Physical Assessment Body Systems: Comprehensive Study Notes

Physical Assessment Body Systems Module

Module Overview

This module covers essential physical assessment skills, including:

  • Skill 1.1 Appearance and Mental Status

  • Skill 1.5 Blood Pressure

  • Skill 1.6 Pulse

  • Skill 1.7 Pulse Oximeter

  • Skill 1.8 Respirations

  • Skill 1.9 Temperature

  • Skill 1.10 Abdomen

  • Skill 1.17 Heart and Central Vessels

  • Skill 1.19 Musculoskeletal

  • Skill 1.22 Neurological Status

  • Skill 1.24 Peripheral Vascular System

  • Skill 1.25 Skin

  • Skill 1.27 Thorax and Lungs

Key Points from Health Assessment

  • Subjective vs. Objective Information:

    • Subjective: Symptoms reported by the patient (e.g., nauseated, headache, anxious).

    • Objective: Signs collected by the nurse or healthcare worker (e.g., physical assessment findings, vital signs, lab results).

  • Primary Source of Information:

    • The patient is always the primary source of information, even if confused, comatose, or a child.

    • Example: A caregiver might report a nonverbal patient has no bathroom issues, but an X-ray shows significant urine in the bladder and stool in the colon, revealing objective data that contradicts subjective family report.

  • Interviewing Questions:

    • Use a mix of open-ended questions (e.g., "What brought you into the hospital?" or "How many drinks do you have per week?") and close-ended questions (e.g., "Do you have a history of heart disease?").

    • If the patient is in distress, closed-ended or yes/no questions are more appropriate.

  • Creating a Comfortable Environment:

    • Reposition the patient for comfort.

    • Stay at eye level or sit down if time allows.

    • Ensure adequate lighting.

    • Adjust the room temperature.

    • Offer to take the patient to the bathroom.

    • Offer pain medication if necessary.

  • Assessment Techniques for Different Age Groups:

    • Toddlers:

      • Offer to let them play with equipment prior to use.

      • Have the toddler/provider demonstrate equipment on the provider or a toy.

      • Allow the child to sit on a parent's lap for non-invasive or non-painful parts of the assessment.

      • Stay at eye level.

      • Save painful or invasive procedures for last and be flexible with the assessment order.

      • Keep words simple and age-appropriate (e.g., "tummy" vs. "abdomen").

      • Incorporate play and being silly.

    • Older Adults:

      • Anticipate potentially more health problems and difficulty keeping track of hospitalizations and medications, which may require more assessment time.

      • Allow sufficient time for questions and answers.

      • Incorporate assistive devices as needed (e.g., walkers, canes, wheelchairs, hearing aids, glasses).

      • Reposition for comfort.

      • Offer to go to the bathroom prior to assessment.

      • Ask the patient to have a home medication list available to confirm accuracy.

      • Ask questions about activities of daily living (ADLs) such as ability to drive, dress, cook, shop, or manage finances.

      • Screen for depression.

  • Four Assessment Techniques:

    1. Inspection

    2. Palpation

    3. Percussion

    4. Auscultation

    • Note: For gastrointestinal (GI) assessment, always auscultate prior to palpating and percussing.

  • Allergy vs. Intolerance:

    • True Allergy: Will cause severe, systemic reactions such as throat or facial swelling, difficulty breathing, chest pain, a drop in blood pressure, urticaria (itching), and rash/hives. Facial/throat swelling is a priority concern.

    • Intolerance: A side effect of a substance, not a severe immune response (e.g., nausea, diarrhea, headache, heartburn, abdominal discomfort, anxiety).

Key Points from Vital Signs

  • The symbol >10 indicates "greater than 10."

  • Newborn Normal Vital Signs:

    • Pulse: 100-205 beats per minute

    • Respirations (RR): 30-80 breaths per minute

    • Temperature (Temp): 36.5-37.5^ ext{o}C (97.7-99.5^ ext{o}F)

    • Blood Pressure (BP): 50-70/30-45 mmHg

  • Adult Normal Vital Signs:

    • Pulse: 60-100 beats per minute

    • Respirations (RR): 12-20 breaths per minute

    • Temperature (Temp): 36.0-38.5^ ext{o}C (96.8-101.3^ ext{o}F)

    • Blood Pressure (BP): <120/<80 mmHg

  • Trending Vital Signs: It is crucial to discuss and monitor significant changes in vital signs over time.

