Nursing Fundamentals - Health and Physical Assessment Part 1

The nurse

Body: assess the physical systems

Mind: assess mental health

Spirit: assess for religious or spiritual beliefs

Assess: gather data

Diagnosis: client problems that are based on medical diagnosis

Plan: goals

Implement: interventions

Evaluate: how the client responded to the intervention

The nursing process is not linear. The nurse will jump back and forth between the steps depending on additional data acquired about the client.

interpreting sign and symptom data

prioritizing what is important

generating solutions by making a plan

understanding WHY an intervention is done

gathering more information if there is not enough to make an informed decision

evaluating if interventions or teaching was effective

A plan that the healthcare team agrees to for guiding client care and is based on evidence based practice (EBP).

During the assessment even while the client is being admitted

During the admission, assessment data is gathered by the nurse such as home environment and available resources so that teaching can begin right away, if there are needs.

By using 2 client identifiers:

1. name and

2. date of birth, social security number, phone number or address

Name and date of birth is most typically used.

gather data (especially abnormal data) about the client to heal the client or prevent them from getting sick.

notify the health care provider (HCP) of immediate complications or changes in the client’s condition in order to update the care plan.

The HCP can be a doctor, nurse practitioner or physician assistant.

inspect

palpate

percuss

auscultate

Focused health assessment: Focuses on the immediate concern and is done when the client has a specific complaint or immediate information is needed.

Comprehensive health assessment: When the nurse assesses the entire client head to toe.

neuro

respiratory

cardiac

gastrointestinal

kidneys

musculoskeletal

skin

labs

CBC, BMP or CMP

labs specific to problem

imaging diagnostic tests

x-rays, CT scan, MRI, etc

medical and surgical history and physical from HCP

medication administration record (MAR)

Post-Op: focused assessments every 5- 15 minutes

ICU: every 1-2 hours

Progressive or Step-down unit: about every 2-4 hours

Medical-surgical unit: about every 4-8 hours

Subjective data: what the client tells you

Objective data: what anyone can observe

Subjective data example: the client’s stated pain level

Objective data example: a set of vital signs

dehydration

stress

ovulation

strenuous exercise

Those at risk of bleeding or infection should avoid rectal temps.

ex: DIC or leukemia

Those that have had oral surgery, because of a risk of trauma to the mouth.

pulse oximeter

Posterior: the back of something

Anterior: the front of something

Assess the level of consciousness by asking the client 4 questions:

Person: “What is your name?”

Place: “Where are you?”

Time: “What year is it?” or “Who is the president?”

Situation: “Do you remember why you are here?”

Distal: away from something

Proximal: closer to something

PERRLA is using a light to check if Pupils are:

Equal

Round

React to Light

Accommodate

Remember: pupils constrict as objects get closer.

Oh, Oh, Oh! To Touch And Feel A Good Velvet, Such Heaven!

Olfactory

Optic

Oculomotor

Trochlear

Trigeminal

Abducens

Facial

Acoustic/Vestibulocochlear

Glossopharyngeal

Vagus

Spinal Accessory

Hypoglossal

This will help you to remember the function and location of the nerves.

I. Olfactory: smell

II. Optic: vision

III. Oculomotor: movement of pupils and eyelids

IV. Trochlear: downward and inward movement of the eyes

V. Trigeminal: chewing

VI. Abducens: eye movement lateral (side to side)

VII. Facial: movement of all the facial muscles and taste

VIII. Acoustic/Vestibulocochlear: hearing

IX. Glossopharyngeal: swallowing and taste

X. Vagus: swallowing and speaking

XI. Spinal Accessory: shoulder movement

XII. Hypoglossal: tongue strength

Used to test a client's balance.

Have client stand with feet apart with eyes closed to assess balance.

When one eye droops.

frontal lobe

parietal lobe

temporal lobe

occipital lobe

cerebellum

Controls:

thinking

speech

personality changes

Processes information for:

temperature

taste

movement

Controls:

hearing

language comprehension

memories

Controls vision.

Controls:

movement

gait

balance

Cervical: C1-C8

Thoracic: T1-T12

Lumbar: L1-L5

Sacral and Coccyx: S1-S5

breathing

arm and neck movement

The strength of the:

chest

back

abdomen

The strength of the:

lower abdomen

buttocks

legs

The strength of the:

thighs

lower leg

genitals

Have you had any difficulty breathing at rest or with activity?

Have you had a cough?

If so, is it dry or a productive cough with mucus?

If productive with mucus, what color is it?

Vesicular

Bronchial (tracheal)

Bronchovesicular

Place the stethoscope at the top and go progressively down the anterior and posterior thorax.

Abnormal breath sounds

An area of the lungs where the movement of air cannot be heard.

dyspnea: difficulty breathing

tachypnea: rapid respirations > 20

bradypnea: slow respirations \< 12

Crackles are lung sounds caused by fluid in the lungs.

fine crackles: a little bit of fluid in the lungs that sounds like high-pitched popping sounds; click HERE for an audio sample.

medium crackles: condition is getting worse and lower-pitched popping sounds.

coarse crackles: bubbling sounds from fluids (really bad!); click HERE for an audio sample.

High squeaky lung sounds.

They are caused by the small airways narrowing, usually in asthma. Click HERE for an audio sample.

