physical assessment handout

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11Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 1

CHAPTER 4Physical AssessmentCHAPTER 4Physical Assessment

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 2

OBJECTIVE DATA DEFINED OBJECTIVE DATA DEFINED

Objective data as OBSERVED by Objective data as OBSERVED by the PTthe PT–– Can be seen, heard, & measured Can be seen, heard, & measured –– Examples: rashes, altered vital signs, Examples: rashes, altered vital signs,

visible drainage or SWELLING/EDEMA visible drainage or SWELLING/EDEMA –– Lab results, diagnostic imaging, and Lab results, diagnostic imaging, and

other studiesother studies


WHAT DO YOU OBSERVE? WHAT DO YOU OBSERVE?

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OBJECTIVE VERSES OBJECTIVE VERSES SUBJECTIVE SUBJECTIVE

–– Subjective dataSubjective data–– Perceived by the patientPerceived by the patient–– Examples: pain, nausea, vertigo, and Examples: pain, nausea, vertigo, and

anxietyanxiety–– Pt may be unaware of symptoms unless Pt may be unaware of symptoms unless

the patient describes the sensationthe patient describes the sensation


Signs and SymptomsSigns and Symptoms

Disease and DiagnosisDisease and Diagnosis–– DiseaseDisease

It is any disturbance of a structure or It is any disturbance of a structure or function of the body.function of the body.It is recognized by a set of signs and It is recognized by a set of signs and symptoms.symptoms.Signs and symptoms are clustered in groups Signs and symptoms are clustered in groups to help the physician to make a medical to help the physician to make a medical diagnosis.diagnosis.The PT also relies on collaboration of the The PT also relies on collaboration of the team evaluations and assessments to collect team evaluations and assessments to collect both subjective and objective data both subjective and objective data


DiseaseDisease–– Disease or illness may be : hereditary, Disease or illness may be : hereditary,

congenital, inflammatory, degenerative, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, infectious, deficiency, metabolic, neoplasticneoplastic, traumatic, and , traumatic, and environmental.environmental.

–– Unknown etiologyUnknown etiologyDiseases that have no apparent cause.Diseases that have no apparent cause.

Signs and SymptomsSigns and SymptomsSigns and Symptoms

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Signs and SymptomsSigns and SymptomsRisk Factors for Development of Risk Factors for Development of DiseaseDisease–– A risk factor is any situation, habit, A risk factor is any situation, habit,

environmental condition, genetic environmental condition, genetic predisposition, physiologic condition, predisposition, physiologic condition, and other that increases the and other that increases the vulnerability of an individual or a group vulnerability of an individual or a group to illness or accident.to illness or accident.

–– Categories of risk factorsCategories of risk factorsGenetic and physiologic, age, environment, Genetic and physiologic, age, environment, and lifestyleand lifestyle



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Terms Used to Describe DiseaseTerms Used to Describe Disease–– ChronicChronic

–– Develops slowly and persists over a long period, Develops slowly and persists over a long period, often for a personoften for a person’’s lifetime s lifetime

–– RemissionRemissionPartial or complete disappearance of clinical Partial or complete disappearance of clinical and subjective characteristics of a diseaseand subjective characteristics of a disease

–– AcuteAcuteBegins abruptly with marked intensity of Begins abruptly with marked intensity of severe signs and symptoms and then often severe signs and symptoms and then often subsides after a period of treatmentsubsides after a period of treatment



–– InfectionInfectionCaused by an invasion of microorganisms, Caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites such as bacteria, viruses, fungi, or parasites that produce tissue damagethat produce tissue damage

–– InflammationInflammationProtective response of the body tissuesProtective response of the body tissuesto irritation, injury, or invasion by diseaseto irritation, injury, or invasion by disease--producing organismsproducing organisms



Frequently Noted Signs and Frequently Noted Signs and SymptomsSymptoms–– Signs of Infection and InflammationSigns of Infection and Inflammation

ErythemaErythemaEdemaEdemaHeat Heat PainPainPurulent drainagePurulent drainageLoss of functionLoss of function

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AssessmentAssessment

Process of making an Process of making an evaluationevaluation or or appraisalappraisal of the patientof the patient’’s conditions conditionCollection of subjective and objective Collection of subjective and objective datadata



Medical AssessmentMedical Assessment–– Functions That May Be Expected of the Functions That May Be Expected of the

PT PT –– Preparing the exam roomPreparing the exam room

Assisting with equipmentAssisting with equipmentPreparing the patientPreparing the patientCollecting specimensCollecting specimens


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Initiating the NurseInitiating the Nurse--Patient Patient RelationshipRelationship

IntroduceIntroduce yourself and state name, position, yourself and state name, position, and purpose of the interview.and purpose of the interview.Give an estimate of time.Give an estimate of time.Ask if the patient has any questions and Ask if the patient has any questions and answer them appropriately.answer them appropriately.Communicate trust and confidentiality.Communicate trust and confidentiality.Convey competence and professionalism.Convey competence and professionalism.

