physical assessment ppt

PHYSICAL ASSESSMENT

MADE EASY

VITAL SIGNS

• Temperature• Apical or Radial Pulse• Respirations• Blood Pressure• Pulse Oximetry• Pain

AUSCULTATION

• Remember Skin to Stethy

PAIN THE 5TH VITAL SIGN

• P- Point of Origin • Where did the pain start

• When did it begin• What were you doing

to cause the pain• Does it radiate?


• A- Alleviating and Aggravating Factors

• What makes the pain better

• What makes it worse• Have you had this

pain before


• I- Intensity

• Wong-Baker Faces Scale

• Rank the pain on a numerical scale of 1-10

• 1-No Pain• 10-worse pain you’ve

ever experienced


• N- Nature of the Pain • Describe the quality of the pain– Burning– Crushing– Sharp– Dull– Constant– Intermittent

PHYSICAL ASSESSMENT

• The Sequence– I Inspect– P(a) Palpate– P(e) Percuss– A

Auscultate

• Sequence for the Abdomen

• I Inspect

• AAuscultate

• P(e) Percuss• P(a) Palpate

SKIN!!!!!!!!!!!!!!!!!

SKIN, HAIR, NAILS

Skin Inspection • Color• Hygiene• Lesions-size, shape,

location, configuration, color, blanching, exudate

• Odors

SKIN, HAIR, NAILS

• SKIN PALPATION • Moisture• Temperature• Texture• Turgor• Elasticity

SKIN, HAIR, NAILS

• HAIR Inspection • Color • Distribution• Quantity

SKIN, HAIR, NAILS

• Nails Inspection • Pigmentation of nail bed

• Ridging, beading, pitting, pealing

• Schamroth Technique

SKIN -Abnormal Findings

• Skin-Melanoma • Sores that do not heal• Nevi-Brown, Black with

Red, White, Blue margins• Development of a nodule,

especially with erosion or ulceration

• Bleeding• Changes in color, size,

thickness

SKIN -Abnormal Findings

• Kaposi Sarcoma • Malignant tumor of the endothelium and epithelial layer of the skin. Lesions are characteristically soft, vascular, bluish-purple and painless.

• See frequently in patients with AIDS

PRESSURE ULCER STAGING

• Stage I

• Stage II

• Redness that is not relieved by stimulation or removal of pressure. Skin is intact.

• Abrasion, blisters or shallow crater due to partial-thickness loss of epidermis/dermis

PRESSURE ULCER STAGING

• Stage III

• Stage IV

• Full-thickness loss with damage to subcutaneous tissue. Deep crater visible.

• Full-thickness skin loss, necrosis, and damage to fascia, connective tissue, muscle or bone.

CHEST AND LUNGSAnatomy

CHEST AND LUNGS

• INSPECTION • Inspect chest movement with breathing for– Symmetry– Bulging– Use of Accessory

Muscles

Evaluate respirations forRate, rhythm, andRespiratory pattern

CHEST AND LUNGS

• Auscultate with diaphragm of stethscope

• Duration• Intensity• Pitch• Timing (Where in

respiratory cycle does sound occur)

Where to Auscultate

CHEST AND LUNGSNormal Breath Sounds

• Bronchial (Tracheal)

• Bronchvesicular

• High pitch, Loud, Inspiration < Expiration, Harsh/Hollow, Heard over Trachea

• Moderate Pitch Inspiration=Expiration, Heard over major bronchus

CHEST AND LUNGSNormal Breath Sounds

• Vesicular • Low, soft, Inspiration>Expiration, Quality of rustling like wind in trees, heard over the peripheral lung fields

• Most frequently heard sound

CHEST AND LUNGSAdventitious Lung Sounds

• Fine Crackles

• Coarse Crackles

• High-pitched, heard during end of inspiration, not cleared by coughing

• Loud, bubbly noise heard during inspiration, not cleared by coughing


• Rhonci

• Wheeze

• Loud, low, coarse sounds, like a snore, most often heard continuously during inspiration and expiration

• Musical noise sounding like a squeak; heard continuously in inspiration and expiration


• www.ymec.com/hp/signal2/lung2.htm

http://www.ymec.com/hp/signal2/lung2.htm

Rub: Cardiac vs. Pleural

• How do you make a decision regarding origin???

