PHYSICAL ASSESSMENT LEARNING GUIDE Fundamentals and Medical/Surgical Neurological Level of consciousness (Must write out descriptors, abbreviations

not acceptable) Areas of Focus and Possible Findings Alert: awake, aware of self and environment Lethargic: drowsy, opens eyes looks at you to verbal stimuli, responds to questions, then goes to sleep Obtunded: opens eyes and looks at you with tactile stimuli; responds slowly and is slightly confused Stupor: arouses from sleep with noxious stimuli, slow verbally or not at all, lapses into unresponsiveness when stimuli stopped Coma: no response with noxious stimuli Assess client orientation: note whether client knows who they are, what time it is, where they are, why they are here Pupils: determine if both pupils are equal in size, measured in mm; if not equal ask about injuries, surgeries Round: shape of both pupils should be round, and midpoint; if not ask about injuries, surgeries Reactive to light: both pupils should react quickly to light - shine penlight from side of head to pupil, does it constrict quickly and equally? Is it sluggish or does it not react at all?; if no reaction, first darken room and re-assess, then ask about injuries and surgeries Accommodation: tests the adaptation of the eye for near vision; ask client to focus on a distant object, then have them focus vision to a near object: hold a pen/pencil 4 5 inches from the clients nose, you should note constriction and lens adjusting) Assess strength of hand grasp: offer client index and middle fingers and ask them to squeeze fingers as hard as they can. Should have strong equal grasps. Assess ability to follow commands readily: when asking client to grasp fingers, did the client follow command readily? Hesitantly? Assess if client not awake, and alert: Did client respond to verbal? (is the patient hard of hearing?) Tactile? Or Noxious? stimuli; was response purposeful (responds as you would expect), or purposeless (response was not what you would normally see in clients)? Areas of Focus and Possible Findings Assess ability to move extremities: assess hand strength and arm movement by asking client to lift arms and legs off the bed, have client press feet against hands when assessing feet and pulses, is client able to turn self in bed? Needs assist with turning? Know client activity level and MD orders.

Orientation (No abbreviations) Pupils (Must write out descriptors, abbreviations not acceptable)

Grasp Follows Commands Response to stimuli

Musculoskeletal Movement

Gait

Assess client gait when ambulating: unless client on bedrest, assess ability to walk: steady/unsteady gait, need assistance, number of people needed, weight bearing/non-weight bearing. Integumentary Areas of Focus and Possible Findings Assess clients skin color: face and neck are best place to assess clients skin color, may be pale, dusky, cyanotic (blue), jaundiced (yellow). Can also assess palms and earlobes for color changes. Bruising and ecchymosis may not be readily visible on dark skinned patients; evidence of cyanosis, pallor, jaundice may be most evident in mucous membranes or sclera Assess the skin temperature: skin is normally dry and warm (best place is to place hand on clients bare upper chest). May be cool, moist, cold and clammy, hot and moist Assess mucous membranes: interior mouth and nose should be pink and moist; may be pale, red, jaundiced, dusky, cyanotic and dry Assess Nailbeds for color and capillary refill: nailbeds should be pink; when compressing nailbed, note the amount of time for the nail color to return, should be less than 3 seconds, may be pale, dusky, cyanotic with sluggish refill, note time in seconds that it takes to return to normal Assess client forearm: pinch skin gently with thumb and index finger - skin should return to normal without tenting Assess condition of client skin: assess skin during the whole assessment as you assess from head-to-toe; note any deviations from normal: size, depth, width, location, color, shape, drainage, incisions, drains, tubes; tenderness of wounds or other lesions; document exactly what you see (dressings/wounds whatever) Areas of Focus and Possible Findings Assess apical heart for one full minute: note rate, strength, rhythm, and abnormalsounds such as swooshing or clicking (should be: lubbdubb (one beat) and even rhythm, without any extra sounds) Assess the brachial, radial, posterior tibial, and dorsalis pedis pulses: assess pulses for presence, equality and strength bilaterally. (No need to feel carotids-client awake and talking they have a carotid) If circulation is impaired to lower legs, then assess popliteal and/or femoral pulses (SCALE: 0 = absent; 1+ = thready (weak), 2+ = normal; 3+ = bounding) Assess hands and feet: should all be equally pink and equally warm to touch (dont chart that the hands and feet are dry or moist here-that goes in the Integumentary) Post Partum: Assess for Homans sign examine legs for areas of redness, swelling, pain; ask client to flex feet (toes toward head); pain

