against the headboard by the parent or an assistant and the knees held so that the hips and knees are extended. The foot piece is moved until it is firmly against the child’s heels. Read and record the measurement to the nearest 1/8 inch. b) A modified technique in home settings is to lay the child flat and straight where the head should be held by the parent and the knees held so that the hips and knees are extended, mark the flat surface at the top of the head and tip of the heels. Move child and measure the distance between the marks with a tape measure. Read and record the measurement to the nearest 1/8 inch. 2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36 months growth chart. When a standing height is obtained for a two year old, plot the finding on the 2 year to 18 year chart. After plotting measurements for children on age and gender specific growth charts, evaluate, educate and refer according to findings. 3. Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults, using a portable stadiometer. The patient is to be wearing only socks or be bare foot. Have the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The flat surface of the stadiometer is lowered until it touches the crown of the head, compress the hair. A measuring rod attached to a weight scale should not be used. Measuring weight: 1. Balance beam or digital scales should be used to weigh patients of all ages. Spring type scales are not acceptable. CDC recommends that all scales should be zero balanced and calibrated. Scales must be checked for accuracy on an annual basis and calibrated in accordance with manufacturer’s instructions. 2. Prior to obtaining weight measurements, make sure the scale is “zeroed”. 3. Weigh infants wearing only a dry diaper or light undergarments. Weigh children after removing outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal clothing. 4. Place the patient in the middle of the scale. Read the measurement and record results immediately. Plot measurements on age and gender specific growth charts and evaluate accordingly Measuring Body Mass Index. 1. The Body Mass Index (BMI) is a measure that can help determine if a person is at risk for a weight-related illness. 2. Instructions for obtaining the BMI are included within the chart in this section for adults. To calculate BMI for children, see BMI Tables for Children and Adolescents for guidance. Measuring Head and Chest Circumference. 1. Obtain head circumference measurement on children from birth to 36 months of age by extending a non-stretchable measuring tape around the broadest part of the child’s head. For greatest accuracy, the tape is placed three times, with a reading taken at the right side, at the left side, and at the mid-forehead, and the greatest circumference is plotted. The tape should be pulled to adequately compress the hair. 2. Head circumference should be measured each visit. 3. Chest: This is measured at the nipple line. 4. In a newborn, the head circumference will be about 2 cm larger than the chest circumference. As the child ages, the chest circumference becomes larger than the head circumference. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Vital Signs Vital signs, generally described as the measurement of temperature, pulse, respirations and blood pressure, give an immediate picture of a person’s current state of health and well being. Normal and abnormal ranges with management guidelines follow for children and adults. Equipment Needed 1. 2. 3. 4. Stethoscope Blood Pressure Cuff Watch Displaying Seconds Thermometer General Considerations 1. The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the exam. 2. Ideally the patient should be sitting with feet on the floor and their back supported. The examination room should be quiet and the patient comfortable. 3. History of hypertension, slow or rapid pulse, and current medications should always be obtained. A. Temperature 1. Temperature can be measured is several different ways: a) Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C) b) Axillary with a glass or electronic thermometer (normal 97.6F/36.3C) c) Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C) d) Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C) 2. Of these, axillary is the least and rectal is the most accurate. 3. Use back of hand (dorsal aspect) to assess skin temperature B. Respiration 1. Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations 2. Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored? 3. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute. 4. In adults, normal resting respiratory rate is between 14-20 breaths/minute. 5. Rapid respiration is called tachypnea. C. Pulse – see also Cardiovascular Exam 1. Sit or stand facing your patient. 2. Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left). There is no reason for the patient's arm to be in an awkward position, just imagine you're shaking hands. 3. Compress the radial artery with your index and middle fingers. 4. Count the pulse for 15 seconds and multiply by 4. 5. Always count for a full minute if the pulse is irregular. 6. Record the rate and rhythm Note whether the pulse is regular or irregular: Regular - evenly spaced beats, may vary slightly with respiration Regularly Irregular - regular pattern overall with "skipped" beats Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Interpretation 1. A normal adult heart rate is between 60 and 100 beats per minute (see below for children). 