lOMoARcPSD|24705376
9/4/22
1
CHAPTER 20
Health History and
Physical Assessment
2
LEARNING OUTCOMES
•LO 20.1 Apply strategies used to conduct a patient interview, health history, and
review of systems.
•LO 20.2 Discuss the environmental and patient care activities that should be
completed before and during history taking and physical examination.
•LO 20.3 Use the four physical assessment techniques when examining each
body system.
•LO 20.4 Discuss factors for consideration during the general survey.
•LO 20.5 Demonstrate a focused and head-to-toe physical assessment, noting
opportunities for patient education.
•LO 20.6 Describe the activities and specific documentation that are required at
the completion of the physical assessment.
3
PATIENT INTERVIEW
•Health history
•Patient interview
•Phases
•Factors that affect the patient interview
•Subjective data
•Objective data
•Data organization
•Review of systems
•General health status
•Conditions or concerns related to each body system
•
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PREPARATION FOR PHYSICAL ASSESSMENT
•Physical environment
•Privacy, lighting, space, and comfort
•Equipment
•Arranged in the order it will be used
•Arranged in the order it will be used
•Prepared and checked for proper function
•Patient preparation
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•Identify verified
•Elimination needs met
•Properly dressed
•Emotional and safety needs met
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PREPARATION FOR PHYSICAL ASSESSMENT
•Privacy and confidentiality
•Personal chart review
•Positioning the patient
•Group techniques by position to limit position changes
•Integration of assessment skills with nursing activities
•Complete physical examination
•Focused assessment
•Preventive care
•Systematic approach
•
6CLIENT POSITIONS
7QUICK QUIZ! (1 OF 2)
1.When meeting a patient for the first time, it is important to establish a
baseline assessment that will enable a nurse to refer back to A.Physiologic
outcomes of care.
B.The normal range of physical findings.
C.A pattern of findings identified when the patient is first assessed. D.Clinical
judgments made about a patient’s changing health status
8
QUICK QUIZ! (2 OF 2) Answer:
C. A pattern of findings identified when the patient is first assessed.
9
ASSESSMENT TECHNIQUES
•Inspection
•Visually assessing a patient’s ambulation, body systems, and symmetry
symmetry
•Palpation- performed immediately after inspection
•Using touch to assess body organs and skin
- Nurse should take note of rebound tenderness or guarding
- Palpation uncovers rigidity, crepitation, and lumps
•relaxed, gentle, and systematic way
warm hands and short fingernails
-depressed 1cm (1/2 inch)
-brief intervals of applying intermittent pressure using 3-4 fingers together
Tender areas last
light then deep palp used to examine organ structures
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ASSESSMENT TECHNIQUES
•Deep palpation- usually practiced by advanced practice nurse or physician
- 4cm(2 inches)
•Bimanual deep palpation
-
Consider the boy area being palpated, reason for it, and patient’s condition
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Do not palpate thyroid of pt with thyroid condition- could release extra
hormone or cause pain/do not palpate major arteries
ASSESSMENT TECHNIQUES
•Percussion
•Tapping the skin to cause a vibration
- Advanced practice technique
•Auscultation
•Listening to sounds made by body organs or systems with and without the
assistance of a stethoscope
Heart, blood vessels, lungs, and abdominal cavity
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-
Some heard by naked ear – stridor, wheezing, or congestion
-
Characteristics of the sound depend on body tissue or organ
-
Sounds typically documented according to duration, intensity, and quality
-
Need to recognize normal body sounds
-
Diaphragm used for high pitch sounds – breath, bowel, normal heart
-
Bell – low pitch sounds – extra distant heart sounds & murmurs
