Physical Assessment
Part 1
Helen Harkreader, RN, PhD

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 gathering information about the health status of a person identify concerns and needs that can be treated or managed by nursing care.
look, listen, touch,
 to make an informed decision about care.

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Initial
Focused
Ongoing
Shift Assessment
Emergency

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Reason for admission/chief complaint
Demographic information
History of present illness
Family history
Other history
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Medical: diabetes, heart disease, renal disease
Surgical history

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 helping the person manage or function with a health problem
 diagnosing and treating illnesses.

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Usually follows history
Head to toe approach
Includes (as needed): inspection, palpation, auscultation, and percussion

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How do they look overall?
What can you discern just by looking at and talking with them?
Are they
?
What is their mood?
How about nutritional status?
Vital signs?

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As you introduce your self and establish trust with the patient your are beginning the general survey

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Level of consciousness
Orientation
Confusion
Memory
Mood, affect
Signs of distress: dyspnea, anxiety

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Sagittal (through midline)-divides right and left; medial and lateral
Frontal plane- divides anterior and posterior
Transverse – divides top to bottom through pelvis; superior and inferior
Proximal and distal

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Visual examination - looking
Color, shape, size, symmetry, position and movement
Good lighting is very important

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Assessment through touch
Temperature, moisture, texture, tenderness, masses, and edema
May be light or deep, one hand or two
Make sure your hands are clean and fingernails short!

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Short, sharp strikes to the body surface to produce palpable vibrations and sounds
Maybe direct (one hand) or indirect (two hands)
Can detect size, shape, density and location of structures

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Listening to the sounds in the body
(usually with a stethoscope)
Used to listen to lung sounds, heart sounds and abdominal sounds
Keep your stethoscope clean!

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Head, Eyes, Ears, Nose, Throat
Look at distribution of hair. Are there any lumps on the head? Discolorations?
Is head normal size? Upright? Are the facial structures symmetrical in shape?

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Basically a Cranial nerve assessment
You
need to check each cranial nerve at this point, but be aware of what they are and how to assess them.

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Does the mouth droop?
Talk to the patient. Do all the facial muscles move together?
Can the person see and hear well?
Pupils equal, round and reactive to light and accommodation.
What does this mean?
Check the eye muscle function. Have the patient follow your finger to all eight positions.
Inspect the ear and assess hearing by talking to the patient

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 examine sensation and movement of the face: the facial nerve--CN VII and the trigeminal nerve--CN V
List the function of each cranial nerve.
Which ones are used for swallowing?

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Check the nose for abnormalities
If warranted, palpate the sinuses for tenderness
Look at mouth and neck. Take a look at the tongue. Are there white patches? Red patches?
Check range of motion for the neck (gently!).
Look at the neck for jugular vein distention.
This could indicate a heart problem.

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Where are these structures?
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Lymph nodes
Jugular veins
Carotid arteries
Trachea
Trapezius and sternocleidomastoid

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To assess the lymph nodes, place both hands on the neck at the same time and palpate using the
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Normal: not palpable or smooth, firm, less than 1 cm, mobile, and nontender

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 size, symmetry, position and movement of head temporomandibular joint

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Inspection
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Intact, free of lesions
Pink toned or underlying healthy glow
Palpation
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Warm, cold, moist, dry
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Lesion: Hard, firm, feels like fluid
Movable, fixed, attached to underlying structures

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 cyanosis (central, peripheral, circumoral), jaundice, pink tone, glowing, ashen pallor, erythema

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Turgor
Moisture
Temperature

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 macules, papules, nodules vesicles, bulla scales, plaque, patches (vitiligo) petechiae, necrosis, keloid linear, annular

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Size, color, type (primary, secondary), location, distribution
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 local vs. generalized
Annular, linear
Abrasion, laceration

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Distribution
Texture
Cleanliness, grooming
Scalp for lesions
Infestations

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Capillary refill
Abnormal shape
Clubbing