ABNORMAL RESPIRATORY PATTERNS

• Cheyne-Stokes Respiration

• Respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing with periods of apnea.

• Normal in the very young and very old during sleep.

ABNORMAL RESPIRATORY PATTERNS

• Kussmaul • Rapid, Deep, Regular• Most commonly seen

in patients in Metabolic Acidosis, usually associated with Renal Failure

PHYSICAL FINDINGS ASSOCIATED WITH COMMON RESPIRATORY CONDITIONS

• Asthma • Inspection-– Tachypnea– Dyspnea

• Auscultation– Prolonged expiration– Wheezes– Diminished lung

sounds


• Bronchitis– Secondary to

proliferation of mucous glands in the passageways, resulting in excessive mucus secretion. Inflammation of bronchi with partial obstruction

• Inspection– Hacking, rasping

cough productive of thick sputum

– Dyspnea, fatigue, cyanosis

• Auscultation– Crackles, Wheeze,

Prolonged expiration


• Emphysema– Secondary to

destruction of pulmonary connective tissue

– Enlargement of air sacs distal to terminal bronchioles

– Increased airway resistance, especially on expiration

– Hyperinflated lungs and lung volume

– Cigarette Smoking

• Inspection– Barrel chest– Use of Accessory

muscles– Dyspnea on exertion

• Auscultation– Decreased breath

sounds– Prolonged expiration– Muffled heart sounds

secondary to overdistention of lungs


• Atelectasis • Inspection– Delayed/diminished

chest wall movement– Tachypnea

• Auscultation– Diminished/absent

breath sounds– Wheezes, Rhonci,

Crackles


• Chronic Obstructive Pulmonary Disease

• Inspection– Respiratory Distress– Audible wheezing– Cyanosis– Distended neck veins– Possibly finger

clubbing (RHF)

• Auscultation– Rhonci, Wheezing,

Crackles


• Pneumonia– With lobar

consolidation

• Inspection– Tachypnea– Shallow breathing

• Auscultation– Crackles– Rhonci– Bronchial breath

sounds


• Pneumothorax– Free air in pleural

space causes partial or complete collapse of lung

• Inspection– Unequal chest

expansion– Tachypnea, Cyanosis,

Apprehension

• Auscultation– Breath sounds

decreased or absent

TRACHEOSTOMY AND TUBES

Purpose of Tracheostomy

• To bypass a compromised upper airway and to provide access to the lower airway for basic air exchange and ventilation

Advantages (Why)

• No upper airway complications• Easier to suction• Easier to stabilize• Well tolerated by patient• Improved communication• Patient can swallow• Easy to change/reinsert

Disadvantages

• Immediate complications

• Surgery• Bleeding• Pneumothorax/pneumomediastinum• Air embolism• Subcutaneous emphysema

Disadvantages

• Late complications

• Infection• False passage into subcutaneous tissue• Hemorrhage (erosion of adjacent structures)• Formation of granulomatous tissue• Tracheomalacia or stenosis• Fistula (TE or TI)• Occluded with secretions

Tracheostomy Tube

Types and Sizes of Tracheostomy Tubes

• Various manufacturers and types• No standardized sizing• Variable size, length and shape• Fenestrated/nonfenestrated• Cuffed/cuffless• Single cannula/double cannula• Disposable/nondisposable• Specialty tubes

Fenestrated Trach Tubes

• Fenestrated trachs– permit use of the

natural airway above the tracheostomy tube when inner cannula is removed and cuff is deflated

Shile 6 FEN

• Fenestrated Low Pressure Cuffed Tracheostomy Tube

• Inner Cannula– Fenestrated– Non fenestrated

• Available sizes 4, 6, 8

• 6.4 mm ID• 10.8 mm OD• 76 mm Length

Fenestrated Trach Tube

Passy Muir valve

• One way flap valve• Allow gas flow

through tracheostomy tube

• Patient exhales via upper airway

• Use caution with increased secretions

• CUFF MUST BE DEFLATED

• Information regarding Tracheostomy Tubes compliments of Mr. Daniel Chapman, Ast. Director Respiratory Therapy, Mass. General Hospital

