evidence-based assessment. health assessment definition –a systematic method of collecting data...

Evidence-Based Assessment

Health Assessment

• Definition– A systematic method of collecting data

about a client

Assessment: Point of Entry in an Ongoing Process

• Subjective data– What patient says about himself or herself

during history taking

• Objective data– Observed when inspecting, percussing,

palpating, and auscultating patient during physical examination

• Data base– Formed from these elements, plus patient’s

record and laboratory studies

Nursing Process

• Assessment• Diagnosis• Outcome identification• Planning• Implementation• Evaluation

Nursing Process: Assessment

• Collect data– Review of clinical record– Interview– Health history– Physical examination– Functional assessment– Cultural and spiritual assessment– Consultation– Review of the literature

Nursing Process: Diagnosis

Interpret dataIdentify clusters of cuesMake inferences

Validate inferencesCompare clusters of cues with definitions

and defining characteristicsIdentify related factorsDocument the diagnosis

Re: Nanda approved Nursing diagnosis 2009-2011 listI do not know about Nanda approved Nursing diagnosis 2009-2011 list.but but this Nanda approved Nursing diagnosis 2007-2008:list of nanda approved nursing diagnosis 2007-2008

List of NANDA Nursing diagnosis Accepted for Use and Research 2007-2008:Divided into 13 domains and 48 classes, below the full list of 13 Domains and 48 classes NANDA Nursing diagnosis. And complete list of NANDA Nursing diagnosis based on alphabetical order.

Domains Health PromotionsHealth awarenessHealth management

Domains nutritionsingestiondigestionAbsorptionMetabolismHydration

Domains Elimination/exchangeUrinary SystemGastrointestinal SystemIntegumentary systemPulmonary System

Domains Activity/RestSleep/RestActivity/ExerciseEnergy BalanceCardiovascular-pulmonary ResponsesSelf-Care

Domains Perception/CognitionAttentionOrientationSensation/PerceptionCognitionCommunication

Domains Self PerceptionSelf-ConceptSelf-EsteemBody Image

Domains Role RelationshipCaregiving RolesFamily RelationshipRole Performance

Domains SexualitySexual IdentitySexual FunctionReproduction

Domains Coping/Stress TolerancePost-Trauma ResponsesCoping ResponsesNeuro-behavioral Stress

Domains Life PrinciplesValuesBeliefsValues/Belief/action Congruence

Domains Safety/protectioninfectionPhysical InjuryViolenceEnviromental HazardsDefensive ProcessesThermoregulation

Domains ComfortPhysical ComfortEnvironmental Comfortsocial Comfort

Domains Growth/DevelopmentGrowthDevelopment

list of NANDA Nursing diagnosis based on alphabetical order

NANDA Nursing diagnosis based on alphabetical order A:Activity IntoleranceActivity Intolerance, risk forAirway Clearance, ineffectiveAllergy Response, latexAllergy response, latex, risk forAnxiety [specify level]Anxiety, deathAspiration, risk forAttachment, risk for impaired parent/infant/childAutonomic DysreflexiaAutonomic Dysreflexia, risk for

NANDA Nursing diagnosis based on alphabetical order B:Blood Glucose, risk for unstableBody Image, disturbedBody Temperature, risk for imbalancedBowel IncontinenceBreastfeeding, effectiveBreastfeeding, ineffectiveBreastfeeding, interruptedBreathing Pattern, ineffective

NANDA Nursing diagnosis based on alphabetical order C:Cardiac Output, decreasedCaregiver Role StrainCaregiver Role Strain, risk forComfort, readiness for enhancedCommunication, impaired verbalCommunication, readiness for enhancedConflict, parental roleConfusion, acuteConfusion, risk for acuteConfusion, chronicConstipationConstipation, perceivedConstipation, risk forContaminationContamination, risk forCoping, defensiveCoping, ineffectiveCoping, readiness for enhancedCoping, ineffective communityCoping, readiness for enhanced communityCoping, compromised familyCoping, disabled familyCoping, readiness for enhanced family

NANDA Nursing diagnosis based on alphabetical order D:Death Syndrome, risk for sudden infantDecisional Conflict (specify)Denial, ineffectiveDentition, impairedDecision-Making, readiness for enhancedDevelopment, risk for delayedDiarrheaDisuse Syndrome, risk forDiversional Activity, deficient

NANDA Nursing diagnosis based on alphabetical order E:Energy Field, disturbed (revised)Environmental Interpretation Syndrome, impaired

NANDA Nursing diagnosis based on alphabetical order F:Failure to Thrive, adultFalls, risk forFamily Processes: alcoholism, dysfunctionalFamily Processes, interruptedFamily Processes, readiness for enhancedFatigueFear (specify focus)Fluid Balance, readiness for enhancedFluid Volume, deficientFluid Volume, excessFluid Volume, risk for deficientFluid Volume, risk for imbalanced

http://www.lifenurses.com/forum/viewtopic.php?p=8&sid=e3a22b437d21e797e4ad7d5385eebbff#p8

http://ngaglik81.blogspot.com/2009/02/list-of-nanda-approved-nursing.html/

http://www.lifenurses.com/forum/viewtopic.php?p=8&sid=e3a22b437d21e797e4ad7d5385eebbff#p8

Nursing Process:Outcome Identification

• Identify expected outcomes• Individualize to patient• Ensure outcomes are realistic and

measurable• Include a time frame

Nursing Process: Planning

• Establish priorities• Develop outcomes• Set time frames for outcomes• Identify interventions• Document plan of care

Nursing Process: Implementation

• Determine patient readiness• Review planned interventions• Collaborate with other team members

• Supervise by delegating appropriate responsibilities

• Counsel person and significant others• Involve person in health care• Refer for continuing care• Document care provided

Nursing Process: Evaluation

• Refer to established outcomes

• Evaluate individual’s condition and compare actual outcomes with expected outcomes

• Summarize results of evaluation

• Identify reasons for failure to achieve expected outcomes

• Take corrective action to modify plan of care

• Document evaluation in plan of care

Evidence Based PracticeEBP

• Best practice technique• Combines clinicians experience /

current research / patient preferences to make decisions about care and treatment

Health Assessment

• Definition– A systematic method of collecting data

about a client

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Chapter 3: The Interview

The Interview

• Subjective data• Results of a

successful interview

Slide 3-14

The Interview (cont.)

