Module 2 Physical Assessment Flashcards
What is involved in a comprehensive assessment?
A comprehensive health assessment includes obtaining information about the
following areas: biographical data, reason for seeking care, past and present health,
family history, psychosocial history, activities of daily living and physical assessment
findings
History assessment
P-Q-R-S-T-U:
* P: What precipitated the problem?
* Q: What is the quality or quantity of the symptoms?
– What does it feel like?
– Is it worse now than before?
* R: What region in the body is the problem in?
* S: How severe are the symptoms?
– 1-10 pain scale.
– Pain getting better or worse?
– Anything make it better or worse?
* T: When did symptoms begin? Onset time?
– Was onset sudden or gradual?
* U: Does patient have an understanding of the disease or of a possible cause?
* V: vital signs: Tell a lot of what is potentially going on! Even if the paramedic just
took them in the ambulance – you do need to take them for yourself
Assessment
Order of exam:
– Most use ‘head-to-toe’:
* For example: Neurological, EENT, respiratory, etc.
– In emergency situations a focused assessment will be used rather than
head-to-toe.
* For example: if a person has chest pain – focus the assessment on
the cardiac system first
Look - Inspect - first look sick/not sick, ABCD’s, symmentry, deformity, bleeding
Listen - Ascultate
Feel - palpate - skin temp, pulses, lumps
Percuss
Inspect
First part of assessment – general survey.
– Observation of patient.
* Be organized and systematic.
* Maintain objectivity – make no assumptions!
– You need to maintain objectivity:
* Even if you have seen the same person many times;
* Do not stereotype;
* Maintain professional approach.
* In triage it’s called ‘the first look’.
* When you first meet your patient you ask
yourself:
* Is his airway patent?
* Is the patient in respiratory distress? SOB?
* Colour of skin?
* Level of consciousness?
– Basically the A-B-C-D’s!
* How does the patient look to you?
Ascultate
When listening to the lungs:
– Listen both anterior & posterior lung areas.
* When listening to the heart:
– You will use both the bell and diaphragm.
* When listening to the abdomen:
– Start at the lower right quadrant for bowel sounds.
– Know where to listen for vascular sounds.
* Interference of sound during auscultation may be due to:
– Hairy chest;
– Muscle contraction, shivering;
– Friction of the stethoscope;
– Clothing (never listen over clothes!);
– Tubing size (longer or wider the tube, the less sound you
hear – it diminishes along the tube).
Palpate
Using sense of touch to determine:
– Firmness: soft or hard/taunt (as in belly);
– Quality of pulses;
– Bone/joint abnormalities, lumps, bumps;
* Use fingertips
– Extent of tenderness, swelling or size of joints;
* Use fingertips,
* Always palpate non-tender area first then proceed
towards tender area.
To assess for:
– Skin temperature/moisture;
* Use back of hand.
– Fluid accumulation and edema;
– Chest wall vibrations
* Use base of fingers.
Percussion
Sounds of Percussion:
* Resonance:
– Low pitch, sounds hollow-like
– Heard over normal lung tissue
* Hyper-resonance:
– Lower than resonance
– Very loud – booming sound
– Found in over-inflated lung (COPD), pneumothorax or in children.
* Dull:
– Muffled sound of short duration
– Found over solid organs: liver, spleen, heart, or pleural effusion.
* Flat:
– Thud like sound of short duration.
– Found over bone or muscle.
* Tympany:
– Very high sound
– Loud
– Sounds musical or drum like
– Long duration
– Found over stomach or air distended abdomen.
Respiratory System
The body depends on the respiratory system for maintenance of adequate gas
exchange, the removal of carbon dioxide, and the replenishment of the oxygen
required by every cell. Changes in this system usually results in alterations to other body systems.
Resp Assessment
Health history - Acute/Chronic
Resp history - treatments medications
Inspection -symmetry/chest deformities/
WOB/resp pattern/landmarks
Palpation crepitus/tenderness/retractions/ symmetry
Percussion-Resonant sounds:
◦ Heard over normal lung tissue.