THE HEART AND BLOOD VESSELS

Auscultation of Heart“ALL PUPPIES TAKE MILK”

Normal Heart Sounds

• S1 • Closure of the AV valves (Tricuspid, Mitral)

• Indicates the beginning of Systole

• Best heart at the Apex• “Lub” sound

Normal Heart Sounds

• S2 • Closure of semilunar valves (Aortic, Pulmonic)

• Best heard at the base

• “Dub” sound

Abnormal Heart Sounds

• S3 • Heard with bell• Follows S2• Ventricular filling

sound• Indicates decreased

compliance of the ventricles

• Frequently seen in patients with LHF


• S4 • Ventricular FILLING sound

• Occurs in late diastole when the atria contract.

• Heard with Bell• Precedes S1


• Gallops • Refers to the speed with which the ventricles are filling.

• Tachycardia may result in a summation gallop in which all 4 sounds are present


MURMURS

• Result from diseased or incompetent VALVES

• Stenosis-Calcification of the valves result in narrowed lumen and restricts forward flow of blood

• Regurgitation-Incomplete closure of the leaflets of the valve, allowing blood to flow backward

MURMURS

• Aortic Stenosis • Restricts forward flow of blood during systole

• LV hypertrophy develops

• Loud, harsh, midsystolic, crescendo-descrescendo

MURMURS

• Aortic Regurgitation • Blood flows back into LV during diastole.

• LV dilatation and hypertrophy

• Murmur starts with S2, soft, high-pitched blowing diastolic, decrescendo

MURMURS

• Mitral Stenosis • Impedes forward flow of blood into LV during diastole

• Enlarged LA• Murmur-low pitched

diastolic rumble, best heard at apex

MURMURS

• Mitral Regurgitation • Blood flows back into LA during systole

• In Diastole, blood flows back into LV along with new flow resulting in LV hypertrophy

• Murmur-Pansystolic, blowing, radiates

GRADING MURMURS

• GRADE1/6

2/6

3/6

4/6

5/6

6/6

• DESCRIPTION• Very faint, difficult to hear

• Quiet, but easier to hear

• Moderately loud

• Loud, may have thrills

• Very loud, +/- thrills, may be heard without stethoscope

• Can be heard without a stethoscope

SOUNDS

• www.med.ucla.edu/wilkes/lungintro.htm

http://www.med.ucla.edu/wilkes/lungintro.htm

PULSES for PALPATIONRADIAL, POSTERIOR TIBIAL, PEDAL

• Palpate right and left pulses simultaneously• Evaluate the pulses for rate, rhythm,

elasticity of vessel wall, and force of amplitude

• Grade the amplitude as– 4+ Bounding– 3+ Increased– 2+ Normal– 1+ Weak– 0 Absent

CAPILLARY REFILL

• An indicator of peripheral perfusion and cardiac output.

• Depress and blanch the nail bed.• Release the nail bed and note the time

for color return.• Normal Capillary Refill is <3 sec.

ALLEN TEST

• Used to evaluate peripheral circulation prior to cannulating radial artery (prior to drawing ABG, or insertion of arterial line)

• Occulde both radial and ulnar arteries.• Have patient make a fist.• Have patient open fist and you release

ulnar artery• Adequate circulation results in return of

normal color in 2-5 seconds

ASSESSING FOR EDEMA

• Press firmly for 5-10 seconds over a bony surface such as tibia, fibula, sacrum, sternum.

• 0 No edema• +1 Slight pitting, no

visible distortion, disappears rapidly

• +2 Deeper pit than 1, disappears in 10-15 sec.

• +3 Pit is deep and may last more than 1 min.

• +4 Deep pit and lasts 2-5 minutes

PERIPHERAL VASCULAR DISEASE IN THE LEGS

• Arterial Insufficiency– 3 P’s- Pain, Pallor,

Pulselessness– 4th P- Paresthesia (acute

occulsion of major artery)

– 5th P- Paralysis- completing the Compartment Syndrome

– Exercise excerberates pain and rest relieves

– Skin lesion is usually small, round, dark

• Venous Insufficiency– Results from

impediment to blood flow

– May be secondary to Deep Vein Thrombosis

– Treatment is Heparizination and bed rest

– Skin lesion is red, has uneven edges, bleeds

THE HOMAN’S SIGN

• A positive finding is suggestive of Thrombophlebitis or DVT

• Flex the knee with one hand and dosiflex the foot.