  • Troubleshooting Scenarios:

    • Cold Fingers: Can affect pulse oximeter readings.

    • Recent Hot Water Intake: Can falsely elevate oral temperature readings.

    • Inability to Use Either Arm for BP: Assess alternative sites like the leg.

    • Inability to Feel Wrist Pulse for Vitals: Assess for an apical pulse or an alternative peripheral site.

Assessment Techniques

  • Inspection: To look or observe.

  • Palpation: To feel with the hands.

  • Percussion: To tap on the body surface to listen for sounds.

  • Auscultation: To listen with a stethoscope.

General Rules for Assessment

  • Always inform the patient what you are going to do before doing it, with the exception of counting respirations (do not tell them explicitly).

  • Keep directions simple and clear.

  • Always compare side-to-side of the body to identify asymmetries or abnormalities.

  • Describe any abnormalities observed, including the surrounding area and the patient's perception of the injury or issue.

  • Save known or assumed assessments that could cause pain for last. (In the clinical setting, once proficient, focused assessments will prioritize, but during initial learning, follow a systematic head-to-toe approach).

  • Focus on assessment techniques and findings, rather than solely on anatomy, physiology, or disease pathology.

General Survey

  • The physical assessment begins with a general survey, which is your overall impression of the patient from your initial observation.

  • Components of a General Survey:

    • Mental Status or Level of Consciousness (LOC): Assess alertness, orientation (person, place, time, situation), behavior, and affect/mood.

    • Glasgow Coma Scale (GCS): A standardized tool to assess LOC. It scores Eye Opening (range 1-4), Verbal Response (range 1-5), and Motor Response (range 1-6). A higher score indicates a better neurological outcome.

    • Appearance: Observe dress, hygiene, grooming, gait, and posture.

    • Anthropometric Measurements: Includes height, weight, and vital signs.

60-Second Assessment (Situational Awareness)

Upon interacting with a patient, quickly develop situational awareness by assessing:

  • Airway, Breathing, Circulation (ABCs): Without physically touching the patient, determine if clinical data indicates an urgent or non-urgent problem with ABCs.

    • Observe patient color (pale, gray, blue, and purple are all abnormal).

  • Tubes and Lines: Identify if any tubes or lines are present, and whether they are functioning correctly and safely positioned.

  • Respiratory Equipment: Check if the patient is using oxygen and if the equipment is functioning properly.

  • Patient Safety Survey: Identify any immediate safety concerns related to the patient.

  • Environment: Assess the room for potential hazards or enhancers of safety. Is the call bell within reach? Are 2-3 siderails up? Is the bed in a low and locked position? Does the patient have necessary assistive devices (e.g., cane, walker, crutches, wheelchair) at the bedside?

  • Sensory Input: What are your senses telling you? What do you hear, see, and smell?

  • Additional Information: What further data is needed to complete the initial assessment?

Neurological System

Brain Anatomy

  • Big Picture Concept: The anatomical structures of the brain and spinal cord directly correlate to the pathology or symptoms an individual will experience if that area is damaged (e.g., a stroke in the occipital region may cause visual deficits). This principle also applies to physical development; if a specific part of the brain is underdeveloped, the patient may lack the ability to perform the correlating function.

  • Central Nervous System (CNS): Comprises the Brain and Spinal Cord.

    • Brain:

      • The control center for the nervous system, regulating homeostasis.

      • Controls basic functions like breathing, heart rate, and blood pressure.

      • Regulates complex functions that define an individual, such as problem-solving, judgment, emotions, feelings, and memories.

      • Protection: Protected by meninges (membranes), cerebrospinal fluid (CSF), skull bones, and the blood-brain barrier (BBB).

        • Blood-Brain Barrier (BBB): Specialized endothelial cells that protect the brain from most substances while allowing passage of glucose, water, and O_2.

        • Note: Inflammation decreases the protective integrity of the BBB, putting individuals at increased risk for infections.

    • Cerebrum: The largest part of the brain, responsible for higher cognitive functions.