GENERAL SURVEY – visual assessment & evaluation of whole pt
•Age – determines which screening exams and general health maintenance
activities are recommended to prevent illness and promote wellbeing
•Race – prevalence of certain health issues in specific races
•Sex and gender identity – conditions specific to gender/anatomy
•Sexual orientation
•Clothing- document clothing inappropriate for the season/circumstance(may be a
manifestation of med condition – cognitive impairment or mental health dis
•Hygiene and grooming- evaluate odors as being exercise, poor hygiene, or
specific disease states
•Affect and mood – mood approp for the situation, facial expressions, distress or
comfort level obv in most cases. Grimace in pain. Extremely dramatic behavior
can be a cultural norm
•
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GENERAL SURVEY
•Safety- fall into 3 categories
1. Use of assistive devices – walker, scooter, hearing aids, glasses
2. Environmental-living cond, home/work air quality, stairs or rugs, and
transportation means (overcrowded = exposure to commun diseases and
smoke inhalation)
3. Personal safety & security- required to ask pt directly if safe in home
o ask questions when pt is alone
o Observe for signs of withdrawal/hesitation when answering
o May need to complete an extensive community assessment
o Discharging for home care- be aware of support services
•Alcohol, tobacco, or recreational drug useo Inquire in nonjudgmental manner
o Avoid unanticipated complications with anesthesia
•Speech – assessed by rate, clarity, tone, and volume
o Difficulty articulating may indicate neurologic impairment
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Listen out for too rapidly or too slowly, moving without speech, talk to
self, whisper to real or imagined – emotional/mental disturbances
•Gait- observe when walking in exam room
o Erect, straight spine, free swing arm, slight round shoulder
o If pt slumped over, limping, holding body part – note this
o Observe for asymmetrical steps or hesitant forward motion of one or
both feet
o Document tremors, shuffling, limping, and ratchet-like movements of
limbs or gait
•Vital sign assessment – done at beginning of exam
o Findings serve as baseline for future assessments to determine pt’s
status
o Temp, pulse, resp, and BP
•Height and weight and body mass index
o Helpful for screening for overall body changes
o
14
o
Baseline height and weight determines med dosage, properly size
antiembolitic stockings, splints, and etc…
o
To accurately track weight – same time, scale, similar clothes
PHYSICAL EXAMINATION
•Skin, hair, and nails
•Skin inspection – natural lighting and room temp/collect subj data visual
inspection
•Skin color alterations
•Absence of pigment
•Absence of pigment
•Cyanosis
•Erythema and purpura
•Jaundice
•Pallor
•Vitiligo
15SKIN COLOR ABNORMALITIES
16PHYSICAL EXAMINATION
•Skin, hair, and nails
•Skin lesions – size, shape, color, location, and distribution
o Measure with clear, flexible ruler – document breadth circumference,
and height
•Primary – arising from normal skin
o Petechiae (tiny dark spots that indicate hemorrhage under the skin),
warts, psoriasis, poison ivy, or insect bites.
•Secondary - resulting from changes in primary lesions due to scratching,
trauma, infection, or the healing process
o Examples - pressure injuries, scars, and wound dehiscence
•Skin malignancies
•ABCDE – asymmetrical, border, color, diameter, evolving
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PHYSICAL EXAMINATION
•Skin, hair, and nails
•Palpation
•Texture – palpated using 2 or 3 fingers
o firm or soft and supple, smooth or rough, and thin or thick
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•Skin temperature- palpating the skin with the back of the hand, and it is
compared symmetrically on each body area
o should be uniform throughout the body
o environment often determines temp and skin appearance
o Palpation is especially critical to determine the level of circulation distal
to injuries or immobilized areas.