Hyperresonance:
◦ Heard over areas of increased air in the lung or pleural space -
emphysema, pneumothorax.
Dullness:
◦ Found over areas of decreased air entry in the lungs - atelectasis,
pneumonia, hemo-pneumothorax.
Flatness:
◦ Is found over areas of consolidation – atelectasis or pleural effusion.
Tympany:
◦ Is found over areas where air has collected – large pneumothorax
Ascultation-Bronchial (tracheal):
◦ Harsh, Loud, high-pitched
◦ Heard over trachea/larynx
Bronchovesicular:
◦ Medium pitched
◦ Heard over main airways, little alveoli in areas.
Vesicular:
◦ Soft & low pitched.
◦ Heard over rest of lung fields
Adventitious-Wheezes: high pitched musical sounds
◦ Narrowed airways
Generally found in expiration, but can be heard upon inspiration.
Heard in:
Asthma, or narrowed airway passages due to allergic
reactions.
Crackles: crackling popping sounds
◦ Fluid in the airways
Fine crackles are heard during inspiration, not cleared by coughing.
Coarse crackles are loud, low-pitched, bubbling and gurgling
sounds that start in inspriation & may be present in expiration.
Heard in:
Pneumonia, pulmonary edema
Pleural Friction Rub:
◦ Inflamed visceral & parital pleural coverings.
Cardiovascular Assessment
History-Obtain a health history – ask about the following:
◦ Risk factors;
◦ History:
Is there a history of cardiac problems?
Medications
Co-mobidities (diabetic, hypertension)
◦ Family history;
◦ Lifestyle (i.e.: smoker?):
Sedentary or active?
Diet
Smoker?
Inspection
Body type:
◦ Average, thin, obese?
Skin:
◦ colour, temperature, moisture
Obvious distress or pain?
Presence of central cyanosis?
Apical impulse:
◦ Normally 5th left intercostal space (ICS), mid-clavicular line.
◦ May see in thin adults, and in children.
◦ If displaced to 6th left ICS and downward – can indicate enlarged heart
Pulsations
Finger clubbing: present?
◦ Other health problem such as COPD present?
Hair distribution on legs, feet.
◦ Decreased hair on limbs could indicate insufficient blood flow to area
JVP - can indicate R ventricular failure
Palpate the apical pulse:
◦ Apical impulse is associated with first heart sound and carotid pulsation.
Check carotid pulse and apical impulse at same time – they should coincide
with each other.
Palpate for a heave:
◦ A heave is the lifting of the chest wall.
◦ Felt during palpation.
◦ Can indicate:
Ventricular hypertrophy (felt over sternal border)
Ventricular aneurysm (felt over left ventricle)
Is skin turgor normal?
Dehydrated?
Renal failure present?
Is edema present? Palpate edema.
◦ Type: pitting, non-pitting, weeping.
◦ Grade for pitting edema: 1+ to 4+:
> 2mm = 1+ pitting edema
>4 mm = 2+ pitting edema
>6mm = 3+ pitting edema
>8 mm = 4+ pitting edema
Take blood pressure: both sides, sitting/lying.
Capillary refill:
◦ Depress & blanch the nail bed. Release & note time for colour to return.
Normal is < 3 seconds. >3 seconds can indicate decreased cardiac output or
cold.
Pulses: Assess rate, rhythm & force
Percussion may help you locate cardiac borders.
◦ Percussion over the heart will produce a dull sound – sound produced with a
blood filled ogran.
◦ Can only percuss left side of heart as right side is under sternum.
Ascultation
◦ Listen for S1 & S2 until your are familiar with them.
◦ Read the patient’s chart to see if they have extra heart sounds – then listen for
them.
Neurological Assessment
Health history
Assess mental status –
◦ LOC, appearance, behaviour, speech
Assess cranial nerve function
Assess sensory function
◦ Pain, light touch, position, discrimination
Assess motor function
◦ Strength, tone
Assess reflexes
Assessment of the neurological system begins as soon as you see the patient.