• Goals– Record complete health history– Optimal health for patient

• Identify health strengths and problems as bridge to physical examination– First and most important part of data collection– Collects subjective data: what person says about

his or her perceived health state– Individual knows everything about his or her own

health state, and nurse knows nothing

Slide 3-15

The Interview (cont.)

• Consider interview a contract between nurse and patient

• Contract consists of spoken and unspoken rules for behavior:– What person needs and expects from

health care and what health professional has to offer

– Mutual goal is optimal health for patient

Slide 3-16

PROCESS OF COMMUNICATION

• External factors– Ensure privacy – Refuse interruptions– Physical environment– Dress– Note-taking may be unavoidable

• Cannot rely completely on memory for details of previous illnesses or review of body systems

– Tape and video recording

Slide 3-17

PROCESS OF COMMUNICATION (cont.)

• Challenges of note-taking– Breaks eye contact too often– Shifts attention away from person,

diminishing his or her sense of importance– Interrupts patient’s narrative flow – Impedes observation of patient’s nonverbal

behavior– May be threatening to patient’s discussion

of sensitive issues

Slide 3-18

TECHNIQUES OF COMMUNICATION (cont.)

• Open-ended questions– Ask for narrative responses– State topic only in general terms– Use them:

• To begin interview• To introduce a new section of questions• Whenever the patient introduces new topic

Slide 3-19


Closed or direct questionsAsk for specific informationElicit short, one-or-two word answers, a yes or

no answer, or a forced choiceUse them:

• After opening narrative to fill in details person may have left out

• When you need many specific facts about past health problems, or during review of systems

• To move the interview along

Slide 3-20


• Ten traps of interviewing– Providing false assurance or reassurance– Giving unwanted advice– Using authority– Using avoidance language– Engaging in distancing– Using professional jargon– Using leading or biased questions– Talking too much or interrupting– Using “why” questions

Slide 3-21


• Nonverbal skills• Physical appearance• Posture• Gestures• Facial expression• Eye contact• Voice• Touch• Closing the interview

Slide 3-22

The Health History: Adult

• It may be helpful to organize same question sequence into a mnemonic, PQRSTU, to help remember all points– P = Provocative or palliative– Q = Quality or quantity– R = Region or radiation– S = Severity scale: 1 to 10– T = Timing or onset– U = Understand patient’s perception of

problem

Slide 4-23

Figure 10.5 OLDCART & ICE acronym.

Figure 10.6 Documentation of the Symptom–Cough, with OLDCART & ICE

Assessment Techniques and the Clinical Setting

Cultivating Your Senses

• The examiner will use the senses—sight, smell, touch, and hearing to gather data during physical examination– Senses will be focused to assess each

person’s health state– Skills performed one at a time, in this order:

• Inspection• Palpation• Percussion• Auscultation

Slide 8-27

Cultivating Your Senses (cont.)

• InspectionClose, careful scrutiny, first of individual as a whole and

then of each body systemBegins when you first meet person with a general surveyAs you proceed through examination, start assessment

of each body system with inspectionInspection always comes firstInspection requires

• Good lighting• Adequate exposure• Occasional use of instruments, including otoscope,

ophthalmoscope, penlight, or nasal and vaginal specula, to enlarge your view

Slide 8-28


• Palpation– Palpation applies sense of touch to assess

• Texture• Temperature• Moisture• Organ location and size• Swelling, vibration or pulsation • Rigidity or spasticity• Crepitation• Presence of lumps or masses• Presence of tenderness or pain

Slide 8-29


• Palpation (cont.)– Different parts of hands are best suited for

assessing different factors• Fingertips: best for fine tactile discrimination of skin

texture, swelling, pulsation, determining presence of lumps

• Fingers and thumb: detection of position, shape, and consistency of an organ or mass

• Dorsa of hands and fingers: best for determining temperature because skin here is thinner than on palms

• Base of fingers or ulnar surface of hand: best for vibration

Slide 8-30

Figure 6.2 Sensitive areas of the hand.


• Palpation (cont.)• Start with light palpation to detect surface

characteristics and accustom person to being touched

• Then perform deeper palpation when needed– Intermittent pressure better than one long continuous

palpation

• Avoid any situation in which deep palpation could cause internal injury or pain

• Bimanual palpation requires use of both of hands to envelop or capture certain body parts or organs, such as kidneys, uterus, for more precise delimitation

Slide 8-32

Figure 6.3 Light palpation.


• Percussion– Tapping person’s skin with short, sharp strokes to

assess underlying structures– Percussion has following uses

• Mapping location and size of organs• Signaling density of a structure by a characteristic

note• Detecting a superficial abnormal mass

– Percussion vibrations penetrate about 5 cm deep – Deeper mass would give no change in percussion

• Eliciting pain if underlying structure is inflamed• Eliciting deep tendon reflex using percussion hammer

Slide 8-34


• Percussion (cont.)– Two methods of percussion can be used—

• Direct, sometimes called immediate, the striking hand directly contacts body wall

• Indirect, or mediate, using both hands, the striking hand contacts stationary hand fixed on person’s skin

Slide 8-35

Percussion Sounds

• Tympany• Resonance• Hyperresonance• Dullness• Flatness

Figure 6.6 Direct percussion.

Figure 6.8 Indirect percussion.

Indirect percussion

Slide 8-39

Cultivating Your Senses

• Auscultation– Listening to sounds produced by body

• Most body sounds are very soft and must be channeled through a stethoscope

• Stethoscope does not magnify sound, but blocks out extraneous sounds

• Of all the equipment you will use, the stethoscope quickly becomes a very personal instrument

• Once you can recognize normal sounds, you can distinguish the abnormal sounds and “extra” sounds

Slide 8-40

Equipment

– Platform scale with height attachment

– Skinfold calipers– Sphygmomanometer– Stethoscope– Thermometer– Pulse oximeter– Penlight

– Pulse oximeter– Penlight– Otoscope– Ophthalmoscope– Tuning fork– Nasal speculum– Tongue depressor– Cotton balls

Slide 8-41

A Safer Environment

• Wash your hands—this is the single most important step to decrease microorganism transmission– Before and after physical contact with each

patient– After inadvertent contact with blood, body

fluids, secretions, and excretions– After contact with any equipment

contaminated with body fluids– After removing gloves

Slide 8-42

A Safer Environment (cont.)