•Turgor - elasticity or ability to resist deformity after being displaced
•assessed by grasping a fold of skin (½ to 1 inch in thickness) on the forearm or
over the sternum along the second or third intercostal space and gently pinching
the fingertips together and then releasing
Not over loose or scarred areas
Decrease skin turgor- moderate to severe dehydration. If persistent pt is at risk of
skin breakdown and opportunistic organisms invading the barrier
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PHYSICAL EXAMINATION
•Skin, hair, and nails
•Edema - (swelling) is caused when there is a buildup of fluid in underlying
tissues
o stretched and glossy
o older pts – spongy resulting from decrease underlying muscle tone and
loss of skin elasticity
•Pitting edema -palpation causes an indentation that persists for some time
after the release of the pressure
Use caution in pt with cond assoc with venous or arterial insufficiency- tissue
trauma leading to bruising, ulceration, or permanent damage requiring skin
grafting
•
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PHYSICAL EXAMINATION
•Hair and scalp inspection and palpation
o Remove hair clips, pins, wig
o Explain assessment of hair and scalp requires separating layers of hair
to detect irregularities beginning at the hair shaft
o Inspect color, quantity, distribution, thickness, and texture
o If scalp lesions or bumps are found – ask pt about recent
trauma;describe characteristics assoc with abnormalities (pain, sz,
drainage); note home remedies if used
•Nail inspection and palpation – nail bed should be pink
o
Reflect pt’s gen health, nutrition, hygiene
o
Inspect for grooming, cleanliness, color, markings, and shape
o
Observe angle between nail plate & nail; condition of lateral & prox nail
folds (folds & cuticles should be smooth, intact skin, no
redness/inflammation
o
Palpate nail bed – firmly attached
o
Capillary refill – indication of peripheral blood flow – gently press with
thumb on pt nail tip for 1 sec and release. Goes white to pink. Tone
should be pink immediately after release
o
Cap refill longer than 2 to 3 sec- sign of respiratory or cardiac disease
assoc with hypoxia, anemia, or conditions linked to circulatory
insufficiency
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Document any abnormalities – thickening or ulceration of nails and skin
surfaces of hands and feet
20PHYSICAL EXAMINATION
21QUICK QUIZ! (1 OF 2)
2. A patient complains of thirst and headache. The patient appears
emaciated. Upon initial examination, you find that the skin does not
return to normal shape. This finding is consistent with A.Pallor.
A.Pallor.
B.Edema.
C.Erythema.
D.Poor skin turgor.
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QUICK QUIZ! (2 OF 2) Answer:
D. Poor skin turgor.
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PHYSICAL EXAMINATION
•Head, ears, eyes, nose, and throat
•Head inspection and palpation
•Head position - held upright, in a midline to trunk position, and remain
motionless during inspection.
•Skull contour- size, shape, and symmetry
o note of any abnormal lesions, incisions, masses, or nodules that are
distinct in appearance, texture, or contour from the skin nearby
o palpate the skull in a circular pattern, progressing systematically from
front to back
o should feel smooth and seamless, with the bones indistinguishable
from one another
o move freely over the skull without tenderness, swelling, or depressions
•Symmetry - The size, shape, and contour of the head and eye and ear
location should be mostly symmetric.
•Spasmodic muscular contraction or tics noted in the face, head, or neck of
the patient are often associated with varying amounts of pressure on facial
nerves and/or with psychogenic or degenerative changes to underlying facial
structures –( examples: nerve damage by cosmetic proc, airbag injury,
varicella-zoster infection)
- EARS – sensorineural – inner ear damage/conductive- vibration interference
to middle ear/mixed-middle-ear nerve damage
- Weber – pt complaint hearing loss in one ear
o Heard in bad ear – conductive
o Heard in good ear – sensorineural
- Rinne – compare bone & air conduction/ AC sound should be heard twice as
long as BC
o Conductive – pt hears BC sound for longer than, or as long as, AC
(BC>AC)
o Sensorineural – AC heard for slightly longer than BC (AC>BC)
- Romberg – equilibrium
o Ft tg, arms by side, eyes open then closed for 20 seconds
•EYES – positioned 1-2 in apart
o
Bulging” eyes often indicate hyperthyroidism or severe increased
intraocular pressure from trauma or glaucoma.
