Physical Assessment NURS G160 Natalie Dalton DNP, RN Why is Physical Assessment so Important? • Essential for providing safe patient care • To identify normal and abnormal findings • You are legally responsible for the care of your patients • Physical assessment is a skill • Under the Nursing Practice Act, only the RN can perform assessments, which includes analysis and formulation of a nursing diagnosis. This responsibility cannot be delegated or assigned to an LVN Pre-Assessment Preparation • Chart review • Chief complaint/reason for hospital admission • Medical history/ significant comorbidities • Surgical history • Vital sign trends • Lab trends • Review recent procedures and their results Basic Assessment Techniques • Inspection • Auscultation • Palpation • Percussion Let’s Start at the Beginning… • Introduction of self • Professional communication • Identify client • Explain purpose of assessment & timeframe • Protect client privacy • PPE considerations • Assess for pain • OLDCART • Visitors at the bedside General Survey • Level of consciousness • Orientation status • Clarity and appropriateness of speech • Facial expression • Facial and body symmetry • Overall appearance • Look around the room What do you see? Head and Neck • Face • Scalp • Need for aids (eyeglasses, hearing aid) • PERRLA • Oral cavity • Tongue • Ears • Neck (including ROM) • Focused questions? Thorax • Inspection • Symmetry • Shape • Breathing pattern • Heart • Apical pulse • Finding the apical pulse • Abnormal sounds • Lungs • Adventitious breath sounds • Focused questions? Adventitious Breath Sounds • Wheezing • Squeaking • Air passing through narrowed airway • Rhonchi • Coarse, snoring • Air passing through or around secretions • Crackles • Bubbling, cracking, popping • Air passing through fluid in the airway • Stridor • Loud, harsh • Narrowing of upper airway or presence of foreign body • Friction Rub • Rubbing or grating • Inflamed pleura rubbing against chest wall Auscultating Lung Sounds Abdomen • Abdominal assessment • Inspect • Auscultate • Gentle palpation • Percussion prn • Focused questions? Extremities & Mobility • Overall appearance • muscle size & tone • joints • Edema • Assess ROM • Strength • Focused questions? Neurovascular Assessment • The 6 P’s • Pain • Pallor • Peripheral pulses • Paresthesia • Paralysis • Pressure Skin Assessment • Color • Temperature • Moisture • Turgor • Signs of breakdown • Wounds and/or incisions • Rash or lesions • IV site • Presence of drains • Focused questions? Psychosocial • Assess for s/s anxiety, fear, stress • Assess primary and secondary roles • Assess support system • Assess for coping and/or defense mechanisms Patient Education • Fall risk reduction measures • Incentive spirometer • Instruct to turn, cough, deep breath (TCDB) • Diet & nutrition • Patient education specific to disease and/or injury management Concluding the Physical Assessment • Assess client concerns • Explain plan of care for the shift • Determine goal(s) for the shift • Answer questions • Assessment has been systematic and organized • Should be completed in 10 - 15 minutes Closing Act • Final check • Ensure safe environment • Call light • Personal items • Inform patient when you will return • Hand hygiene • Document assessment • Include significant positive and negative findings • Do not leave blank content areas or use ”N/A” inappropriately when documenting