You may ask yourself the following questions:
◦ Do they respond to my voice?
◦ Can they communicate with me?
◦ Are they responding appropriately to my questions?
Assess for orientation to person, place and time.
◦ What is your name?
◦ What year/month/date/day of the week is it?
◦ Where are you now?
If response is appropriate, document as “Patient is orientated to person,
time and place”.
If a patient answers incorrectly it may indicate a need for a more in-depth
mental status exam
Assessed by applying stimuli:
◦ Auditory – voice, questions & responses;
◦ Supra-orbital pressure;
◦ Tactile – no response to voice – gentle stimulate patient for response:
Pressure to nailbed: peripheral response – could receive reflex response.
Pressure to trapezius or pectorial muscles – could be more reliable, as is a
central response.
The GCS is used to assist in assessing LOC.
◦ Scores LOC: 15 being best score, 3 worst.
◦ Score <8 usually indicates coma &patient will be unable to protect own
airway. The patient needs airway protection & probable intubation
Look for symmetry between sides!
Purposeful
◦ Withdrawals from painful stimuli & may push examiner’s hand away – light
coma
Non-purposeful
◦ Stimulated area moves slightly, may attempt to grab your hand, but does not
get near it.
Unresponsive
◦ No reaction – deep coma
LOC Pneumonic AEIOU & TIPPS
To help determine the cause of the LOC:
A-E-I-O-U: alcohol, epilepsy, insulin, opium, uremia
TIPPS: tumor, injury, psychiatric, stroke, sepsis.
Psychiatric causes should be considered only after all other possibilities
have been ruled out
Motor Assessment
◦ Arms:
Flex each arm, ask them to resist or pull against this movement.
Repeat procedure by having patient resist extension.
◦ Legs:
Ask patient to raise each knee against the resistance of your hands.
Have them straighten their knee & leg against resistance.
Have patient dorsi-flex & plantar flex feet against the resistance of your
hands.
Observe for arm drift:
◦ Ask patient to close eyes - hold out both arms with palms up.
◦ Drifting of an arm downward may indicate a neurological injury.
Evaluate hand strength:
◦ Patient grasps two fingers of nurse’s hands & note if strength in both hand is
equal.
◦ Unequal strength is abnormal
Sensory Assessment
Check for ability to feel sharp or dull:
◦ Check distal portion of limb first – if the person can feel sharp or dull distally
then can feel through the length of the limb.
◦ Numbness or tingling in hands or feet:
◦ Check for symmetry in both limbs;
Pupil Assessment
Normal size: 2-6 mm in diameter.
Shape: normally round, abnormal is oval, keyhole, or irregular.
Reaction to light: direct light reflex:
◦ Note whether they react briskly (normal) or are sluggish to react or are fixed.
◦ Cranial Nerve III is involved in reaction to light.
◦ With increasing neurological dysfunction may become sluggish, fixed or no
response.
Pupil Assessment: PERLA – Pupils Equal & Reactive to Light and Accommodation
Consensual response:
◦ A light is shone in one eye will not only constrict that pupil (direct light reflex)
but also in the other eye (consensual response).