2. A pulse greater than 100 beats/minute is defined to be tachycardia. A pulse less than 60 beats/minute is defined to be bradycardia. 3. Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning). Tachycardia is a normal response to stress or exercise. D. Blood Pressure – see also Cardiovascular Exam Blood pressure (BP) is the pressure by circulating blood on the walls of blood vessels. Arterial refers systemic circulation. During each heartbeat, blood pressure varies between a maximum systolic and a minimum diastolic pressure. The blood pressure in the circulation is principally due to the pumping action of the heart. Differences in mean blood pressure are responsible for blood flow from one location to another during circulation. The rate of mean blood flow depends on the resistance to flow presented by the blood vessels. Mean blood pressure decreases as the circulating blood moves away from the heart through arteries, capillaries and veins due to viscous losses of energy. Mean blood pressure drops over the whole circulation, although most of the fall occurs along the small arteries and arterioles. Gravity affects blood pressure via hydrostatic forces (e.g., during standing) and valves in veins, breathing, and pumping from contraction of skeletal muscles also influence blood pressure in veins. The measurement blood pressure without further specification usually refers to the systemic arterial pressure measured at a person's upper arm and is a measure of the pressure in the brachial artery, major artery in the upper arm. A person’s blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure and is measured in millimeters of mercury (mmHg). To measure Blood Pressure The patient should not have eaten, smoked, taken caffeine, or engaged in vigorous exercise within the last 30 minutes. The room should be quiet and the patient comfortable. 1. Position the patient's arm so the antecubital fold is level with the heart. 2. Center the bladder of the cuff over the brachial artery approximately 2 cm above the antecubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow. 3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure. 4. Place the stethoscope over the brachial artery. 5. Inflate the cuff 20 to 30 mmHg above the estimated systolic pressure. 6. Release the pressure slowly, no greater than 5 mmHg per second. 7. The level at which you consistently hear beats is the systolic pressure 8. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure. 9. Record the blood pressure as systolic over diastolic (120/70). Interpretation 1. Higher blood pressures are normal during exertion or other stress. Systolic blood pressures below 80 may be a sign of serious illness or shock. 2. Blood pressure should be taken in both arms on the first encounter. If there is more than 10 mmHg difference between the two arms, use the arm with the higher reading for subsequent measurements. 3. Always recheck "unexpected" blood pressures yourself. 4. It is frequently helpful to retake the blood pressure near the end of the visit. Earlier pressures may be higher due to the "white coat" effect. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE In children, pulse and blood pressure vary with the age. The following table should serve as a rough guide: Average Pulse and Blood Pressure in Normal Children Age Birth 6mo 1yr 2yr 6yr 8yr Pulse 140 130 115 110 103 100 Systolic BP 70 90 90 92 95 100 10yr 95 105 Blood Pressure Classification in Adults Category Systolic Diastolic Normal <130 <85 High Normal 130-139 85-89 Mild Hypertension 140-159 90-99 Moderate Hypertension 160-179 100-109 Severe Hypertension 180-209 110-119 Crisis Hypertension >210 >120 ****************************************************************************************************** PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE The Physical Exam A. B. C. D. E. F. G. H. I. Skin Head and Neck Exam; Lymphatic Exam Eye Exam Chest and Lung Exam Cardiovascular Exam and Peripheral vascular System Abdominal Exam Musculoskeletal Exam Neurologic Exam Genito-Urinary A. Examination of Skin 1. 2. 3. 4. Inspect: skin color and uniformity of color, moisture, hair pattern, rashes, lesions, pallor, edema Palpate: temperature, turgor, lesions, edema, texture Percussion and auscultation: rarely used on skin Terminology: pallor, cyanosis, edema, ecchymosis, macule, papule, cyanosis, jaundice, types of edema, vitiligo, hirsutism, alopecia, etc. 5. Pale, cool, moist skin can be indicative of heat stroke, shock or other cardiac complications. 6. There are abnormal and normal skin findings (such as nevus) ************************************************************************************************* B. Examination of the Head and Neck Equipment Needed 1. 2. 3. 4. Otoscope Tongue blades Cotton tipped applicators Non-latex exam gloves General Considerations The head and neck exam is not a single, fixed sequence. The assessment varies depending on the examiner and the situation. Head 1. Look for scars, lumps, rashes, hair loss, or other lesions. 2. Look for facial asymmetry, involuntary movements, or edema. 