      • Frontal Lobe: Speech, thought, learning, emotion, voluntary movement.

      • Parietal Lobe: Processes sensory information.

      • Occipital Lobe: Processes vision.

      • Temporal Lobe: Stores memory, interprets auditory stimuli.

    • Cerebellum:

      • Controls muscle movement and balance.

      • Coordinates stimuli from the cerebral cortex and spinal cord.

      • Grooves on its surface (folia) allow for more neurons, increasing signal-processing capabilities.

    • Diencephalon: Located between the cerebrum and the brainstem.

      • Thalamus: The brain's relay center for sensory and motor signals.

      • Hypothalamus: Links the endocrine system to the nervous system and is the autonomic control center (e.g., regulating hunger, thirst, sleep, body temperature).

      • Epithalamus: Contains the pineal gland, which secretes melatonin.

      • Subthalamus: Integrates with the basal ganglia for motor control.

    • Brainstem: Connects the cerebrum and cerebellum to the spinal cord.

      • Contains the midbrain, pons, and medulla oblongata.

      • Controls reflexes.

      • Influences breathing, blood pressure, and heart rate.

      • Connects sensory and motor pathways.

      • Contains the Reticular Formation:

        • Relays information to the cerebral cortex about alertness and arousal mechanisms.

        • Directs the brain's attention to sensory events.

Cranial Nerves

  • Spinal Cord:

    • An extension of the medulla oblongata, passing through the skull.

    • Protected by meninges, cerebrospinal fluid (CSF), and bony vertebrae.

    • Transmits impulses to and from the brain.

    • Ventral roots: Carry motor nerve fibers.

    • Dorsal roots: Carry sensory nerve fibers.

  • Cranial Nerves (12 Pairs):

    • I - Olfactory: Sensory, responsible for smell.

    • II - Optic: Sensory, responsible for vision.

    • III - Oculomotor: Motor, controls pupillary reflex, eyelid movement, and allows eye movement in most directions (not controlled by IV & VI).

    • IV - Trochlear: Motor, turns the eye downward and laterally.

    • V - Trigeminal: Mixed (sensory and motor), with ophthalmic, maxillary, and mandibular branches controlling sensory impulses on the head.

    • VI - Abducens: Mixed (primarily motor, but listed as mixed in transcript), controls outward lateral eye movement.

    • VII - Facial: Mixed, responsible for taste (anterior 2/3 of tongue), facial movements (smiling, closing eyes, frowning), and production of tears and saliva.

    • VIII - Vestibular/Acoustic (Vestibulocochlear): Sensory, vestibular branch aids equilibrium and provides information about balance, posture, and movement; cochlear branch is responsible for hearing.

    • IX - Glossopharyngeal: Mixed, produces the gag and swallowing reflexes, taste (posterior 1/3 of tongue), and senses carotid blood pressure.

    • X - Vagus: Mixed, innervates voluntary muscles for coughing, swallowing, and speech; involuntarily senses aortic blood pressure, slows heart rate, and stimulates digestive organs.

    • XI - Spinal Accessory: Motor, controls movement of the trapezius and sternocleidomastoid muscles; helps control swallowing.

    • XII - Hypoglossal: Motor, controls tongue movement involved in speech and swallowing.

  • Spinal Nerves (31 Pairs):

    • 8 cervical

    • 12 thoracic

    • 5 lumbar

    • 5 sacral

    • 1 coccygeal

    • Each pair is responsible for a specific dermatome (segment of the body), though overlapping does occur.

Neurological Assessment

Mental Status and Level of Consciousness (LOC)

  • Mental Status: Assessed with a mini-mental test covering appearance, orientation, attention span, memory, language skills, and judgment skills.

  • Level of Consciousness (LOC): Refers to an individual's alertness and awareness of self and environment, and their appropriate response to stimuli. It is assessed using the Glasgow Coma Scale (GCS).

  • Glasgow Coma Scale (GCS): A tool used at the bedside, in conjunction with other clinical observations, to establish a baseline and provide ongoing measurement of a patient's LOC.

    • GCS scores less than 8 (<8) indicate a severe head injury; consider protection of the airway via intubation (i.e., GCS <8 = intubate).