o
Abnormal eye protrusion – tumors or inflammation of orbit
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o
Ask pt to raise and lower eyebrows – observe for symmetry – indicative
of facial nerve palsy or facial cranial nerve dysfunction
o
Eye is open- superior eyelid should cover portion or iris not the pupil
o
Observe pt’s ability to completely open and close eyelid and blink –
close symmetrically
o
Eyelid drooping- congenital or aquired weakness of levator muscle or
paralysis affecting all portions of the oculomotor cranial nerve III
o
Orbital area for edema, puffiness, or sagging tissue below the orbit
o
Periorbital edema is never a normal finding – hypothyroidism, allergies,
renal disease, or infection
o
Slightly raised, flat, irregularly shaped, yellow-tinted lesions on the
periorbital tissues are called xanthelasma – abnormal lipid metabolism
o
Note how often lids close and if symmetric, infrequent, rapid or
uniocular
o
Palpate eyelids for nodules then gently palpate the eye with lids closed
– is it hard or does gentle pressure cause discomfort
o
Lids should feel smooth and same color as facial skin
PUPILLARY REFLEXES & ACCOMMODATION
o
– dark environment
o
REFLEX - Approach from one side while asking pt to focus straight
ahead in distance. And ask pt to avoid looking dir at light
o
Pupil should constrict immediately to indirect light followed by
constriction of the opposite pupil (consensual constriction). Repeat on
other side
o
ACCOMMODATION: eval eye ability to focus on near objects
o
– observe whether pupils converge and constrict when focused on obj
at close range
o
-have pt focus on distant obj & then on a pen or unlit penlight closer to
pt’s nose. Slowly move penlight closer to pt’s nose, look for bilateral
convergence & constriction of pupils
EXTRAOCULAR MOVEMENT
o
Multi-directional eye movement controlled by 3 cranial nerves (III,
oculomotor; IV, trochlear; and VI, abducens) and six extraocular
muscles
o
Critical aspect of assessing EO Movement is examination of the six
fields of vision
o
Pt & nurse seated or stand approx. 2 ft apart at eye level. Ask pt to
follow finger with just eyes through 6 fields of gaze. Smooth gliding
motion R, L, diag..approx 6-12 in from pt fields of vision. Then ask pt to
move eyes to the extreme lateral position (toward the ears), both left
and right. As the patient looks in each direction, note the presence of
normal parallel and equal eye movement and lid position or any signs
of abnormal movement.
VISUAL ACUITY
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o
Assess ability to see at close range
o
Evaluates cranial nerve II (optic nerve), patency, and central vision
o
Ask pt to read material at comfortable distance (14 in) glasses worn
o
Snellen – 20 ft; one eye at a time
•Nose and sinus inspection and palpation
•Nose – straight, symmetrical, smell, and breathe
•Sinuses – inspect maxillary sinuses below eyes for swelling and discoloration –
sinusitis, allergies, recent viral infection
palpate frontal sinuses using thumbs to press down on eyebrows without
pushing on eyes. Move gently down sides of nose to palpate maxillary sinuses
24 •Mouth, throat, and neck inspection and palpation
•Mouth – eval oral hygiene, teeth/gum cond, hydrated?, airway patency, ability
to meet nutrition needs, patency of cerebral blood flow
o Seated or lying down with elevated head 45
o Gloves, penlight, 2x2gauze, depressor
o Oral cavity- lips, buccal mucosa, gums, teeth, tongue, palate, mouth
floor, and pharynx. Steth for carotid patency in neck
o
•Dental assessment
•Oral mucosa, gums, tongue, uvula, tonsils, and palate- tongue blade and
penlight – inspect for color, texture, lesions, ulcers, bleeding, and patency
- Mucosa membranes – pale pink to pinkish red, moist, smooth, uninterrupted
surface
- Hard palate- depress tongue 2-3 cm clefts, signs of palate repair, yellow
coating over lining of pharynx – sinus inflammation. Ask pt to ‘ah’ soft palate
should move symm with vulva stighlty retracting but stayed in center
- Observe vulva & tonsils for enlargement, edema, and discoloration
- GUMS – pink-red, sheen of saliva
•Jaw- inspect for redness or swelling & palpate for edema or warmth.
