Physical Assessment

Acute Care Nursing Program 2005

Outline

Assessment Process Respiratory Assessment Cardiac Assessment Neurological Assessment Abdominal Assessment Neurovascular Assessment

Assessment Process

Inspection Palpation Percussion Auscultation Gather information base line Record trends

Respiratory Assessment

Inspection Palpation Percussion Auscultation

Respiratory Assessment

Inspection

General appearance, colour Scaring Symmetry Shape Position of trachea Work of breathing

Rate Rhythm Cough productive?

Respiratory Assessment

Palpation

Chest excursion Tactile and vocal fremitus

Respiratory Assessment

Percussion

Normal resonant, hollow sound Solid - dull Percussion is done in the intercostal spaces Percussion is done both on the posterior chest and lateral chest

Respiratory Assessment

Auscultation

Systematic approach Note adventitious (extra)

Crackles Wheeze Friction rub

Respiratory Assessment

Cardiac Assessment

Inspection Palpation (Percussion) Auscultation

Cardiac Assessment

Inspection

JVP Oedema Colour

Cardiac Assessment

Palpation

Pulse Oedema Capillary refill Blood pressure

Cardiac Assessment

Auscultation

Normal

S1 S2 S2 split S3 S4

Abnormal

Cardiac Assessment

Neurological Assessment

Glasgow Coma Scale Cranial Nerves

Glasgow Coma Scale

Assess neurological status Assessment of best response

Eyes Verbal Motor

Glasgow Coma Scale

Score 6 5 4 3 2 1 Best Eye -------------------Spontaneous To speech To Pain None Best Verbal ----------Orientated Confused Inappropriate Best Motor Obeys Localises pain Withdraws Flexion

Incomprehensible Extension None None

Cranial Nerves

12 cranial nerves 3rd 12th within brainstem (Midbrain, Pons, Medulla)

Cranial Nerve

I Olfactory
Function: Sensory Smell

Assessment: Recognition of odor

Cranial Nerve

II Optic
Function: Sensory Information from the retina Assessment: Visual acuity

Cranial Nerve

III Oculomotor
Function: Motor Four of the six extra-ocular muscles Assessment: Response to light Moves eye Elevates upper eyelid

Cranial Nerve

IV Trochlear
Function: Motor Controls the oblique eye muscle Assessment: Moves eye right, left, up and down

Cranial Nerve

V Trigeminal
Function: Mixed Three sensory

Corneal Reflex

One motor

Assessment: Normal facial sensation Blinks Clenches teeth

Cranial Nerve

VI Abducens
Function: Motor Lateral rectus muscle of eye Assessment: Moves eye laterally

Cranial Nerve

VII Facial
Function: Mixed Sensory

Tongue Eyelids

Motor

Assessment: Elevates eyebrows Puffs checks Recognizes tastes

Cranial Nerve

VIII Vestibulocochlear
Function: Sensory Hearing

Assessment: Whisper in each ear

Cranial Nerve

IX Glossopharyngeal
Function: Mixed Sensory

Taste buds Gag reflex

Motor

Assessment: Taste testing Test gag

Cranial Nerve

X Vagus
Function: Mixed Motor branches to the pharyngeal and laryngeal muscles Viscera of the thorax and abdomen Assessment: Same as IX

Cranial Nerve

XI Accessory
Function: Motor Innervates the sternocleidomastoid and trapezius muscles Assessment: Shrugs shoulders

Cranial Nerve

XII Hypoglossal
Function: Motor Tongue muscles

Assessment: Sticks out tongue

Abdominal Assessment

Inspection Auscultation Percussion Palpation

Abdominal Assessment

Inspection

Asymmetry Engorged veins Intestinal movements Lesions Scars Swelling

Abdominal Assessment

Auscultation

Systematic Bowel sounds

Abdominal Assessment

Percussion

All four quadrants

Tympanic- air filled structures Dull solid structures

Bowel Liver Bladder

Abdominal Assessment

Palpation

Light and Deep

Tenderness, guarding, rigidity

Define organs Kehrs sign McBurneys point Murphys sign

Neurovascular Assessment

Colour Temperature Capillary Refill Peripheral Pulses Swelling Movement Sensation

References

A Practical guide to clinical assessment http://medicine.ucsd.edu/clinicalmed/ Smith SF, Duell DJ & Martin BC, 2005, Clinical Nursing Skills, Prentice Hall, New Jersey.