    • GCS Scoring Breakdown:

      • Eye Opening Response (Total 4 points):

        • Spontaneous (open with blinking at baseline): 4 points

        • To verbal stimuli, command, speech: 3 points

        • To pain only (not applied to face): 2 points

        • No response: 1 point

      • Verbal Response (Total 5 points):

        • Oriented: 5 points

        • Confused conversation, but able to answer questions: 4 points

        • Inappropriate words: 3 points

        • Incomprehensible speech: 2 points

        • No response: 1 point

      • Motor Response (Total 6 points):

        • Obeys commands for movement: 6 points

        • Purposeful movement to painful stimulus: 5 points

        • Withdraws in response to pain: 4 points

        • Flexion in response to pain (decorticate posturing): 3 points

        • Extension response in response to pain (decerebrate posturing): 2 points

        • No response: 1 point

Nerves and Reflexes

  • Reflexes: Involuntary, almost instantaneous motor responses to a stimulus, assessed with a reflex hammer.

    • Reflex Arcs: Neural pathways that allow a sensory neuron to synapse in the spinal cord, resulting in a lightning-fast response.

    • Sensory input reaches the brain, but the brain does not need to process the signal to elicit the motor response.

    • Somatic Reflex: Causes skeletal muscle contractions.

    • Autonomic Reflex: Causes reactions from smooth muscle, cardiac muscle, or glands.

  • Developmental Reflexes: Some reflexes normal in newborns and infants are signs of peripheral nervous system (PNS) or central nervous system (CNS) damage in older children or adults.

    • Sucking reflex

    • Grasp reflex

    • Babinski Reflex (Plantar Reflex):

      • Testing: A healthcare professional uses the blunt end of an instrument to press a line into the bottom of the patient's foot. The line runs from the heel, along the outside of the foot toward the toes, and across the ball of the foot.

      • Normal (>2 years old and adults): All 5 toes bend downward; this reaction is called a negative Babinski.

      • Abnormal (>2 years old and adults): In a positive Babinski response, the toes spread outward, and the big toe moves upward and backward, indicative of an upper motor neuron dysfunction.

      • Normal (newborn, infant, and child <2 years old): The opposite is true; toes fan outward (+ Babinski) is a normal finding.

Motor and Sensory Function

  • Range of Motion (ROM): Assess by having the patient actively (by themselves) or passively (with nurse assistance) move arms and legs in circular motions. Assess for pain or limited mobility, and stop ROM exercises if pain occurs, reducing movement.

  • Motor Function: Compare strength side-to-side by having the patient push, pull, resist, or lift against the healthcare provider's resistance (e.g., patient squeezes both nurse's hands while the nurse compares for equal strength).

  • Sensory Function: Compare sensation side-to-side by lightly touching the skin with cotton wool or gently poking with a blunt pin (ensure no skin damage) to determine if sensation is felt and if it is felt equally on both sides.

Alterations in Neurologic Function

  • Decreased Level of Consciousness (LOC): A critical alteration that often precedes or accompanies many severe neurological conditions.

  • Increased Intracranial Pressure (IICP): A sustained elevated pressure above 15 mmHg within the skull.

    • Manifestations: Leads to oxygen deficit in the brain, causing personality changes and impairing memory and judgment. IICP is a medical emergency.

    • Interventions: Maintain a patent airway, monitor neurological assessment closely (LOC, behavior, motor/sensory function, pupillary size and reaction to light, vital signs), monitor ICP, implement seizure precautions, elevate the head of bed to 30^ ext{o} (unless otherwise indicated), monitor arterial blood gases (ABG), fluids and electrolytes, bladder distension, and bowel constipation. Provide emotional support, decrease environmental stimulation, avoid activities that increase ICP (e.g., coughing, sneezing, vasovagal maneuvers), and treat the underlying cause.

  • Seizure Disorder: Involuntary movements caused by abnormal electrical discharges in the brain; can be focal (localized) or general (widespread).

    • Interventions: Maintain airway patency, ensure patient safety, administer medications as ordered, provide emotional support, and identify and treat the underlying disorder.