Face asymmetry – swelling or malocclusions. Ask abt trauma, recent dental sx
or procedures
Jaw pain- impending myocardial infarction
Listen for clicking – refer tp spec
•
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PHYSICAL EXAMINATION
•Lymph nodes- defense against infection & abnormal cells -pro lymphocytes & A/b
•located neck and head
Note size, shape, location, & consistency of palpable nodes
Abnormal – hard, fixed, enlarged (immunocompromised/autoimmune
conditions, malignancy, allergies, or lupus (SLE)
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PHYSICAL EXAMINATION
•Neck – includes inspection, palpation, and auscultation
o Neck muscles examined for flexibility, strength, & discomfort
o Should be able to move head up, down, side to side without limitation
or pain
•Jugular veins
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o
Distended veins (JVD) indicate increased blood volume of conditions
interfering with the flow of blood into right side of heart
o
Observe with pt seated and head elevated at 45 degrees
o
Document by noting whether JVD is present or absent
Carotid Arteries
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o
Assess for patency and blood flow – visible bounding pulses
o
Palpate arteries separately or risk syncope
o
Then auscultate each artery for presence of a bruit
PHYSICAL EXAMINATION
•Thyroid gland – inspect for position and enlargement
o Should appear midline in neck and move up and down sans discomfort
when pt swallows
o Note any thyroid enlargement to be further palpated by advanced
nurse
•Trachea – cartilage rings – anterior to the esophagus and midline in the neck
directly above the sternal notch
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o
Passage of air from lungs to upper resp
o
Should be palpated by feeling for rings at sternal notch
o
Deviation to one side – tumors, thyroid gland enlargement, or cond like
pneumothorax
o
Promptly id abnormalities, movement limitations, or emergent
conditions to prevent perm disability or loss of function
RESPIRATORY ASSESSMENT
•Respiratory assessment BEGINS with questioning pt about risks for pulmonary
complications by using health assessment questions
•Inspection of the chest and breathing
o Need access to pt thoracic area
o Disrobe to waist- gown for privacy
o Sitting is best for posterial and lateral chest
o Anterior chest – sit or lie down
•Shape and configuration
•Breathing patterns – adult resp rates 12-20 – relaxed, automatic, effortless
o
Expand symm, breathing quiet
30PHYSICAL EXAMINATION
•Abnormal assessment findings
-
-
Barrel chest- chronic lung cond – horizontal ribs – hypertrophy neck
muscles
o
CLD – hyperinflation of lungs – pt adopts ‘tripod position’ – pursed lip
breathing to slow breathing rate & decrease resp effort
Limited thoracis cage movement – rib frac, cer palsy, musculoskel deform
31PHYSICAL EXAMINATION
•Auscultation of the lungs- steth- categorized by the airways that transmit them to
the chest wall. Larger airways produce louder/higher-pitched sounds
-
Inspire normally longer than exp in adults
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Harder in obese pt – move breast
-
Children – louder sounds
-
o
Pt sitting head bent forward – start at top of lung over posterior chest
wall between the ribs at C7
o
Ask pt to inhale and exhale
o
Side to side sequence moving downward comparing sides
Normal breath sounds
o
Tracheal – high, harsh, loud
o
Bronchial – high, hollow, loud – insp/exp- over main bronchi
o
Brochovesicular – medium, mixed quality, medium amp – insp/exp –
post between scapulae anter around uppersternum in first 2 intcost
spaces
o
Vesicular – low, blowing quality, soft amp – insp/exp- over most of lung
fields
A.Crackles – R & L lung base – sudden opening of small airways & alveoli
collapsed by fluid or exudate; CF, COPD, bronchitis, PE from left sided heart
failure
Brief crackling – blocked airway suddenly opens; inspiration described as fine,
med, or course
Fine - Soft, high-pitched, and very brief sounds during late inspiration and not
cleared by coughing
Medium - Lower-pitched, moist sounds best heard at the inspiratory midpoint
Couarse - Loud, effervescent sounds heard best during inspiration and not