• A complaint of calf pain with the procedure is a positive sign.

ABDOMEN

ABDOMEN

• Inspection– Observe for contour,

symmetry, location of the umbilicus, skin color

• Abnormal findings– Jaundice– Cyanosis– Glistening, taut

appearance (ascites)– Bluish discoloration

around umbilicus (Cullen’s Sign)

– Striae (Cushing Disease-purple and do not fade)

ABDOMEN

• Auscultation– Use Diaphragm of

stethscope– Begin at RLQ-ileocecal

valve area– Listen in each

quadrant for up to 5 minutes

• Abnormal– Hyperactive-loud,

high-pitched, tinkling• Stomach growling-

Borborygmus

– Hypoactive or absent-postoperatively, inflammation of peritoneum

TYPES OF OSTOMIES

COLOSTOMY

• Descending or Sigmoid - This type of colostomy may often produce formed stools. Irrigation (enema) may be recommended by the physician to regulate bowel movement, in which case only a special pad or small security pouch is needed to be worn over the stoma.

COLOSTOMY

• Transverse - This type of colostomy generally does not result in formed stools, it being more likely that stools will be loose. Irrigation may regulate bowel movement in some but not in the majority of cases. Special care must be taken to protect the skin from discharge. It is probably necessary to wear an appliance at all times.

ILEOSTOMY

• This type of ostomy involves the surgical construction of a connection from the small bowel to the abdomen, forming a stoma which allows for the discharge of body wastes. Surgery often involves removal of the colon and rectum.

ILEOSTOMY

• The discharge will vary from being quite liquid at first to semisolid as time goes on. It is necessary to wear an appliance at all times, and special care must be given to protecting the skin. It is important for the ileostomate to take meals at regular hours and to drink lots of fluid to keep electrolytes in balance. Diet will have a bearing on the quantity and character of output.

•

UROSTOMY

• This type of ostomy involves the surgical construction of a connection from the ureters to the abdomen, forming a stoma, which permits the discharge of urine after removal or dysfunction of the bladder.

UROSTOMY

• The ureters carry the urine from the kidneys to the Ileal Conduit (pipeline created from a small section of the ileum) through which it flows to the outside of the body. Wearing an appliance is needed at all times and great care must be taken to protect the skin around the stoma. After the 15 cm piece of ileum is removed to create the conduit and stoma, the cut ends of the ileum are joined and the intestinal tract will soon function the same as before the surgery.

•

NEUROLOGIC

CRANIAL NERVES

• CN I-Olfactory (On)• CN II-Optic (Old)• CN III-Oculomotor

(Olympus)• CN IV-Trochlear

(Towering)• CN V-Trigeminal

(Tops)

• Smell• Visual acuity• Pupil response

• Downward, inward eye movement

• Jaw opening, chewing

CRANIAL NERVES

• CN VI-Abducens (A)• CN VII-Facial (Finn)

• CN VIII-Accoustic (And)

• CN IX-Glossopharyngeal (German)

• CN X-Vagus (Viewed)

• Lateral Eye movement

• Facial expression, close jaw

• Hearing• Swallowing, gag

reflex

• Speech, swallowing, parasympathetic

CRANIAL NERVES

• CN XI-Spinal Accessory (Some)

• CN XII-Hypoglossal (Hops)

• Shrug shoulders

• Tongue movement

NEUROLOGIC ASSESSMENT

• Level of Consciousness– Ease of arousal– State of awareness– Orientation

• Motor Function

• Person• Place • Time

• Squeeze hand, smile, stick out tongue, raise eyebrows

NEUROLOGIC ASSESSMENT

• Pupillary Response • Size• Shape• Symmetry of pupils

• Document degree of constriction to light– 5/4

Glasgow Coma Scale

• A quantitative tool that defines the level of consciousness by giving it a numeric value.