• Wear gloves– When potential exists for contact with any

body fluids, for example, blood, mucous membranes, body fluids, drainage, and open skin lesions

– Wearing gloves is not a protective substitute to washing hands

– Wear a gown, mask, and protective eyewear when potential exists for any blood or body fluid spattering

Slide 8-43

http://www.medclip.com/index.php?page=videos&section=view&vid_id=100839



Slide 23-44







General Survey

• Launch a general survey at moment you first encounter person– What leaves an immediate impression? Does

person stand promptly as his or her name called and walk easily to meet you?

• Or does person look sick, rising slowly or with effort, with shoulders slumped and eyes without luster or downcast?

• Is hospitalized patient conversing with visitors, involved in reading or television, or lying perfectly still?

• Even as you introduce yourself and shake hands, you collect data

Slide 9-45

Components of the General Survey

• Physical appearance• Mental status• Mobility• Behavior

Objective Data

• Physical appearance– Age: person appears his or her stated age– Sex: sexual development appropriate for

gender and age– Level of consciousness: person alert and

oriented, attends to your questions and responds appropriately

– Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesions

Slide 9-47

Objective Data

• Body structure– Stature: height appears within normal range for

age, genetic heritage– Nutrition: weight appears within normal range for

height and body build; body fat distribution even– Symmetry: body parts look equal bilaterally and

are in relative proportion– Posture: person stands comfortably erect as

appropriate for age• Note normal “plumb line” through anterior ear,

shoulder, hip, patella, ankle

Slide 9-48

Objective Data

• Mobility– Gait: normally, base is as wide as shoulder

width • Foot placement: accurate; walk smooth, even,

and well-balanced; and associated movements, such as symmetric arm swing, are present

• Range of motion: note full mobility for each joint, and that movement is deliberate, accurate, smooth, and coordinated

• No involuntary movement

Slide 9-49

Objective Data

• Behavior (cont.)– Speech: articulation (ability to form words)

clear and understandable• Stream of talking is fluent, with an even pace• Conveys ideas clearly• Word choice appropriate to culture and

education• Person communicates in prevailing language

easily by himself or herself or with interpreter

Slide 9-50

Objective Data

• Behavior (cont.)– Dress: appropriate to climate, looks clean and

fits body, and is appropriate to person’s culture and age group; for example, normally:

• Amish women wear clothing from nineteenth century • Indian women may wear saris• Culturally-determined dress should not be labeled as

bizarre by Western standards or by adult expectations

– Personal hygiene: person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group

Slide 9-51

Objective Data

• Measurement– Weight

• Use a standardized balance or electronic standing scale

• Instruct person to remove his or her shoes and heavy outer clothing before standing on scale

• When sequence of repeated weights is necessary, aim for approximately same time of day and same type of clothing worn each time

• Record weight in kilograms and pounds• Show person how his or her weight matches up to

recommended range for height

Slide 9-52

Figure 7.2 Measuring the client’s height with a platform scale.

Objective Data

• Measurement (cont.)– Body mass index

• Body mass index is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition

Slide 9-54

Temperature Routes

• Oral• Rectal• Axillary• Tympanic• Temporal Artery

Objective Data

• Pulse– Stroke volume: amount of blood every heart beat

pumps into aorta • About 70 ml in adult• Force flares arterial walls and generates pressure

wave, which felt in periphery as pulse• Palpating peripheral pulse gives rate and rhythm of

heartbeat, as well as local data on condition of artery• Radial pulse usually palpated while vital signs

measured• Using pads of the first three fingers, palpate radial pulse

at flexor aspect of wrist laterally along radius bone

Slide 9-56

Figure 7.10 Body sites where the peripheral pulse is most easily palpated.

Objective Data

• Pulse– Stroke volume: amount of blood every

heart beat pumps into aorta• If rhythm is regular, count number of beats in

30 seconds and multiply by 2.

• The 30-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular

Slide 9-58

Objective Data

• Force– Force of pulse is strength of heart’s stroke volume

• Weak, thready pulse reflects a decreased stroke volume (e.g., as occurs with hemorrhagic shock)

• Full, bounding pulse denotes increased stroke volume, as with anxiety, exercise, and some abnormal conditions

• Pulse force recorded using three-point scale– 3+ full, bounding– 2+ normal– 1+ weak, thready– 0 Absent

Slide 9-59

Objective Data

• Respirations– Normally, person’s breathing is relaxed,

regular, automatic, and silent• Because most people are unaware of their

breathing, do not mention that you will be counting respirations, because sudden awareness may alter normal pattern

• Instead, maintain your position of counting radial pulse and unobtrusively count respirations

Slide 9-60

Objective Data

• Respirations (cont.)• Count for 30 seconds, or full minute if you

suspect an abnormality

• Normally, both pulse and respiratory rates rise as a response to exercise or anxiety

Slide 9-61

Objective Data

• Blood pressure– Blood pressure (BP) is force of blood pushing

against side of its container, vessel wall• Strength of push changes with event in cardiac

cycle• Systolic pressure: maximum pressure felt on

artery during left ventricular contraction, or systole• Diastolic pressure: elastic recoil, or resting,

pressure that blood exerts constantly between each contraction

Slide 9-62

Table 18.2 National Institutes of Health (NIH) Blood Pressure Guidelines

Objective Data

• Blood pressure (cont.)– Level of BP determined by these factors

• Cardiac output: if heart pumps more blood into blood vessels, pressure on container walls increases

• Peripheral vascular resistance: opposition to blood flow through arteries; when vessels becomes smaller or constricted pressure needed to push becomes greater

• Volume of circulating blood: refers to how tightly blood is packed into arteries; increasing contents in vessels increases pressure

• Viscosity: “thickness” of blood determined by its formed elements, blood cells; when contents thicker, pressure increases

Slide 9-64

Objective DataDevelopmental Competence

• Additional techniques– Measurement of oxygen saturation

• Pulse oximeter a noninvasive method to assess arterial oxygen saturation (SpO2)

• Sensor attached to person’s finger or earlobe has diode that emits light and detector measures relative amount of light absorbed by oxyhemoglobin (HbO2) and unoxygenated (reduced) hemoglobin (Hb)

Slide 9-65

Objective DataDevelopmental Competence

• Additional techniques– Measurement of oxygen saturation (cont.)

