1. 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.”

2. Chapter 13:
Physical Assessment

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

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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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)

19. 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

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

21. Ears: cerumen; Weber test; Rinne test; audiometry

22. 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

23. 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

24. 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.

25. 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

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

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

28. 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

30. 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

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

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

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

35. 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

38. Self-Examinations
Breast-page 246
Testicular- page 252

39. 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.”