• Divided into 3 parts-Eye Opening, Verbal Response, Motor Response

Glasgow Coma Scale

• Best Eye Opening Response

• Spontaneously 4• To Speech 3• To Pain 2• No Response 1

Glasgow Coma Scale

• Best Motor Response • Obeys Verbal Command 6

• Localizes pain 5

• Flexion-withdrawal 4

• Flexion-Decorticate 3

• Extension-Decerebrate 2

• No Response 1

Glasgow Coma Scale

• Best Verbal Response

• Oriented x3 5• Conversation confused

4• Speech inappropriate

3• Sounds

incomprehensible 2• No response 1

Glasgow Coma ScaleE+M+V=15

• 90% scores less than or equal to 8 are in a coma

• Greater than or equal to 9, not in coma• 8 is the critical score• Less than or equal to 8 at 6 hrs—50% die• 9-11----moderate severity• Greater than or equal to 12----minor

injury

Glasgow Coma Scale

• COMA IS DEFINED AS• 1 NOT OPENING EYES• 2 NOT OBEYING COMMANDS• 3 NOT UTTERING UNDERSTANDABLE

WORDS

PATHOLOGIC REFLEXES

• Babinski-stroke lateral aspect and across ball of foot

• Is indicative of stroke, brain tumor, head, neck, back injury.

• Extension of great toe, fanning of toes

PATHOLOGIC REFLEXES

• Kernig-Raise leg straight or flex thigh on abdomen, then extend knee

• Brudzinski-Flex chin on chest

• Resistance to straightening, pain down posterior thigh, indicates meningeal irritation

• Resistance and pain in neck, indicates meningeal irritation

• ELECTROLYTES AND PHYSICAL ASSESSMENT FINDINGS

Sodium135-145 mEq/l

• Hyponatremia <135 Confusion, poor skin tugor, lethargy, muscle excitability, cold, clammy skin, abdominal cramps, N/V/D, Tachycardia, Headache, Seizures

Sodium135-145 mEq/l

• Hypernatremia >145

• May be secondary to dehydration

• Confusion, hot, flushed skin, dry mucous membranes, furrowed tongue, fever, temperature, hypotension, extreme thirst, decrease urine output, seizures, increase in muscle tone and deep tendon reflexes

Potassium 3.5-5.0 mEq/L

• Hypokalemia <3.5 • Muscle cramps and weakness, nausea, vomiting, hypoactive/absent bowel sounds, weak/irregular pulse, difficulty breathing, hypotension, disorientation

Potassium 3.5-5.0 mEq/L

• Hyperkalemia >5.0 • Muscle weakness, paraesthesia, nausea, slow/irregular pulse, cardiac dysrhythmias, respiratory difficulty, decreased urine output

Calcium8-10.0 mEq/l

• Hypocalcemia <8.0 mEq/l

Chvostek-twitching of facial muscles when tapped in front of ear

• Numbness, tingling of fingers, hyperactive reflexes, positive Trousseau’s (carpal spasm)

Calcium8.0-10.0 mEq/L

• Hypercalemia->10.0 mEq/l

• Loss of muscle coordination

• Anorexia• N/V• Decreased LOC• Personality changes• Cardiac Arrest

Magnesium1.5-2.5 mg/dl

• Hypomagnesium <1.5

• Muscular tremors• Hyperactive DTR• Confusion/

Disorientation• Dysrhythmias

Magnesium1.5-2.5 mg/dl

• Hypermagnesium >2.5

• Hypoactive DTR• Decreased

respirations• Hypotension

Acid Base

• R-espiratory• 0-pposite• M-etabolic• E-equal

• pH 7.35-7.45• pCo2 35-45• HCO322-26

Intravenous Solutions

ISOTONIC FLUIDS

• Most resemble normal plasma• Do not cause RBC to either swell or

shrink• Used to treat dehydration, and in fluid

resuscitation

– Dehydration caused by running, fever, labor, Burns

ISOTONIC FLUIDS

• Normal Saline 0.9% NS• Lactated Ringer’s (contains a balance of

electrolytes)• D5W –Dextrose in Water

HYPOTONIC FLUIDS

• Causes fluid to move from the ECF (circulating volume) to ICF (inside the cells)

• Indicated for cellular dehydration

HYPOTONIC FLUIDS

• Half strength Normal Saline- 0.45% NS or • ½ Normal Saline (1/2 NS)• Quarter Strength Normal Saline-0.25% NS

or• ¼ Normal Saline (1/4 NS)

• Assists with renal function. Provides free water, Na, and Cl.