relieved after coughing
B.Rhonchi – over trachea & bronchi; increased secretions in airways due to
pneumonia, increase airway turb fro mucus or muscle spasm; low pitched
snoring during inspiration or exp; cleared with coughing
C.Wheezes – all lung fields; High-velocity airflow through severely constricted
or obstructed airways due to asthma, foreign objects, bronchiectasis, or
emphysema; High-pitched, whistling sound heard on inspiration or expiration
but most obvious and loudest during expiration; also called sibilant wheezing
D.Stridor – trachea and large airways – turb sirflow upper airway – ind
seriouse airway obstruction from epiglottitis, croup, a foreign body lodged in
the airway, or a laryngeal tumor; Intense, high-pitched, and continuous
monophonic wheeze or crowing sound, loudest during inspiration when
airways collapse due to lower internal lumen pressure; often heard without the
aid of a stethoscope
E. Pleural Rub – ant lat thorax; inflamed pleural surfaces rubbing tg during
resp due to pneumonia or pluritis; low pitched, grating, or creaking insp & exp
B. Rhonchi- Anterior lateral thorax
Inflamed pleural surfaces rubbing together during respiration, due to pneumonia
or pleuritis
Low-pitched, grating, or creaking sound heard during inspiration or expiration and
not cleared by coughing
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PHYSICAL EXAMINATION
•Cardiac and peripheral vascular assessment – builds on info gained during resp
assessment
Cardiovascular system dependent on rhythmic, electrical cardia impulses &
adequate blood supply
•Inspection and palpation of the heart – best position lying on back – supine or
fowlers
Right ventricle – most of heart’s ant surface
Left ventricle – portion closest to 4 and 5 intcos spaces, medial to left
midclavicular line
-
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Begin at heart base moving toward apex
PHYSICAL EXAMINATION
1 •Auscultation of the heart – focus to ID low-intensity sounds from heart valve
clsures
•Heart sounds (S1-S4)
- S1&S2 – lub dub, one full heartbeat
- S3 – lub dub dub- rapid ventricular filling/children & adolescents. Usually
benign. Abnormal in adults 25-30 yo
- S4 – atria contract to enhance ventricular filling – not normal in adults but can
be normal in healthy older adults, children, and athelets. Document and report
•Dysrhythmias – can be life threatening; failure of the heart to beat at regular,
successive intervals
Apical pulse – listen over mitral area for 1 minute noting intervals between s1
and s2 and intervals between end and beginning of one heartbeat – should be
regular intervals
•Pulse deficit - radial pulse rate is slower than the apical pulse rate because of
cardiac contractions that are weak or ineffective at pumping blood to the
peripheral tissues and extremities.
•Cardiac murmurs (Grade 1-Grade 6) are blowing or swishing sounds heard in
systole or diastole. Increased or abnormal blood flow through the valves of the
heart/ asymptomatic or benign.
Doc location, char, intensity
Grade 1: Scarcely audible with a good stethoscope in a quiet room
Grade 2: Quiet but readily audible with a stethoscope
Grade 3: Easily heard with a stethoscope
Grade 4: A loud, obvious murmur with a palpable thrill
Grade 5: Very loud with a palpable thrill; heard over the pericardium and
elsewhere in the body (radiates)
Grade 6: Heard with a stethoscope off the chest; thrill palpable and visible
•Bruits -Auscultation for bruits should be performed over the abdominal aorta
using the bell of the stethoscope. Abdominal bruits or pulsations can be a sign
of an abdominal aortic aneurysm
•
35
PHYSICAL EXAMINATION
•Peripheral vascular assessmentInspection & Palpation- assess peripheral pulses and blood flow
Critical – jugular vein and carotid arteries
Auscultation – BP and listen for bruits over peripheral arteries
Use doppler for weak pulses
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•Peripheral vascular assessment
•Inspection and palpation of peripheral pulses - nurse notes its intensity, rate,
and rhythm as well as the existence of blood vessel tenderness, tortuosity
(bending and twisting), or nodularity.
