Davis Fundamentals Chapter 21 Physical Assessment

The first step of the nursing process and is ongoing throughout the nurse-patient relationship. It is the process you use to collect physical data that is relevant to the patient's health.

Assessment

Adventitous Breath Sounds

abnormal breath sounds heard (Crackles, course, stridor)

Atelectasis

Accumulation of fluid's somewhere in the body

Accommodation Response

A measure of the eye muscles ability to focus on an image up close and in the distance

Cheilitis

inflammation of the lip

Consensual Reflex

The reaction of the pupil when doing pupila

Crackles

discontinuous breath sounds heard usually when inspiration that may be either fine or course

Dysphagia

difficulty swallowing

Dysphasia

difficulty speaking

Eructation

belching (burping)

Excursion

chest expansion during respiration

Guarding

Protecting, clenching something that hurts

Halitosis

bad breath

Lethargic

sluggish

Ophthalmoscope

instrument used to examine the the eye

Otoscope

instrument for examining the ear

Paresthesia

Numbness anywhere in the body

Percussion

Usually done by a physician striking or tapping a body part with tips of fingers to located and determine the the size of a structure and if its hollow or solid

Ptosis

droopy eyelids

PERRLA

pupils equal, round, reactive to light and accommodation

Solar Lentigines

sun spots

Turgor

A test to test Elasticity of the skin

When you first start a physical assessment make sure to go over

Pre taken vitals, scan the room, wash your hands

The purpose of a physical Assessment

To establish the Pt's current condition, identify problems the Pt may have or potentially develop, evaluate the effectiveness of nursing interventions, monitor for changes in the body function, detect specific body systems that need further assessment or testing

Assessment of the whole person including the physical, mental, emotional, cultural, and spiritual aspects of the patient

Comprehensive health assessment

Assessment preformed at the begging of the shift when the nurse first sees the patient

Initial head to toe shift assessment

An assessment that involves an examination and an interview regarding a specific body system

Focused Assessment

Assessment finding are outside the normal range for specific patient

Abnormal assessment findings

Abnormal findings should be

reassessed within 4 hours or possibly sooner, depending on the severity of the finding

Objective data

Inspection or observation

Palpation

Percussion

Auscultation

Olfaction

When interviewing make sure to collects a patients

identity and demographics, details about their current condition, medical history, social history, allergies, height and weight, and expectations

Social History includes

Drugs, alcohol, smoking ,sex

Neurological Assessment includes

Vitals and level of consciousness, farcical symmetry, pupil size and reaction, ability to follow simple commands, speech, hand grip, feet flexion

Cardiovascular Assessment includes

Blood pressure and pulse, skin check, Color of mucous membranes, jugular vein distention, Heart Sounds, peripheral pulses, capillary refill, edema check, color and temp of extremities, clubbing of finger tips, activity tolerance, Laboratory results

clubbed fingers is a symptoms of what

heart disease and can be associated with lung disease

Skin color, moisture , and temperature, Turgor, and skin integrity is apart of

Integumentary Assessment

When checking skin color, moisture and temperature your looking for?

smooth, dry and intact

Anorexia

Not eating/ loss of appetite

Gastrointestinal Assessment your looking for

Anorexia,

Nausea or vomiting

Shape or distention of abdomen, Consistency of abdomen

Bowel sounds

Bowel elimination

Incontinence

Flatus

The abdomen should be

flat and non tender

Respiratory Assessment includes

Respiratory rate,

Respiratory effort

Respiratory pattern,

Symmetry of excursion,

spO2,

Breath sounds,

Use of accessory respiratory muscles,

Shape of chest,

Retractions,

Cough and sputum,

Skin color

Color of nail beds

Tolerance for activity

Laboratory test result

Symmetry of excursion is

symmetry of the chest

Last voided,

Distention of bladder

frequency , burning, or urgency

Color and clarity of urine

Incontinence is apart of

Genitourinary assessment

Musculoskeletal Assessment includes

Range of motion in joints

Presence of contractures

Strength of hand grip

Strength of foot flexion

Ability to sit up or turn to side

Eupnea

normal breathing/ normal rhythm

What is Accuchecks

blood sugar test

What is GCS and abbreviation for

Glasgow Coma Scale

What is the Glasgow Coma Scale

A scale that describe the extent of impaired consciousness

6 Cardinal Positions of Gaze

right & up

right

right & down

left & up

left

left & down

normal pupil dilation

is 3-7mm bilateral

5 Areas For listening to the heart

All People Enjoy Taking Money

Aortic, pulmonic,

ERBS Point, Tricuspid, Mitral

Documentation Of Assessment Findings

findings must be documented as soon as possible, Some hospitals use computerized documentation; others use handwritten documentation , Each facility will have a specific policy and procedures to follow, Facilities have designated forms to complete for initial head-to-toe shift assessments