Color

Skin Mucous Membranes Nailbeds

Skin Turgor Skin Integrity

Cardiovascular/Peripheral Vascular Apical pulse Peripheral Pulses

Extremities

Peripheral Edema

in calf may indicate positive Homans sign and presence of DVT (deep vein thrombosis) Assess extremities for edema: press fingers firmly for 5 seconds into skin on top of foot or inner ankle bone. Normal is no imprint or indentations present after fingers released (some clients have fat ankles, if you are not sure whether they are edematous or not, ask the client). If edema is present: is it pitting? Non-pitting? Where is it located, how far up does it extend, (can have generalized edema, meaning they are edematous all over). When sitting client up to assess posterior lung sounds, assess for sacral edema and/or dependent edema (SCALE: + 0 = no edema; +1 = 0 to inch pitting (mild); +2 = - inch pitting (moderate); +3 = - 1 inch pitting (severe); +4 = greater than 1 inch pitting (severe) Areas of Focus and Possible Findings Assess the type of oxygen in use and the amount client is receiving: Normal would be withoutxygen. Note delivery route, (nasal cannula, masks, trach, etc), liter flow, (look on O2 flow meter and document level of middle of ball) Assess O2 sat monitor and peripheral oxygen percent: normal 95 100 % Assess the rate and quality of breathing: normal respiratory rate 12 20, should be even and unlabored; note retractions, depth, rythm Assess the lung sounds anteriorly and posteriorly in all 5 lobes: should be clear and equal throughout. Can have: rhonchi = secretions in the bronchioles, sounds like a squeaky door, rumbling with expiration most prominent and can be heard sometimes on inspiration, can clear with coughing crackles = excess fluid present, sounds like hair strands rubbing together, noted on inspiration most of the time, can be heard on expiration wheezes = air passing through narrowed airways, can be heard on inspiration and expiration, or can be audible can hear without a stethoscope diminished = soft, faded, sound distant (mostly in lower lobes) Assess cough: presence, quality; note if cough is productive (can cough up fluid) or non-productive (unable to produce fluid); is force of cough, weak, strong, forceful? Assess any secretions produced by cough: note the amount, color, and consistency of fluid produced Areas of Focus and Possible Findings Assess swallow: assess for risk of choking or aspiration; observe for coughing during eating, change in voice tone or quality after

Respiratory Oxygenation

O2 saturation Respirations Lung Sounds

Cough Secretions Gastrointestinal Swallow

Abdomen

Bowel Movements

swallowing, abnormal movements of the mouth, tongue, or lips; listen for slow, weak, or uncoordinated speech; delayed swallowing or pooling food may indicate difficulty. Post operative patients may have diminished gag reflex. Assess the abdomen: Inspect the abdomen, note if it is round, flat, pendulous, distended (should be flat or slightly rounded) Assess the bowel sounds: auscultate all 4 quadrants with the stethoscope and listen to each for one minute and count the sounds (normoactive = 5 30 X /minute; hypoactive = < 5 sounds/minute; hyperactive = > 30 X / minute; absent = must listen for 5 full minutes can indicate bowel obstruction. (After surgery it is common for bowel sounds to be back to normal in 1 2 days; after abdominal surgery 3 5 days). Assess the abdomen: palpate the abdomen using light palpation in all four quads (press fingers down 1 2 cm) to assess that the abdomen is soft and pliable. Note tenderness, masses, bulges) Assess last bowel movement: ask client, record date, amount (large, small, medium), color (brown, yellow, black), consistency (formed, liquid, soft, tarry). If no BM in last 2 days, assess need for prn meds Ensure that BMs are documented. Areas of Focus and Possible Findings Assess bladder: place hand slightly above the symphysis pubis, should be flat and not felt (if able to feel the bladder, this is abnormal), note distention, level of extension or displacement, etc.) Assess urinary output: measure and record in ml. ensure adequate output (> 30 mL/hr), note color, clarity, odor, sediment; record number of times voided and changed if wears briefs; note presence and patency of catheter or and drains; note whether use of bedpan, BSC, urinal; note if continent or are incontinent.

Genitourinary Bladder Urine

Revised 7/09 bh