Accommodation:
◦ Have your patient focus on your finger, held a couple of feet away from
her/his eyes. Notice that the pupils constrict as your finger moves closer and
converge inwards
Cranial Nerves
Cranial Nerve Hint to remember How to assess
1 (Olfactory) We have one nose smell
2 (Optic) We have two eyes Pupil reflex to light,Accommodation, Confrontation, Visual field
3 (Oculomotor) 4 (Trochlear) 6 (Abducens)
3-4-6 my eyes do tricks Pupil size, reflex,
equality, Consensual, Accommodation
5 (Trigeminal) 5 Rhymes with TRI Motor function of the face-clench teeth
Sensation dull/sharp
7 (Facial) 7 fits on your face smile
8 (Acoustic) 8 fits nicely into your
ear Hearing
9 (Glossopharyngeal) 10 (Vagus)9-10 fits under your chin Gag reflex
11 (Spinal Accessory) Put a 1 on each shoulder Strength in shoulder, shrug and turning head
12 (Hypoglossal) Stick your tongue out
you are done
Neuro postering
Decorticate Posturing
Rigid flexion
Upper arms held tight to sides of body
Elbows, wrists & fingers flexed
Feet, plantar flexed
Legs extended and internally rotated
May exhibit fine tremors
Decerebrate Posturing
Rigid extension
Arms fully extended; forearms pronated
Wrists and fingers flexed
Jaw clenched and neck extended
Back may be arched; feet plantar flexed
Abdominal Assessment
Health History
Health history will provide valuable information about GI status and substantiate
physical assessment findings.
Chief complaint – what is concerning this patient? Obtain story and history from
patient
Pain: acute vs chronic. Follow the PQRST method as described previously in this
lesson to assess pain. The location of pain is critical as it may indicate a
localized issue. The pain along with other symptoms can help us determine the
potential diagnosis and the lab and diagnostics required. Refer to figure 3 in
regards to potential etiologies associated with the pain. This list is not all
encompassing but will give you a general start. Always think of the life-
threatening causes that could be underlying.
There are three types of pain often seen in the abdomen:
Visceral pain: caused by a direct injury to an organ or by stretching,
inflammation or ischemia. Usually described as cramping or gas-like, but
can feel deep, dull and diffuse towards the midline of the abdomen. Pain
is wave-like in intensity, either constant or intermittent. An example
would be early appendicitis with periumbilical pain
Parietal pain: caused by receptors found in the skin and deep tissues of
the parietal lining. Can be exacerbated by movement, usually described
as a constant, sharp, localized pain. Peritonitis and late stage appendicitis
can elicit this pain due to peritoneal irritation
Referred pain: pain that occurs from a distant site from the originating
cause, believed to be due to nerve tracts developed during fetal
development. Can provide a hint to potential diagnosis. As an example,
right scapular pain can be biliary in nature or epigastric pain as a
myocardial infarction.
Intake vs output: are they tolerating PO intake? Do they appear dehydrated?
Nausea or vomiting: Frequency and amount? Consistency, colour, odour? Blood
or bile?
Diarrhea or constipation: LBM and frequency? Consistency and colour? Blood
(red or tarry) or mucous?
Fever and chills? can indicate a bacterial infection or inflammation of an organ
(appendicitis, cholecystitis)
Any bloating, abdominal mass, weight change?
Jaundice?
Eating habits/appetite, alcohol intake
Recent travel
PMH: previous surgeries, previous abdominal issues, medications, efforts to
relieve symptoms
Abdominal Assessment
Inspection
Take a good look at the abdomen. Is it rounded or flat? Is the patient guarding a
painful area? Is the belly board-like?
◦ Colour: colour of abdomen should be consistent with rest of body unless
patient has a tan.
◦ Scars: document location & size of scar as well as reason.
◦ Rashes: describe colour, consistency, location.
◦ Engorged superficial veins: These may indicate inferior vena cave
obstruction or hepatic cirrhosis.
◦ Edema: If present, skin may appear tense & glistening.
Movements in the abdomen:
◦ Respiratory:
Abdominal breathing is common in males. Pain can cause a
decrease in respiration.
◦ Peristaltic:
Usually not visible except in very thin persons & children. Strong
peristaltic waves indicate abnormality such as obstruction. Note
location.
◦ Pulsations:
In thin adults may see slight pulsation of aorta. Marked pulsations
can result secondary to increased intra-abdominal pressure or from
abdominal aortic aneurysm.
Auscultation
Auscultation is always done before palpation or percussion.
Use the diaphragm of the stethoscope – press lightly.
Listen to all 4 quadrants of abdomen.
