Bell Ringer True/False 1. Weight and height is generally measured and noted during the first interaction with the client. 2. The head-to-toe approach involves a number of position changes required of the client. 3. The Rinne test is an assessment technique for comparing air versus bone conduction of sound. 4. Prolonged “tenting” of the skin when assessing skin turgor indicates edema in the client. 5. The lub-dub sounds of the heart are called “S1and S2.”

Chapter 13: Physical Assessment

Question Is the following statement true or false? The first step of the nursing process is planning.

Answer False. The first step of the nursing process is assessment.

Physical Assessment First step of the nursing process Assessment Physical assessment One method for gathering health data

Overview of Physical Assessment Purposes To evaluate the client’s current physical condition To detect early signs of health problems To establish baseline for future comparisons To evaluate client’s responses to medical and nursing interventions

Overview of Physical Assessment: Four Basic Physical Assessment Techniques Inspection(purposeful observation) Examining particular body parts Looking for specific normal and abnormal characteristics Using special instruments to inspect parts of the body inaccessible to ordinary visual inspection techniques

Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) Percussion Striking or tapping the body with fingertips to produce vibratory sounds Quality of sounds determines location, size, and density of underlying structures; variation in sound could mean possible pathologic change Pain: possible disease process or tissue injury

Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) Palpation Lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand Deep palpation Information: normal tissue and unusual masses; bilateral structures; skin temperature and moisture

Overview of Physical Assessment: Four Basic Physical Assessment Techniques (cont’d) Auscultation Used for assessing the heart, lungs, and abdomen Soft sounds, loud sounds Nurses: practice auscultation repeatedly to gain proficiency; to ensure accuracy, eliminate or reduce environmental noise

Question What is lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand called? a. Inspection b. Percussion c. Palpation d. Auscultation

Answer c. Palpation Palpation involves lightly applying pressure to the body using fingertips, back of the hand, or palm of the hand. Inspection is looking for specific normal and abnormal characteristics. Percussion is striking or tapping the body with fingertips to produce vibratory sounds. Auscultation is listening to the sounds of the heart, lungs, and abdomen with a stethoscope.

Overview of Physical Assessment Equipment Gloves Examination gown Cloth or paper drape Scale Stethoscope BP cuff Thermometer Pen light Tongue blade Assessment form and pen

Overview of Physical Assessment (cont’d) Environment Special examination room or at bedside Easy access to a restroom; a door or curtain to ensure privacy Adequate warmth Lined receptacle for soiled articles Adequate lighting

Overview of Physical Assessment (cont’d) Environment (cont’d) Padded, adjustable table or bed Sufficient room for movement around client Facilities for hand hygiene Clean counter or surface for placing examination equipment

Performing a Physical Assessment: Basic Activities During a Physical Assessment Gather general data during first contact with client Physical appearance; gait; coordinated movement; use of ambulatory aids; mood and emotional tone Preliminary data Vital signs, weight, height, documentation

Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) Drape and position the client Ensure that client is covered with a drape (sheet of soft cloth or paper) Begin examination with the client standing or sitting

Performing a Physical Assessment: Basic Activities During a Physical Assessment (cont’d) Select a systematic approach for collecting data Head-to-toe approach: prevents over looking some aspect of data collection; less time; less position changes for client Body systems approach: findings are clustered making the problem easier to identify; disadvantage- takes longer and the nurse look at same areas of the body several times Examining the client: Outline procedure for performing a physical assessment(Skill 13-1)

Data Collection: 6 General Areas for Data Collection Head and neck Mental status assessment Eyes: accommodation; Snellen eye chart; Jaeger chart; extraocular movements Ears: cerumen; Weber test; Rinne test; audiometry Nose: abnormalities; smelling acuity

Eyes: accommodation; Snellen eye chart; Jaeger chart; extraocular movements

Ears: cerumen; Weber test; Rinne test; audiometry

Data Collection: Six General Areas for Data Collection (cont’d) Head and neck (cont’d) Mouth and oral mucous membrane Unusual breath odors Assessment of taste Facial skin: alterations in skin *See table 13-4* Hair, scalp Neck

Question When preparing a client for the Rinne Test, which of the following equipment should the nurse keep ready? a. Stethoscope b. Tuning fork c. Snellen chart d. Jaeger chart

Answer b. Tuning fork A tuning fork is required to conduct the Rinne test to determine hearing impairment. A stethoscope is used to listen to lung, heart, and abdominal sounds. A Snellen chart and a Jaeger chart are tools for assessing far and near vision respectively.

Data Collection: Six General Areas for Data Collection (cont’d) Chest and spine Skin turgor Assess chest shape and movement; chest expansion Spine: lordosis, kyphosis, scoliosis Breasts Heart sounds: S1, S2, S3, S4

Collection: Six General Areas forData Data Collection (cont’d)

Collection: Six General Areas forData Data Collection (cont’d)

Data Collection: Six General Areas for Data Collection (cont’d) Chest and spine (cont’d) Lung sounds Normal Tracheal sounds Bronchial sounds Bronchovesicular sounds Vesicular sounds

Data Collection: Six General Areas for Data Collection (cont’d) Chest and spine (cont’d) Lung sounds (cont’d) Adventitious lung sounds Crackles Gurgles Wheezes Rubs

Question Which sound is not a normal lung sound? a. Tracheal b. Bronchial c. Vesicular d. Wheezing

Answer d. Wheezing Wheezing is an adventitious lung sound; it is not normal. Tracheal sound, bronchial sound, and vesicular sound are normal lung sounds.

Data Collection: Six General Areas for Data Collection (cont’d) Extremities Assessment of: Capillary refill Muscle strength Fingernails and toenails Edema: measurement Skin sensation

Data Collection: Six General Areas for Data Collection (cont’d) Abdomen Bowel sounds: hyperactive, hypoactive, absent Abdominal girth measurement Genitalia Anus and rectum Client positioning; trauma; hemorrhoids

Self-Examinations Breast-page 246 Testicular- page 252

Bell Ringer Answers True/False T 1. Weight and height is generally measured and noted during the first interaction with the client. F 2. The head-to-toe approach involves a number of position changes required of the client. T 3. The Rinne test is an assessment technique for comparing air versus bone conduction of sound. F 4. Prolonged “tenting” of the skin when assessing skin turgor indicates edema in the client. T 5. The lub-dub sounds of the heart are called “S1and S2.”