| Term | Definition |
|---|
| Physical assessment (data collection) | systematic examination of body structures |
| Purposes of physical assessment | evaluate the client's physical condition, detect early signs of developing health problems, establish a baseline for future comparison, evaluate the client's response to medical and nursing interventions |
| 4 assessment techniques | inspection, palpation, percussion, auscultation |
| Inspection | purposeful observation |
| percussion | striking or tapping a part of a client's body with the fingertips (least used by nurses) |
| palpation | lightly touching or applying pressure to the body (light and deep) |
| light palpation | using the fingertips, back or palm of hand |
| deep palpation | depressing tissue approximately 1 in with the forefingers of one or both hands |
| palpation provides info about | size, shape, consistency and mobility of normal tissue and unusual masses, symmetry or asymmetry of bilateral structures, skin temp and moisture, tenderness, unusual vibration |
| auscultation | listening to body sounds |
| assessment environment should include | door/curtain for privacy, padded/adjustable table or bed, room to move to either side of the client, adequate lighting, facility for hand washing, clean counter for equipment, lined receptacle for soiled articles |
| General data obtained when first meeting with the client includes | appearance regarding clothing/hygiene, level of consciousness (alert & oriented), body size, posture, gait/coordinated movement, use of ambulatory aid, mood/emotional tone |
| Two types of approach for data collection | head-to-toe and body system |
| head-to-toe | gathering data from the top of the body to the feet |
| body system approach | collecting data according to the functional systems of the body, exam of structures in each system separately |
| Order of data collection for head-to-toe | head and neck, chest, extremities, abdomen, genitalia, anus, rectum |
| data collection for the head involves | mental status, eyes, ears, mouth and oral membranes, facial skin, hair, scalp |
| mental status assessment | technique for determining the level of the client's cognitive functioning (for most, charting will read "alert and oriented" |
| when assessing the eyes, the nurse notes | general appearance, reaction to light and condition of conjunctiva |
| consensual response | brisk, equal, and simultaneous constriction of both pupils when one eye then the other is stimulated with light |
| PERRLA | normal nursing note for the eyes (Pupils are Equally Round and React to Light and Accommodation) |
| To assess the conjunctiva of the eye | the nurse pulls down the bottom eyelid -- normal is "pink and moist" |
| when assessing the ear of a child | the nurse pulls the ear down and back -- small amt of cerumen present is normal |
| when assessing the ear of an adult | the nurse pulls the ear up and back -- small amt of cerumen present is normal |
| when assessing the mouth and oral mucous membranes the nurse notes as normal | smile symmetrical, tongue midline, oral mucosal pink and moist |
| when assessing facial skin (and all other body areas) | skin should be smooth, unbroken, uniform in color, warm and resilient. should not be wet or dry |
| alterations in skin integrity | wound, ulcer, abrasion, laceration, fissure, scar |
| wound | a break in the skin |
| ulcer | open crater-like area |
| abrasion | an area that has been rubbed away by friction |
| laceration | torn, jagged wound |
| fissure | crack in the skin, especially in or near a mucous membrane |
| scar | mark left by the healing of a wound or lesion |
| when assessing the hair, the nurse inspects for | color, texture, distribution, and inspects for head trauma |
| when assessing the scalp, the nurse inspects for | smoothness, intact and free of lesions, also palpates the skull for unusual contour |
| when assessing the neck, the nurse inspects for | ROM, support of the head, JVD, thyroid for edema, coratid pulse, lymph nodes |
| when assessing the chest, the nurse inspects for | shape of chest (symmetrical is normal), skin turgur, heart rate |
| when assessing the lungs, the nurse inspects for | normal sounds in all fields (tracheal, bronchial, bronchovesicular, vesicular) and cough (if not normal, describe) |
| when assessing the upper extremities, the nurse inspects for | bilateral muscle strength by asking client to grasp, squeeze and release her fingers, pushes and pulls on forearms while client resist, checks capillary refill and radial pulse bilat |
| when assessing the abdomen, the nurse will | visually inspect for distention/symmetry then auscultation then palpate (in this order, out of order will result in false reporting), not LBM and voiding |
| when assessing the genitalia, the nurse notes | condition of skin, whether or not there is odor and whether or not there is drainage |
| when assessing the buttocks, the nurse notes | whether or not there is skin breakdown |
| when assessing the spine, the nurse notes | no curvature, or abnormal curvature (scoliosis, kyphosis, lordosis) |
| when assessing the lower extremeties, the nurse inspects | pedal pulses and ROM bilat (DP and PT) |
| DP (dorsalis pedius) | pulse on top of the foot |
| PT (posterior tibia) | pulse found at the ankle (interior) |
| when ending nurses notes of physical assessment the nurse | notes "no complaint of pain and no signs and symptoms of distress" if normal |
| when assessing the nose, the nurse inspects for | midline septum, clear of drainage |
| Lordosis | exaggerated natural lumbar curve of the spine |
| kyphosis | increased thoracic curve of the spine |
| scoliosis | pronounced lateral curvature of the spine |
Combine with other sets
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