Begin in right lower quadrant (RLQ):
◦ Bowel sounds are normally present here.
Listen in each quadrant for sounds.
Recommended that you listen for 5 minutes in RLQ however, sometimes patient condition does not allow for this.
◦ Describe bowel sounds in terms of frequency & character.
Friction Rubs:
Grating sound with respiratory variation:
◦ Can indicate inflammation of an organ’s peritoneal surface.
Are rare, if present can detected by auscultation over the two costal margins.
Rubs indicate:
◦ Tumor, infection, infarct, peritoneal inflammation or metastasis
Percussion
Percuss all 4 quadrants to identify organs, masses, fluid or air.
◦ Tympany: normal – indicates air.
◦ Dull: distended bladder, adipose tissue, fluid, mass, heard over liver,
heart and spleen.
◦ Hyperresonant: may indicate gaseous distension.
Palpation
Palpate all 4 quadrants using light palpation.
◦ Light palpation is a light, gentle, rotational dipping motion using the first
4 fingers. A downward maximum depth of 1 cm is used.
◦ Do not palpate a pulsatile midline abdominal mass as it may be a
dissecting aortic aneurysm.
◦ Note the location, size, consistency and mobility of organs.
◦ Note abnormal enlargement, masses or tenderness
Guarding:
◦ Is either voluntary or involuntary rigidity or spasm or muscles.
◦ Voluntary guarding occurs if patient is not relaxed:
Ask patient to palpate his/her own abdomen, then place your
hands over patient’s. Slowly let your fingers to drift to the patient’s
abdomen.
◦ Involuntary is a constant board-like rigidity of the muscles that occurs
with inflammation of the peritoneum.
Rebound tenderness: Hold your hand perpendicular to the abdomen & push
down slowly – then lift up quickly.
◦ A negative or ‘normal’ response is no pain on release of pressure.
◦ Pain felt on release confirms rebound tenderness.
Possible sign of peritoneal inflammation.
Perform at end of assessment as it can cause pain.
Genitourinary system Assessment
Health history
Urinary system
Pain? Follow PQRST. Pain can occur anywhere from the flanks where the kidney
resides to the end of the urethra.
Urine: color, odour, consistency, urgency, frequency, retention – these can help
rule out infection vs blood clot vs renal calculi. Obtain a urine sample for dip
and/or culture
GU Assessment
Palpation and percussion
o Bladder – full feels like firm mass above symphysis pubis following an
urge to void with palpation. This would warrant a bladder scan to detect
distention
o Kidneys: are posterior organs protected by back muscles and ribs. To feel
for kidneys, refer to the costovertebral angle (CVA) formed by the bottom
of the ribcage at the 12th rib and the spine. It is often difficult to feel
normal kidneys, especially the left kidney as the spleen sits on top.
Abnormalities such as masses may be palpable. Be cautious palpating
with suspected spleen involvement to avoid potential rupture.
o Light percussion on the flanks can help indicate pyelonephritis. Lay one
hand palm down over the flank area and lightly punch that dorsal hand.
Tenderness may indicate a kidney infection, stones, or other medical
problems. Again, caution advised on left flank with potential spleen
involvement.
Reproductive system
Penis: assess for new pain, discharge, lesions.
Scrotum: assess for pain, discolorations, swelling, and lumps. Often
excruciating sudden pain in a testicle, usually during sleep or after trauma, can
indicate a testicular torsion.
Assessment of penis and scrotum include inspection and palpation for any new changes.
Sexual history and use of contraceptives
Vaginal: pain, abnormal menstrual bleeding, discharge, lesions
Last menstrual period: to determine possibility of pregnancy and estimated
gestational age. If patient complains of excessive vaginal bleeding note the
character, amount, and changes from their normal menstruation
Possibility of pregnancy: All people with a uterus post puberty to age 55 need
to be tested for possible pregnancy. Obtain a urine beta-HCG sample, and if
positive obtain a serum blood HCG level. Some patients may have had a
hysterectomy – verify which organs removed
Lower abdo/pelvic pain can indicate ovarian torsion, pelvic inflammatory
disease, menstrual cycle issues, spontaneous abortions, endometriosis and
ectopic pregnancies
A pelvic exam may be required to assess for abnormalities and collection of
specimens.