• Healthy person with no lung disease and no anemia normally has an SpO2 of 97% to 98%

• Select appropriate pulse oximeter probe• Finger probe spring loaded and feels like

clothespin attached to finger but does not hurt• At lower oxygen saturations, earlobe probe

more accurate and less affected by peripheral vasoconstriction

Slide 9-66

Pain Assessment:The Fifth Vital Sign

Pain Assessment

• Definitions– Comes from the Greek word meaning

“penalty.”– McCaffery

• Pain is “whatever the person says it is, existing whenever he or she says it does.”

Pain

• Pain is a highly complex and subjective experience that originates from the central nervous system (CNS), the peripheral nervous system (PNS), or both

Slide 10-69

Nociception

Slide 10-70

Structure and Function

• Types of pain (by duration)– Pain can be classified by its duration

• Duration can provide information on possible underlying mechanisms and treatment decisions

– Pain is divided into acute or chronic categories• Acute pain is short term and self-limiting, often follows a

predictable trajectory, and dissipates after an injury heals• Examples of acute pain include surgery, trauma, and

kidney stones• Acute pain serves a self-protective purpose; acute pain

warns individual of actual or potential tissue damage

Slide 10-71

Structure and Function (cont.)

• Types of pain – Pain is divided into acute or chronic categories

• In contrast, chronic (or persistent) pain is diagnosed when pain continues for 6 months or longer

• It can last 5, 15, or 20 years and beyond

– Chronic pain can be further divided into malignant (cancer related) and nonmalignant

• Malignant pain often parallels pathology created by tumor cells

• Pain induced by tissue necrosis or stretching of an organ by growing tumor

Slide 10-72

Subjective Data

• Pain – Defined as an unpleasant sensory and emotional

experience– Associated with actual or potential tissue damage or

described in terms of such damage• Pain is always subjective• Pain is whatever the experiencing person says it is, existing

whenever he or she says it does• Subjective report is most reliable indicator of pain• Because pain occurs on a neurochemical level, clinician

cannot base diagnosis of pain exclusively on physical examination findings, although these findings can lend support

Slide 10-73

Pain Assessment Tools

• Numeric rating scales ask patient to choose a number that rates level of pain, with 0 being no pain and highest anchor 10 indicating worst pain– It can be administered verbally or visually

along a vertical or horizontal line

Slide 10-74

Nutritional Assessment

Nutritional Assessment

• Nutritional status refers to the degree of balance between nutrient intake and nutrient requirements

• This balance is affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic factors

Slide 11-78

Structure and Function:Defining Nutritional Status

• Undernutrition – Occurs when nutritional reserves are depleted

and/or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands

• Vulnerable groups, infants, children, pregnant women, recent immigrants, persons with low incomes, hospitalized people, and aging adults, are at risk for:

– Impaired growth and development – Lowered resistance to infection and disease– Delayed wound healing– Longer hospital stays– Higher health care costs

Slide 11-79

Structure and Function:Defining Nutritional Status (cont.)

• Overnutrition– Caused by consumption of nutrients, especially

calories, sodium, and fat in excess of body needs• Major nutritional problem today, overnutrition can lead

to obesity and is risk factor for: – Heart disease and hypertension– Type II diabetes– Stroke– Gallbladder disease– Sleep apnea– Certain cancers– Osteoarthritis

Slide 11-80

Structure and Function:Defining Nutritional Status (cont.)

• Overnutrition • Estimated 17% of children and adolescents, ages 2 to

19• 66% of adults in U.S. are either overweight or obese• For children, overweight defined as body mass index

(BMI) equal to or greater than 95th percentile based on age- and gender-specific BMI charts

• For adults– Overweight defined as BMI of 25 or greater– Obesity defined as BMI of 30

• Being overweight during childhood and adolescence associated with increased risk for becoming overweight during adulthood

Slide 11-81

Table 9.3 Classification of Body Mass Index (BMI) in Adults


• Purposes and components of nutritional assessment – 24-hour recall

• Easiest and most popular method for obtaining information about dietary intake

• Individual or family member completes questionnaire or interviewed and asked to recall everything eaten within last 24 hours

Slide 11-84

Abdomen

Abdomen

– Abdomen is a large oval cavity extending from diaphragm down to brim of pelvis

• It is bordered in back by vertebral column and paravertebral muscles and at sides and front by lower rib cage and abdominal muscles

• Four layers of large, flat muscles form ventral abdominal wall

• These are joined at midline by a tendinous seam, the linea alba

Slide 21-86

Figure 19.2 Muscles of the abdominal wall.


• Internal anatomy– Inside abdominal cavity, all internal organs

are called viscera• Important to know location of these organs so

well that you could draw a map of them on skin • You must be able to visualize each organ that

you listen to or palpate through abdominal wall• Solid viscera are those that maintain a

characteristic shape: liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus

Slide 21-88


• Internal anatomy

• Shape of hollow viscera, such as stomach, gallbladder, small intestine, colon, and bladder depends on contents

– Usually are not palpable, although you may feel a colon distended with feces or a bladder distended with urine

Slide 21-89

Quadrants

Slide 21-90

Internal Anatomy

Slide 21-91

Deep Internal Anatomy

Slide 21-92

Subjective Data

• Appetite• Dysphagia• Food intolerance• Abdominal pain• Nausea and vomiting• Bowel habits• Abdominal history• Medications

Slide 21-93

Physical Assessment of the Abdomen

• Techniques– Inspection– Auscultation – Percussion– Palpation

Objective Data

• Preparation (cont.)– Following measures will enhance abdominal

wall relaxation• Person should have emptied bladder, saving urine

specimen if needed• Keep room warm to avoid chilling and tensing of

muscles• Position person supine, with head on pillow, knees

bent or on pillow, and arms at sides or across chest• Note: Discourage person from placing his or her

arms over head because this tenses abdominal musculature

Slide 21-95

Objective Data (cont.)