•Intensity or volume of peripheral pulses
•0: Absent pulse
•1: Diminished
•2: Normal
•3: Bounding
37PHYSICAL EXAMINATION
1 •Brachial pulses
38PHYSICAL EXAMINATION
•Radial pulses outside wrist - thumb
•
39
PHYSICAL EXAMINATION
•Femoral pulses - groin
•
40PHYSICAL EXAMINATION
•Popliteal pulses – back of knee medial
41PHYSICAL EXAMINATION
•Pedal pulses – inner ankle
•Posterior tibial artery
42
PHYSICAL EXAMINATION
•Pedal pulses – top of foot
•Dorsalis pedis artery
43
PHYSICAL EXAMINATION
•Pedal pulses
•Doppler
44
PHYSICAL EXAMINATION
•Assessment for venous and arterial insufficiency - observe the patient’s skin
characteristics, especially in the lower extremities, in both sitting and standing
positions. Note any swelling, redness, nodules, protruding superficial veins, or
peripheral edema.
•Varicose veins – enlarged superficial veins- pregnancy, obesity, andv age, long
periods of standing
•Dependent edema – mostly lower extrem and caused by venous insufficiency
Gross amt of swelling in calves and lower leg – CHF or liver disease
•Phlebitis- inflammation of a vein typically due to irritation, often from iv
solutions or infection
•Five Ps – pt with arterial insufficiency exhibit 5 ps of circulation
•Pain
•Pallor
•Pulselessness
•Paresthesia – numbness/tingling
•Paralysis
- Cap refill to determine adequate blood supply and document
•Lack of hair growth, recurring ulcers, and brittle/thin skin
•
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45
PHYSICAL EXAMINATION
•Musculoskeletal assessment
•Inspection and palpation of the musculoskeletal system
o Begin with gait, arm swing normally
•Postural irregularities
•Mobility and strength
- ROM assessment – doc moves all extremities
•
•
46
PHYSICAL EXAMINATION
•Abdominal assessment •Inspection – quadrants/dorsal recumbent position
•Auscultation – supine/diaphragm side/soft gurgle every 2-5 sec
Bowel sounds can be described as normal, audible, absent, hypoactive,
hyperactive, or distant.
Then listen for bruits (swooshing)
•Palpation - bladder distention and ab wall irregularity – lipoma hernia
•
47
QUICK QUIZ! (1 OF 2)
4. When conducting an abdominal assessment, the first skill a nurse puts to
use is A.Auscultation. B.Inspection.
C.Palpation.
D.Percussion.
48
QUICK QUIZ! (2 OF 2)
Answer:
B. Inspection
49
PHYSICAL EXAMINATION
•Breasts and genitals – safety, security, comfort
•Breast assessment – teach pt importance of being familiar with look and feel
and report changes immediately
•Inspection - symmetry, size, and shape.
- Note any lumps, masses, flattening, retraction, or dimpling of the breast tissue,
as well as any drainage, bruising, scarring, or excoriation.
- Symmetry – raise arms then press against hips, extend arms traight while
sitting and leaning forward
- Divide into quads to document findings
•Palpation- mass usually felt in outer quad
•
•
50
PHYSICAL EXAMINATION
•The assessment of the female genitalia
•Inspection
•Palpation – inguinal area for lymoh nodes
51
PHYSICAL EXAMINATION
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•The assessment of the male genitalia
•Penis
•Inspection
•
52
PHYSICAL EXAMINATION
•The assessment of the male genitalia
•Penis
•Palpation
•
53
PHYSICAL EXAMINATION
•The assessment of the male genitalia
•Scrotum and testes
•Inspection
•Palpation
54
COMPLETION OF THE PHYSICAL ASSESSMENT
•Allow time to dress and offer needed supplies
•Return the exam area to its original condition
•Use PPE and infection control protocols
•Record the assessment in the EHR promptly
•Report serious abnormalities or questionable findings and document report
•Document patient education related to the physical examination
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Downloaded by kaylee chaffins (kayleechaffins1@gmail.com)