• Does not assist with electrolyte replacement or provision of calories

HYPERTONIC FLUIDS

• Draws water out of the cells and into the extracellular compartment to restore equilibrium. The cells will shrink.

• Used to increase circulating volume without requiring large infusions of IV fluids.

HYPERTONIC FLUIDS

• D5RL

• D10RL

• 3%NS

• D5 and 0.45%NS

ACCESS DEVICES

• PICC TLC VAD

VENOUS ACCESSIndications for Use

Chemotherapy Total Parenteral Nutrition (TPN)Antibiotics (Long Term)Blood transfusions Rehydration Multiple / frequent blood tests

Central Venous AccessWhy is it useful?

Reduces damage to small peripheral veins from toxic solutions

Long-term placement of these devices allows for reduced number of venous punctures

CENTRAL VENOUS ACCESS DEVICES

Port-a-Cath Usually implanted under skin under the clavicle. A tubing connects the “port” to a central vein.

“Port” refers to the lumens that are available to receive medications or for blood draws. “Ports” are usually either single or double lumens.

Huber Needle

• A special right angled needle utilized to “access” the lumen of the Port-a-Cath.

• IV tubing is attached to one end of the Huber utilizing sterile technique

• The tubing and the needle are flushed with a normal saline solution. The needle is inserted into the lumen of the port and the infusion started

HUBER NEEDLE

Venous Access PortPort-a-Cath

• How is it cared for?• Dressing worn for 1 week • Steri-strips • Sterile transparent non-occlusive dressing • Post-procedure instructions Avoid use

for 48 – 72 hours to minimize the risk of an infected blood clot Keep site clean and dry for 7 – 10 days Remove suture in 7 – 10 days Flush monthly and after each use using saline and heparin

PICC LINE

Peripherally inserted central catheter It’s a non-tunneled external catheter

• Small flexible catheter inserted into a peripheral vein then threaded so that its tip is positioned in a central location

• Mid-line catheter stops midway up the arm

PICC LINES

• Best suited for treatments lasting from several weeks to 6 months requiring frequent access to veins

Care of the PICC LINE

Dressing:• The dressing should be changed

frequently: – every 72 hrs – whenever they lose adhesion – whenever they become wet

• Swimming and rigorous arm work is discouraged – a waterproof barrier such as plastic kitchen

wrap should be applied before showering

PICC LINE Care (cont)

• How is it cared for?• Flushing: The PICC line should be

flushed (rinsed) with 10 cc’s (1 cc = 1 milliliter) of saline solution and then 5 cc’s heparin (an agent that prevents clotting) daily and after each use

PICC LINE

Triple Lumen Catheter

TLCTriple Lumen Catheters

• Placed in either right or left subclavian vein• Utilized for administration of up to three

infusions• Infusions may be maintenance fluid, drips,

blood• Any of the 3 “Ports” may be utilized for

medication administration or blood draws• “Ports” not being utilized must be flushed

with a heparin or normal saline solution every shift

LABORATORY TEST

Basic Metabolic Panel (BMP)– Creatinine Potassium– CO2 Sodium– Chloride BUN– Glucose Calcium

COMPLETE METABOLIC PANEL(CMP)

• Albumin Chloride• Alkaline Phos Creatinine• ALT Glucose• AST Potassium• Total Bilirubin Sodium• Calcium Total Protein• CO2 BUN

COMPLETE BLOOD COUNT(CBC)

• WBC• WBC with Differential-specific patterns

of WBC• RBC• Hct/Hgb


• RBC indices-calculated values of size and Hgb content of RBC’s. Important in anemia evaluationsComponents of the RBC indices are:

MCV-Mean Corpuscular volume

MCHC-Mean Corpuscular hemoglobin concentrationMCH-Mean Corpuscular hemoglobin


• Platelet count• RDW-Red Cell Distribution width.

Indicates abnormal variation in size of RBCs.

• MPV-Mean Platelet Volume-indicates uniformity of size of the platelet population

COAGULATION STUDIES

• PT-Prothrombin time-used to measure warfarin therapy

• INR-International Normalized Ratio• PTT/APTT-test for the same functions

and is used to monitor heparin therapy

physical assessment ppt

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