• Preparation – Following measures will enhance abdominal wall

relaxation • To avoid abdominal tensing, stethoscope endpiece

must be warm, your hands must be warm, and your fingernails must be very short

• Inquire about any painful areas; examine such an area last to avoid any muscle guarding

• Finally, learn to use distraction: enhance muscle relaxation through breathing exercises; emotive imagery; your low, soothing voice; and person relating his or her abdominal history while you palpate

Slide 21-96


• Inspect the abdomen– Contour

• Stand on person’s right side and look down on abdomen

• Then stoop or sit to gaze across abdomen• Your head should be slightly higher than

abdomen • Determine profile from rib margin to pubic

bone; contour describes nutritional state and normally ranges from flat to rounded

Slide 21-97

Contour

Slide 21-98


• Inspect the abdomen (cont.)– Umbilicus

• Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia

• Becomes everted and pushed upward with pregnancy

• Umbilicus is common site for piercings in young women; site should not be red or crusted

– Skin• Surface smooth and even, with homogeneous color;

good area to judge pigment because often protected from sun

Slide 21-99


• Inspect the abdomen – Pulsation or movement

• Normally, you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation

• Respiratory movement also shows in abdomen, particularly in males

• Finally, waves of peristalsis sometimes are visible in very thin persons; they ripple slowly and obliquely across abdomen

Slide 21-100


• Auscultate bowel sounds and vascular sounds– This is done because percussion and

palpation can increase peristalsis, which would give a false interpretation of bowel sounds

• Use diaphragm endpiece because bowel sounds are relatively high pitched

• Begin in RLQ at ileocecal valve area because bowel sounds are normally always present here

Slide 21-101


• Auscultate bowel sounds and vascular sounds – Bowel sounds

• Note character and frequency of bowel sounds• Bowel sounds originate from movement of air and fluid

through small intestine• Depending on time elapsed since eating, a wide range

of normal sounds can occur• Bowel sounds are high pitched, gurgling, cascading

sounds, occurring irregularly anywhere from 5 to 30 times per minute; do not bother to count them

• Judge if they are normal, hypoactive, or hyperactive

Slide 21-102


• Auscultate bowel sounds and vascular sounds – Bowel sounds

• One type of hyperactive bowel sound is fairly common

– This is the hyperperistalsis when you feel your “stomach growling,” termed borborygmus

• Perfectly “silent abdomen” is uncommon; you must listen for 5 minutes by your watch before deciding bowel sounds are completely absent

Slide 21-103


• Auscultate bowel sounds and vascular sounds – Vascular sounds

• As you listen to abdomen, note presence of any vascular sounds or bruits

• Using firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension

• Usually, no such sound is present

Slide 21-104

Figure 19.12 Auscultatory areas for vascular sounds.


• Percuss general tympany, liver, and splenic dullness– Percuss to assess relative density of abdominal

contents, to locate organs, and to screen for abnormal fluid or masses

– General tympany• First, percuss lightly in all four quadrants to determine

prevailing amount of tympany and dullness • Move clockwise; tympany should predominate

because air in intestines rises to surface when person is supine

Slide 21-106


• Palpate surface and deep areas– Perform palpation

• Judge size, location, and consistency of certain organs and screen for an abnormal mass or tenderness

• Because most people are naturally inclined to protect abdomen, you need to use additional measures to enhance complete muscle relaxation

Slide 21-107


• Palpate surface and deep areas (cont.)– Light and deep palpation (cont.)

• Begin with light palpation• With first four fingers close together, depress skin

about 1 cm • Make gentle rotary motion, sliding fingers and skin

together• Then lift fingers (do not drag them) and move

clockwise to next location around abdomen• Objective is not to search for organs but to form an

overall impression of skin surface and superficial musculature

Slide 21-108



• Now perform deep palpation using same technique described earlier, but push down about 5 to 8 cm (2 to 3 inches)

• Moving clockwise, explore entire abdomen• To overcome resistance of a very large or

obese abdomen, use a bimanual technique– Place your two hands on top of each other– Top hand does pushing; bottom hand relaxed and

can concentrate on sense of palpation

Slide 21-109



• With either technique, note location, size, consistency, and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or masses

• Making sense of what you are feeling is more difficult than it looks

• Inexperienced examiners complain that abdomen “all feels same,” as if they are pushing their hand into a soft sofa cushion

• Helps to memorize anatomy and visualize what is under each quadrant as you palpate

Slide 21-110

Normally Palpable Structures

Slide 21-111


• Palpate surface and deep areas – Liver

• Place your left hand under person’s back parallel to 11th and 12th ribs and lift up to support abdominal contents

• Place your right hand on RUQ, with fingers parallel to midline

• Push deeply down and under right costal margin• Ask person to take a deep breath; it is normal to feel

edge of liver bump your fingertips as diaphragm pushes it down during inhalation

• It feels like a firm regular ridge; often liver is not palpable

Slide 21-112

Figure 19.19 Palpating the liver.