Low-pitched lungs sounds that resemble snoring.

It is caused by secretions in the airway. They may clear with cough. Click HERE for an audio sample.

An incomplete expansion of the lung that causes diminished breath sounds.

It is most common with pneumonia.

Apnea lasting 10-60 seconds followed by hyperventilation.

It indicates a dying client but may be normal in babies.

A high-pitched, harsh sound from an obstructed airway.

A low-pitched grating sound from pleurisy (inflammation in the lungs).

Click HERE for an audio sample.

asking the client about chest pain or chest discomfort

listening to heart sounds

checking pulses

checking capillary refill

checking skin temperature and color

checking for edema and skin turgor

assessing cardiac rhythm strip

Brady means slow

Tachy means fast

Bradycardia means a heart rate \< 60

Tachycardia means a heart rate >100

Use the mnemonic: "APE To Man" to remember.

Blood flow through the heart:

from systemic circulation into the vena cavas

right atrium > tricuspid valve > right ventricle

pulmonary valve > pulmonary artery > lungs

pulmonary veins

left atrium > mitral valve > left ventricle

aortic valve > aorta

systematic circulation (throughout the body)

back to the vena cavas

S1 and S2 are the normal heart sounds

It is sometimes known as "lub dub".

Click HERE for an audio sample.

S3 is usually an abnormal heart sound. Click HERE for an audio sample.

S4 is almost always associated with cardiac disease. Click HERE for an audio sample.

S3 and S4 are associated with fluid volume overload.

An abnormal heart sound other than "lub-dub". It can be a whooshing, swishing or clicking noise.

Click HERE for an audio sample.

4+: strong and bounding - indicates fluid volume overload

3+: full pulse - less severe fluid volume overload

2+: normal - easily palpable

1+: weak, barely palpable - indicates fluid volume deficit

Edema: when there's too much fluid in the body. It can be localized or throughout the body.

Pitting edema: when the skin remains indented after pressing with a finger.

Assessment criteria:

1+, 2mm: a small pit and rebounds in a few seconds

2+, 4mm: a medium pit and rebounds in a few seconds

3+, 6mm: a deep pit and rebounds in 10-20 seconds

4+, 8mm: very severe edema and rebounds in >30 seconds

Another word for generalized edema.

Assessing the client's fluid status by pinching a fold of skin.

If the skin tents up = dehydration or fluid volume deficit.

if the skin returns to the normal position = no fluid issue.

By pressing down on the nail bed.

if the pink color comes back in < 3 seconds, that is normal.

if the pink color comes back in > 3 seconds, it is abnormal.

Cap refill assesses the client's blood circulation.

Loss of consciousness

appendix, esophagus, gallbladder, large intestine, liver, pancreas, rectum, small intestine, stomach

listening to bowel sounds

ask when last bowel movement was

ask if passing gas

ask if patient experiences nausea/vomiting/diarrhea

determining appetite

Blood in the stool.

Sometimes called "tarry stools".

Blood in the vomit.

Malnutrition/wasting away.

inspect

auscultate

percuss

palpate

It is done from least to most invasive in order to not disturb the abdomen and cause inaccurate findings.

Listen to each quadrant for 5 minutes = a total of 20 minutes.

start at upper left, upper right, lower right, lower left

go in a counterclockwise direction

absent: no bowel sounds

hypoactive: 1 sound every 3-5 minutes

normal: 5-30 clicks or gurgles per minute

hyperactive: > 30 sounds per minute or an increase from the client's baseline

BMI = kg ÷ m2

Example: if a client weighs 70 kg and is 1.8 meters tall, the BMI is 70 ÷ 1.82 = 21.6

normal weight = 18.5 to \< 25

overweight = 25 to \< 30

obese = > 30

Nothing by mouth.

Don't allow the client to eat or drink anything. This is a common order for preventing aspiration during surgeries and procedures or when having an acute GI issue.

endocrine organ: to release insulin so the body can regulate glucose/sugar

exocrine organ: to release enzymes for food digestion

To store bile that's made by the liver for food digestion.

to make clotting factors to prevent bleeding

to make proteins so all the organs and cells can function

to metabolize toxins and cholesterol

to make bile for digestion

checking urine: output and color

monitoring: intake and output

checking labs: BUN, creatinine, GFR, electrolytes

urinalysis

adult: at least 30 mL/hour

infant (up to 1 year): at least 2ml/kg/hour

checking: muscle strength and range of motion

asking about: pain, numbness, and tingling

checking: electrolytes and other labs

imaging tests: spine and head

0 is no muscle strength

5 is normal muscle strength

0 = no response; always abnormal

1+ = a slight but present response; may or may not be normal

2+ = a brisk response; normal

3+ = a very brisk response; may or may not be normal

4+ = a tap elicits a repeating reflex called clonus; always abnormal

Deep tendon reflex grading is using a hammer to tap the knee.

A curved thoracic spine (hunchback).

It is common in the elderly with osteoporosis.

Lateral spine curvature.

It is tested in teenagers.

skin color

wounds (especially on bony areas)

rashes

bruising

abnormal moles/freckles

asking about new meds or exposure to infectious diseases (many cause rashes)

urticaria: hives

pruritis: itching

When the skin has a blue tint due to a low oxygen reading.