AssessmentAssessmentAssessment



Nursing AssessmentNursing Assessment–– The InterviewThe Interview

Provide relaxed, unhurried manner.Provide relaxed, unhurried manner.Conduct in a quiet, private, wellConduct in a quiet, private, well--lighted lighted setting.setting.Convey feelings of compassion and concern.Convey feelings of compassion and concern.Determine by what name the patient wishes Determine by what name the patient wishes to be addressed.to be addressed.PT should have an accepting posture, PT should have an accepting posture, relaxed, eye level, and pleasant facial relaxed, eye level, and pleasant facial expression.expression.


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Guess what ? Time to put you in Guess what ? Time to put you in the driver seat.the driver seat.

Break into twoBreak into two’’ssGrab your mind Grab your mind Shy ones are going to have an anxiety Shy ones are going to have an anxiety attack!attack!Practice makes perfect Practice makes perfect Perform a nursing introduction to your Perform a nursing introduction to your partner partner

We will discuss the process after the We will discuss the process after the exerciseexercise



Nursing Health HistoryNursing Health History–– Reasons for Seeking Health CareReasons for Seeking Health Care

Chief complaintChief complaint–– Document information in patientDocument information in patient’’s own words.s own words.


SOAP:SOAP:

SSubjective dataubjective dataOObjective data, bjective data, AAssessment, ssessment, PPlan. lan.

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Present Illness health historyPresent Illness health historyThe data collected from both subjective and The data collected from both subjective and objective data can found in the chart. objective data can found in the chart. IDNIDN’’ssand Doctors progress notes will describe the and Doctors progress notes will describe the time of onset of the current signs and time of onset of the current signs and symptoms.symptoms.

––Past Health HistoryPast Health HistoryPrevious hospitalizationsPrevious hospitalizationsAllergiesAllergiesHabits and lifestyle patternsHabits and lifestyle patternsAbility to perform Ability to perform ADLsADLsPatterns of sleep, exercise, and nutritionPatterns of sleep, exercise, and nutrition



Nursing Health HistoryNursing Health History–– Family HistoryFamily History

Includes health or cause of death, as well as Includes health or cause of death, as well as history of illnesshistory of illnessObjective is to determine patientObjective is to determine patient’’s risk for s risk for illnesses of a genetic or familial natureillnesses of a genetic or familial nature



–– Environmental HistoryEnvironmental HistoryProvides data about patientProvides data about patient’’s home s home environmentenvironment

–– Psychosocial and Cultural HistoryPsychosocial and Cultural HistoryData about primary language, cultural Data about primary language, cultural groups, educational background, attention groups, educational background, attention span, and developmental stagespan, and developmental stageCoping skills and family supportCoping skills and family supportIdentify major beliefs, values, and behaviors Identify major beliefs, values, and behaviors when treating themwhen treating them

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Nursing Health HistoryNursing Health History–– Review of SystemsReview of Systems

Systematic method for collecting data on all Systematic method for collecting data on all body systems.body systems.Record in clear and concise manner with Record in clear and concise manner with appropriate terminology.appropriate terminology.Ask specific questions relating to functioning Ask specific questions relating to functioning of each system.of each system.




–– Methods of Nursing Physical AssessmentMethods of Nursing Physical AssessmentHeadHead--toto--toetoeSystemSystem--byby--systemsystemFocusedFocused

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Nursing Physical AssessmentNursing Physical Assessment–– Performing the Nursing Physical Performing the Nursing Physical

AssessmentAssessmentItems needed: penlight, stethoscope, blood Items needed: penlight, stethoscope, blood pressure cuff, thermometer, gloves, and a pressure cuff, thermometer, gloves, and a tongue bladetongue bladePT also makes use of the senses; touch, PT also makes use of the senses; touch, smell, sight, and hearing.smell, sight, and hearing.



Figure 4Figure 4--11

Equipment used during a physical examination.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

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–– HeadHead--toto--Toe AssessmentToe AssessmentNeurologicNeurologic

––Level of consciousnessLevel of consciousness––Level of Level of orientationorientation––Hand gripsHand grips



Assess skin turgor by grasping fold of skin on back of patient’s hand, sternum, forearm, or abdomen.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)



–– HeadHead--toto--Toe Assessment (continued)Toe Assessment (continued)Head and neckHead and neck

––Note facial expression.Note facial expression.––Note symmetry of features.Note symmetry of features.

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Palpation of arterial pulses.

(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)


TIME FOR YOUR PHYSICAL TIME FOR YOUR PHYSICAL

““My name is weeMy name is wee--wee and I will be wee and I will be doing your head to toe assessment doing your head to toe assessment todaytoday””

physical assessment handout

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