• Palpate surface and deep areas (cont.)– Kidneys

• Search for right kidney by placing your hands together in a “duck-bill” position at person’s right flank

• Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask person to take deep breath

• In most people, you will feel no change• Occasionally, you may feel lower pole of right kidney

as a round, smooth mass slide between your fingers• Either condition is normal

Slide 21-114


– Costovertebral angle tenderness• Indirect fist percussion causes tissues to vibrate

instead of producing a sound• To assess kidney, place one hand over 12th rib at

costovertebral angle on back• Thump that hand with ulnar edge of your other fist• Person normally feels thud but no pain

– Its usual sequence in complete examination is with thoracic assessment, when person is sitting up and you are standing behind

Slide 21-115

Heart and Neck Vessels

Precordium, Apex, and Base

Slide 19-117


• Heart wall, chambers, and valves– Heart wall has numerous layers

• Pericardium: tough, fibrous, double-walled sac that surrounds and protects heart

– Has two layers that contain a few milliliters of serous pericardial fluid; this ensures smooth, friction-free movement of heart muscle

• Pericardium: adherent to great vessels, esophagus, sternum, and pleurae and anchored to diaphragm

• Myocardium: muscular wall of heart; it does pumping• Endocardium: thin layer of endothelial tissue that

lines inner surface of heart chambers and valves

Slide 19-118


• Heart wall, chambers, and valves – Common metaphor is to think of heart as a

pump• But consider that heart is actually two pumps; right

side of heart pumps blood into lungs, and left side of heart simultaneously pumps blood into body

• Two pumps are separated by an impermeable wall, septum

– Each side has an atrium and a ventricle• Atrium: thin-walled reservoir for holding blood• Ventricle: thick-walled, muscular pumping chamber

Slide 19-119


• Heart wall, chambers, and valves – Four chambers separated by valves, whose

main purpose is to prevent backflow of blood• Valves are unidirectional: can only open one way • Valves open and close passively in response to

pressure gradients in moving blood

– Four valves in heart• Two atrioventricular (AV) valves• Two semilunar (SL) valves

Slide 19-120

Valves

• Permit the Flow of Blood Between Chambers and Into Blood Vessels

• Atrioventricular (AV)– Tricuspid– Mitral

• Semilunar– Pulmonary– Aortic

Heart Sounds

S1

S2

Figure 17.5 Heart sounds in systole and diastole.

Chambers and valves

Slide 19-124

Conduction System of the Heart

• Sinoatrial (SA) node• Intra-atrial pathways• AV node• Bundle of His• Right and left bundle branches• Purkinje fibers

Figure 17.11 Electrocardiogram wave.


• Pumping ability– In resting adult, heart normally pumps

between 4 and 6 L of blood per minute throughout body

• This cardiac output equals volume of blood in each systole (called stroke volume) times number of beats per minute (rate)

• Heart can alter its cardiac output to adapt to metabolic needs of body

• Preload and afterload affect heart’s ability to increase cardiac output

Slide 19-127

Structure and Function:Developmental Competence (cont.)

• Aging adult – Incidence of coronary artery disease increases

sharply with advancing age and accounts for about half of deaths of older people

• Hypertension and heart failure also increase with age• Lifestyle habits play a significant role in the acquisition

of heart disease

– Also, increasing physical activity of older adults associated with a reduced risk of death from cardiovascular diseases and respiratory illnesses

Slide 19-128

Structure and Function:Cultural Competence (cont.)

– Although all adults have some potential CVD risk, some groups, defined by race, ethnicity, gender, socioeconomic status, and educational level carry an excess burden of CVD

• Higher percent of men than women have hypertension until 45 years, after which the percentages are similar

– After 64 years, women have much higher percentage than men

• Hypertension is 2 to 3 times more common among women taking oral contraceptives, especially obese and older women

• Hypertension in African Americans is among highest in world and is rising

Slide 19-129


• Smoking– Nicotine increases risk of myocardial

infarction (MI) and stroke by causing:• Increase in oxygen demand with a concomitant

decrease in oxygen supply • Activation of platelets, activation of fibrinogen;

and an adverse change in lipid profile

Slide 19-130


• Serum cholesterol– High levels of low density lipoprotein

gradually add to lipid core of thrombus formation in arteries, which results in MI and stroke

Slide 19-131


• Type II diabetes mellitus (DM)– Risk of CVD is 2-fold greater among

persons with DM• Increased prevalence of DM in U.S. is being

followed by an increasing prevalence of CVD morbidity and mortality

• Diabetes causes damage to large blood vessels that nourish brain, heart and extremities; this results in stroke, coronary artery disease, and peripheral vascular disease

Slide 19-132

Subjective Data

• Chest pain• Dyspnea• Orthopnea• Cough• Fatigue• Cyanosis or pallor• Edema

• Nocturia• Past cardiac history• Family cardiac history• Personal habits

(cardiac risk factors)

Slide 19-133

Objective Data

• Neck vessels– Palpate carotid artery

• Yields important information on cardiac function• Palpate each carotid artery medial to sternomastoid

muscle in neck; palpate gently• Palpate only one carotid artery at a time to avoid

compromising arterial blood to brain• Feel contour and amplitude of pulse• Normally contour is smooth with a rapid upstroke and

slower downstroke, and the normal strength is 2+ or moderate

• Findings should be same bilaterally

Slide 19-134


• Neck vessels – Auscultate carotid artery

• For persons middle-aged or older, or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for presence of a bruit

– This is a blowing, swishing sound indicating blood flow turbulence; normally none is present

Slide 19-135

Objective Data

• Precordium– Inspect anterior chest

• Pulsations: you may or may not see apical impulse, pulsation created as left ventricle rotates against chest wall during systole

– When visible, it occupies the fourth or fifth intercostal space, at or inside midclavicular line

– Easier to see in children and in those with thinner chest walls

Slide 19-136


• Precordium – Auscultation

• Identify auscultatory areas where you will listen; these include five traditional valve “areas”

– Valve areas are not over actual anatomic locations of valves but sites on chest wall where sounds produced by valves are best heard

Slide 19-137

Auscultatory Areas

Slide 19-138

Figure 17.19 Landmarks for palpation of the chest.