Heart ascultation
A aortic 2nd ICS R sternal border S2
P pulmonary2nd ICS L sternal border S2
E erbs point 3rd ICS L sternal border
T tricuspid 4th ICS L sternal border S1
M mitral 5th ICS L mid clavicular line S1
Cardiovascular Clinical Ax
History - present illness, general cardiovascular status, general health and family history, lifestyle and risk factors
Physical exam
INSPECTION
Face colour pallor flushed pain jaundice
Thorax anatomical abnormalities, wounds PPM resp rate, WOB
Abdomen distension, ascites, adiposity
Nails clubbing, cyanosis
Lower extremeties hair, edema, varicose veins, PAD, PVD, hemosidrin staining, wounds
Posture upright SOB, leaning forward percarditis
Weight BMI risk for cardiovascular disease
Mentation decreased hypotension, hypoxemia
Jugular veins JVP elevation R side heart failure, fluid overload
Abdominojugular reflex
Apical impulse visible at mid clavicular 5th ICS
PALPATION
Arterial pulses 7 places
Carotid,
Brachial, Ulnar and Radial,
Femoral,
Popliteal,
Dorsalia pedis, Post tibial
Descending Aorta Pulse
Cap refill arterial circulation less than 2sec
Edema fluid in ectravascular spaces 0-4+
ASCULTATION
DIrect BP via intra arterial catheter
Indirect Stethoscope sphygmomanometer
Indirect note assymentry in BP’s measured at the level of the heart
Orthostatic hypotension sys BP drop great than 20 or dia greater than 10 with position change caused by volume depletion, medications, vascular vasodilation
Pulse pressure difference between sys and dia pressure normal 40 narrow pulse pressure compensatory mechanism
Hypotensive with sepsis widened pulse pressure dur to vascular dilation
Pulsus paradoxus pulse strength fluctuates during respiration normal 2-4. greater than 10 = pulsus paradoxus
Pulsus alternans pulse amplitude changes between weaker and stronger beats = end stage LVHF
Vascular bruits - whooshing sound caused by blood flowing past occlusion
Heart sounds
Heart Sounds
S1 and S2 normal heart sounds
S1 mitral and tricuspid valve closure start of systole
S2 aortic and pulmonic valve closure
S3 Ventricular gallop rapid filling of ventricle
S4 Atrial gallop end of diastole when ventricle is full
Heart Murmurs produced by turbulent flow, narrowed flow or backwatds regurgitation through incompetent valves
Mitral stenosis - narrowing of mitral valve orifice low pitched murmur results in L atrial enlargement, AF and atrial thrombi
Mitral regurgitation (ACUTE) with ventricle contraction a jet of blood is sent backwards in to the atrium increasing L atrial pressure resulting in acute pulmonary edema, low cardiac output, cardiogenic shock (CHRONIC) caused by deterioration of valve structures and loss of valvular tissue or when a dilated ventricle impedes the closure of the valve
Aortic stenosis - narrowing of the aortic valve L ventricle increased difficylty ejecting blood resulting in L ventricular hypertrophy resulting in decrease in L ventricular contractile force = decreased blood entering aorta and perfusing the cotonary arteries resulting on chest pain
Aortic insufficiency/aortic regurgitation left ventricle ejects blood valve not closed blood flows back into L ventricle
Papillary muscle rupture heard at apex medical emergency assoc with persistant pain and cardiac dysfunction
Ventricular septal rupture occurs after a MI new hole between the ventricles results in acute ventricular failure and cardiogenic shock
Cardiac rubs
Pericardial friction rubs results from pericardial inflammation heard as a grating or scratching sound assoc with chest pain aggrevated by deep inspiration coughing and change position.