3. Palpate to identify any areas of tenderness or deformity. Fontanels in a newborn - toddler: 1. Posterior fontanel – triangle shaped; closes 1-2 months 2. Anterior fontanel – diamond shaped; closes at 9 months – 2 years PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Ears - See also notes under Cranial Nerves for other assessments related to ears and hearing 1. Inspect the auricles and move them around gently. Ask the patient if this is painful. 2. Palpate the mastoid process for tenderness or deformity. 3. Assess ears using otoscope: a) Hold the otoscope upside down with your thumb and fingers so that the ulnar aspect of your hand makes contact with the patient. b) For adults, pull the ear upwards and backwards to straighten the canal. c) PEDIATRICS: For children pull the ear down and back. d) Use the largest speculum that will fit comfortably. e) Inspect the ear canal and middle ear structures noting any redness, drainage, or deformity. f) Insufflate the ear and watch for movement of the tympanic membrane. g) Repeat for the other ear. 4. Normal color of eardrum: shiny translucent, pearly gray. 5. Abnormal findings: a) erythema – suppurative Otitis Media. purulent drainage. b) Dull, nontransparent gray – serous otitis media with effusion 6. Conductive hearing loss is due to mechanical dysfunction of inner or middle ear. 7. Sensory-neural loss is due to pathological problem of inner ear, CNS or cerebral cortex. 8. In older adults, there may be some normal high-tone hearing loss. Nose and sinuses It is often convenient to examine the nose immediately after the ears using the same speculum. 1. Tilt the patient's head back slightly. Ask them to hold their breath for the next few seconds. 2. Insert the otoscope into the nostril, avoiding contact with the septum. 3. Inspect the visible nasal structures and note any swelling, redness, drainage, or deformity. 4. Repeat for the other side. 5. Turbinates should be pink and moist 6. Frontal sinuses are below eyebrows 7. Maxillary sinuses are below zygomatic arch Mouth and Throat It is often convenient to examine the throat using the otoscope with the speculum removed. 1. Ask the patient to open their mouth. 2. Using a wooden tongue blade and a good light source, inspect the inside of the patients mouth including the buccal folds and under the tongue. Note any ulcers, white patches (leukoplakia), or other lesions. 3. If abnormalities are discovered, use a gloved finger to palpate the anterior structures and floor of the mouth. 4. Inspect the posterior oropharynx by depressing the tongue and asking the patient to say "Ah." Note any tonsillar enlargement, redness, or discharge. 5. Hard palate is located in the anterior part of the mouth. It is made of bone and is pale or whitish. 6. Soft plate is located in the posterior part of the mouth. It is softer, more mobile and pink in color. Neck 1. Inspect the neck for asymmetry, scars, or other lesions. 2. Palpate the neck to detect areas of tenderness, deformity, or masses. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Lymph Nodes 1. Systematically palpate with the pads of your index and middle fingers for the various lymph node groups. 2. Preauricular - In front of the ear 3. Postauricular - Behind the ear 4. Occipital - At the base of the skull 5. Tonsillar - At the angle of the jaw 6. Submandibular - Under the jaw on the side 7. Submental - Under the jaw in the midline 8. Superficial (Anterior) Cervical - Over and in front of the sternomastoid muscle 9. Supraclavicular - In the angle of the sternomastoid and the clavicle 10. The deep cervical chain of lymph nodes lies below the sternomastoid and cannot be palpated without getting underneath the muscle. Inform the patient that this procedure will cause some discomfort. 11. Hook your fingers under the anterior edge of the sternomastoid muscle. 12. Ask the patient to bend their neck toward the side you are examining. 13. Move the muscle backward and palpate for the deep nodes underneath. 14. Note the size and location of any palpable nodes and whether they were soft or hard, nontender or tender, and mobile or fixed Thyroid Gland 1. Inspect the neck looking for the thyroid gland. Note whether it is visible and symmetrical. A visibly enlarged thyroid gland is called a goiter. 2. One way to look is to have person swallow sip of water; the thyroid gland will move upward with a swallow. 3. Move to a position behind the patient. Have the patient tilt head slightly to right. 4. Identify the cricoid cartilage with the fingers of both hands. 5. Move downward two or three tracheal rings while palpating for the isthmus. 6. Move laterally from the midline while palpating for the lobes of the thyroid. 7. Note the size, symmetry, and position of the lobes, as well as the presence of any nodules. The normal gland is often not palpable. Special Tests A. Facial Tenderness 1. 2. 3. 4. Ask the patient to tell you if these maneuvers cause excessive discomfort or pain. Press upward under both eyebrows with your thumbs. (frontal sinus) Press upward under both maxilla with your thumbs. (maxillary sinus) Excessive discomfort on one side or significant pain suggests sinusitis. B. Sinus Transillumination 1. Darken the room as much as possible. 2. Place a bright otoscope or other point light source on the maxilla. 3. Ask the patient to open their mouth and look for an orange glow on the hard palate. 4. A decreased or absent glow suggests that the sinus is filled with something other than air. 5. Not always definitive of disease process.