  • Status Epilepticus: A continuous seizure lasting >30 minutes without regaining consciousness between seizures. This may cause alterations in breathing, injury, or pain perception and is considered a medical emergency.

    • Interventions: Maintain a patent airway, keep suction equipment at the bedside for excessive secretions, give oxygen by mask, monitor vital signs and circulation, perform frequent neurological assessments, establish IV access, insert a nasogastric (NG) tube if indicated, ensure safety, manage thermoregulation, and administer medications as ordered (e.g., anti-convulsants, which may cause apnea and require ventilation).

  • Concussion: A minor traumatic brain injury (TBI) that is common and can be difficult to diagnose due to symptoms manifesting days to weeks after the injury.

    • Symptoms: Confusion, nausea, headache, sensitivity to light or sound, and memory loss. Initial injury may or may not involve loss of consciousness.

    • Interventions: Seek medical evaluation, consider concurrent spinal cord injury, perform neurological assessment, ensure safety, monitor vital signs, provide emotional support, conduct vigilant neurological assessments looking for changes, and seek immediate medical attention if changes occur.

  • Traumatic Brain Injury (TBI): Typically results from a violent injury to the head, often by an object penetrating the skull.

    • Symptoms: Vary based on the location and amount of injury, and can include loss of consciousness, confusion, slurred speech, headache, nausea, mood swings, loss of balance, decreased LOC, weakness, and death.

    • Interventions: Maintain airway patency, keep suction equipment at the bedside, administer oxygen if needed, perform frequent neurological assessments (especially for signs of increased ICP or decreased LOC), monitor vital signs, consider a high probability of concurrent spinal cord injury, ensure safety, establish IV access, administer medications as ordered, and provide emotional support.

Head and Neck Assessment

The assessment includes evaluating facial symmetry, pupils, oral mucosa, dentition, swallow ability, and tracheal position.

  • Facial Symmetry: Compare the right and left sides of the face. Ask the patient to smile, raise eyebrows, and stick out their tongue. Look at folds of skin, wrinkles, and eyelids to identify differences. Dual neurological assessments are encouraged if you are unsure or suspect a neurological injury (e.g., a stroke).

  • Pupils:

    • Assess pupil size; normal size is typically 3-7 mm.

    • Mydriasis: Enlarged/dilated pupils. Can be caused by brain injury or certain drugs that increase adrenaline (e.g., atropine, amphetamines, LSD, marijuana).

    • Miosis: Constricted pupils. Can be caused by medications such as opioids or barbiturates, irritation to various parts of the eye, strokes, and other brain injuries.

  • PERRLA: Stands for Pupils are Equal, Round and Reactive to Light and Accommodation.

    • Pupils constrict when looking at objects close to the face and dilate when looking at objects far away.

    • To assess pupillary reaction to light, shine a bright light from the side of the eyes, moving towards the eyes, and watch for pupil response and size. Avoid shining the light directly into the patient's eyes, which can cause temporary vision impairment.

  • Snellen Chart: Used for visual acuity testing (common eye exam chart with letters or pictures).

    • Place the patient 20 feet from the chart.

    • Normal vision is 20/20 (what a person without visual problems can see at 20 feet).

    • A patient with 20/40 vision can see at 20 feet what a normal sighted person can see at 40 feet from the chart.

  • Hearing Tests:

    • Whisper Test: Whisper words behind the patient to see if they can hear them.

    • Audiograms: Tests ability to hear high-pitched and low-pitched sounds per ear.

    • Conduction Issues: Tested with a tuning fork.

      • Rinne Test: Tap the tuning fork and place it on the mastoid process.

      • Weber Test: Place the tuning fork on the patient's skull (midline).

  • Nasal Patency: Assess air movement through each nostril, ensuring there are no obstructions.

  • Oral Mucosa (including back of throat): Mucous membranes should be pink, moist, smooth, and without lesions.

    • Abnormal findings: Red, swollen tonsils with exudate or large white spots.

    • Technique: Avoid eliciting the gag response when using a tongue depressor by inserting it from the side of the mouth and asking the patient to open wide.

    • Any lesion or ulceration persisting for 2 weeks should be investigated by a physician.

    • Halitosis: Bad breath.

    • Leukoplakia: Chalky white raised patches, often called