• Precordium – Auscultation

• Before you begin, alert person that you always listen to heart in a number of places on chest, and just because you are listening a long time does not necessarily mean that something is wrong

• After you place stethoscope, try closing your eyes briefly to tune out any distractions

Slide 19-140

HEART SOUNDS

• S 3• S 4• Murmurs

Slide 23-141

Peripheral Vascular System and Lymphatic System

Vascular System and Lymphatics

• Vascular system consists of vessels of body– Vessels are tubes for transporting fluid, such as

blood or lymph– Any disease in vascular system creates

problems with delivery of oxygen and nutrients to tissues or elimination of waste products from cellular metabolism

– The lymphatics form completely separate vessel system, which retrieves excess fluid from tissue spaces and returns it to the bloodstream

Slide 20-143

Subjective Data

• Leg pain or cramps• Skin changes on arms or legs• Swelling• Lymph node enlargement• Medications

Slide 20-144

Objective Data

• Inspect and palpate the arms – With person’s hands near level of their heart,

check capillary refill• An index of peripheral perfusion and cardiac output• Depress and blanch nail beds; release and note

time for color return• Normal if color returns in less than 1 or 2 seconds• Note conditions that can skew your findings: a cool

room, decreased body temperature, cigarette smoking, peripheral edema, and anemia

• The two arms should be symmetric in size

Slide 20-145


• Inspect and palpate the legs– Uncover the legs while keeping genitalia

draped• Inspect both legs together, noting skin color, hair

distribution, venous pattern, size (swelling or atrophy), and any skin lesions or ulcers

• Normally hair covers legs; even if leg hair is shaved, you will still note hair on dorsa of toes

• Venous pattern normally flat and barely visible; note obvious varicosities, but are best assessed standing

• Both legs should be symmetric in size without any swelling or atrophy

Slide 20-146


• Inspect and palpate the legs – If lower legs look asymmetric, measure leg at widest

point, taking care to measure other leg in exactly same place, same number of centimeters down from patella or other landmark

• If deep venous thrombosis suspected, measure calf circumference with nonstretchable tape measure

• If lymphedema suspected, measure also at ankle, distal calf, knee, and thigh

• Record findings in centimeters

– In presence of skin discoloration, skin ulcers, or gangrene, note size and exact location

Slide 20-147

Posterior Tibial Pulse

Slide 20-149


• Inspect and palpate the legs – Check for pretibial edema

• Firmly depress skin over tibia or medial malleolus for 5 seconds and release

• Normally, your finger should leave no indentation, although a pit commonly is seen if person has been standing all day or during pregnancy

• If pitting edema is present, grade it on following scale:– 1+ Mild pitting, slight indentation, no perceptible swelling– 2+ Moderate pitting, indentation subsides rapidly– 3+ Deep pitting, indentation remains, leg looks swollen– 4+ Very deep pitting, indentation lasts long time, leg very

swollen

Slide 20-150

Pitting Edema

Slide 20-151

From Bloom A, Watkins PH, Ireland J: Color atlas of diabetes, ed 2, St. Louis, 1992, Mosby.


• Inspect and palpate the legs – Ask the person to stand so that you can

assess venous system• Note any visible, dilated, and tortuous veins

Slide 20-152


• Doppler-ultrasonic stethoscope– Use this device to detect a weak peripheral

pulse, to measure low blood pressure or blood pressure in lower extremity

• Doppler stethoscope magnifies pulsatile sounds from heart and blood vessels

• Place drop of coupling gel on end of handheld transducer

• Place transducer over pulse site, swiveled at a 45-degree angle; apply very light pressure; locate pulse site by the swishing, whooshing sound

Slide 20-153

Thorax and Lungs


Slide 18-155

• Position and surface landmarks– Thoracic cage is a bony structure with a conical

shape, which is narrower at top • Defined by sternum, 12 pairs of ribs and 12 thoracic

vertebrae• Floor is the diaphragm, a musculotendinous septum that

separates thoracic cavity from abdomen• First seven ribs attach to sternum by costal cartilages• Ribs 8, 9, and 10 attach to costal cartilage above• Ribs 11 and 12 are “floating,” with free palpable tips

Anterior Thoracic Cage

Slide 18-156

Anterior Reference Lines

Slide 18-157

Posterior Reference Lines

Slide 18-158


Slide 18-159

• Thoracic cavity– Mediastinum: middle section of thoracic cavity

containing esophagus, trachea, heart, and great vessels• Right and left pleural cavities, on either side of mediastinum,

contain lungs• Lung borders: In anterior chest, apex of lung tissue is 3 or 4

cm above inner third of clavicles• Base rests on diaphragm at about sixth rib in midclavicular

line• Laterally, lung tissue extends from apex of axilla down to

seventh or eighth rib


Slide 18-160

• Thoracic cavity – Pleurae

• The thin, slippery pleurae form an envelope between lungs and chest wall

• Visceral pleura lines outside of lungs, dipping down into fissures

• It is continuous with parietal pleura lining inside of chest wall and diaphragm

• Pleural cavity is potential space filled only with few milliliters of lubricating fluid


Slide 18-161

• Thoracic cavity – Pleurae

• Pleural cavity normally has a vacuum, or negative pressure, which holds lungs tightly against chest wall

• Lungs slide smoothly and noiselessly up and down during respiration, lubricated by a few milliliters of fluid

• Similar to two glass slides with a drop of water between them; although it is difficult to separate slides, they slide smoothly back and forth

• This is a potential space; when it abnormally fills with air or fluid, it compromises lung expansion


Slide 18-162

• Thoracic cavity – Trachea and bronchial tree

• Trachea lies anterior to esophagus and is 10 to 11 cm long in the adult

• Begins at level of cricoid cartilage in neck and bifurcates just below sternal angle into right and left main bronchi

• Right main bronchus is shorter, wider, and more vertical than the left main bronchus

Structures of Respiratory System

Slide 18-163


Slide 18-164

• Mechanics of respiration – Body tissues are bathed by blood that normally has

a narrow acceptable range of pH• Although a number of compensatory mechanisms

regulate pH, lungs help maintain balance by adjusting level of carbon dioxide through respiration

• Hypoventilation (slow, shallow breathing) causes carbon dioxide to build up in blood, and hyperventilation (rapid, deep breathing) causes carbon dioxide to be blown off


Slide 18-165

• Mechanics of respiration – Control of respirations

• Normally our breathing pattern changes without our awareness in response to cellular demands

– This involuntary control of respirations is mediated by respiratory center in brainstem (pons and medulla)

• Normal stimulus to breathe for most of us is an increase of carbon dioxide in blood, or hypercapnia

• Decrease of oxygen in blood (hypoxemia) also increases respirations but less effective than hypercapnia

Subjective Data

Slide 18-166

• Cough• Shortness of breath• Chest pain with breathing• History of respiratory infections• Smoking history• Environmental exposure• Self-care behaviors

Objective Data

Slide 18-167

• Inspect the anterior chest – Assess quality of respirations

• Normal relaxed breathing is automatic and effortless, regular and even, and produces no noise

• Chest expands symmetrically with each inspiration; note any localized lag on inspiration

• No retraction or bulging of interspaces with inspiration

• Normally, accessory muscles are not used to augment respiratory effort


Slide 18-168

• Inspect the posterior chest– Thoracic cage

• Note shape and configuration of chest wall• Anteroposterior diameter should be less than transverse

diameter; ratio of anteroposterior to transverse diameter is from 1:2


Slide 18-169

• Inspect the posterior chest – Thoracic cage

• Note position person takes to breathe• Includes relaxed posture and ability to support one’s own

weight with arms comfortably at sides or in lap• Assess skin color and condition• Color should be consistent with person’s genetic background,

with allowance for sun-exposed areas on chest and back• No cyanosis or pallor should be present• Note any lesions; inquire about any change in nevus on back


Slide 18-170

• Palpate the posterior chest – Symmetric expansion

• Confirm symmetric chest expansion by placing your warmed hands on posterolateral chest wall with thumbs at level of T9 or T10

• Slide your hands medially to pinch up a small fold of skin between your thumbs; ask person to take a deep breath

• Your hands serve as mechanical amplifiers; as person inhales deeply, your thumbs should move apart symmetrically; note any lag in expansion


Slide 18-171

• Palpate the posterior chest – Tactile fremitus

• Fremitus is a palpable vibration• Sounds generated from larynx are transmitted through

patent bronchi and through lung parenchyma to chest wall, where you feel them as vibrations

• Use either palmar base (ball) of fingers or ulnar edge of one hand, and touch person’s chest while he or she repeats words “ninety-nine” or “blue moon”

• These are resonant phrases that generate strong vibrations


Slide 18-172

• Percuss the posterior chest – Lung fields

• Determine predominant note over lung fields; start at apices and percuss band of normally resonant tissue across tops of both shoulders

• Then, percussing in interspaces, make side-to-side comparison all the way down lung region

• Percuss at 5-cm intervals; avoid damping effect of scapulae and ribs

• Resonance is low-pitched, clear, hollow sound that predominates in healthy lung tissue in adult


Slide 18-173

• Auscultate the posterior chest – Passage of air through tracheobronchial tree creates

a characteristic set of noises that are audible through chest wall

– These noises also may be modified by obstruction within respiratory passageways or by changes in lung parenchyma, the pleura, or chest wall


Slide 18-174

• Auscultate the posterior chest – Breath sounds

• Evaluate presence and quality of normal breath sounds• Instruct person to breathe through mouth, a little bit

deeper than usual• Use flat diaphragm endpiece of stethoscope and hold it

firmly on person’s chest wall; listen to at least one full respiration in each location

• Side-to-side comparison is most important


Slide 18-175

• Auscultate the posterior chest – Breath sounds

• Become familiar with these extraneous noises that may be confused with lung pathology if not recognized

– Examiner’s breathing on stethoscope tubing– Stethoscope tubing bumping together– Patient shivering– Patient’s hairy chest; movement of hairs under stethoscope

sounds like crackles (rales); minimize this by pressing harder or by wetting the hair with damp cloth

– Rustling of paper gown or paper drapes


Slide 18-176

• Auscultate the posterior chest (cont.)– Breath sounds (cont.)

• While standing behind person, listen to following lung areas– Posterior from apices at C7 to bases around T10 – Laterally from axilla down to seventh or eighth rib

• Continue to visualize approximate locations of lobes of each lung so that you correlate your findings to anatomical areas

• As you listen, think – What am I hearing over this spot? – What should I expect to be hearing?


Slide 18-177

• Auscultate the posterior chest – Adventitious sounds

• Added sounds that are not normally heard in lungs

• Sources differ as to the classification and nomenclature of these sounds but crackles (or rales) and wheeze (or rhonchi) are terms commonly used by most examiners

Neurologic System

Central Nervous System (CNS)

• Consist of 2 parts• CNS – brain & spinal cord• PNS – 12 pairs of cranial nerves, 31

pairs of spinal nerves

Central Nervous System (CNS)

Damage affects function: motor weakness, paralysis, loss of sensation, impaired understanding & language.

Causes: related to decrease blood supply1. Cerebral artery occlusion2. CVA (Brain Attack) (bleeding)3. Vasospams

Cerebral Cortex

Subjective Data—Health History Questions

• Headache• Head injury• Dizziness/vertigo• Seizures• Tremors• Weakness

Health History Questions (cont.)

• Incoordination• Numbness or tingling• Difficulty swallowing• Difficulty speaking• Significant history• Environmental/occupational

hazards

Objective Data—The Physical Exam (cont.)

Test Cranial Nerves• I—Olfactory

• II—Optic

• III—Oculomotor, IV—Trochlear, VI—Abducens

• V—Trigeminal– Motor function

– Sensory function

– Corneal reflex

• VII—Facial

– Motor function


• VIII—Acoustic (vestibulocochlear)

• IX—Glossopharyngeal, X—Vagus

– Motor function


• XI—Spinal accessory

• XII—Hypoglossal


Motor System—Inspect and palpate • Muscles

– Size– Strength – Tone– Involuntary

movements

• Cerebellar function– Balance tests

• Gait• Tandem walking• Romberg’s test• Shallow knee bend

– Coordination and skilled movements• Rapid alternating movements • Finger-to-finger test• Finger-to-nose test • Heel-to-shin test


Sensory System• Person is alert,

cooperative, and comfortable

• Spinothalamic tract– Pain– Temperature– Light touch

Posterior column tract– Vibration– Position (kinesthesia)– Tactile discrimination

(fine touch) Stereognosis Graphesthesia Two-point discrimination Extinction Point location


• Neurologic recheck• Level of consciousness AAOx3

– Person– Place– Time

• Motor function• Pupillary response• Vital signs• Glasgow Coma Scale (GCS)

evidence-based assessment. health assessment definition –a systematic method of collecting data...

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