Physical Assessment

• Respiratory System
•   Breath Sounds
•   Chest Tube
• Cardiac
•   Heart Sounds
•   Tissue Perfusion
• Abdomen/GI
• Neuro Exam
• Psychosocial
• Mental Health
• Pain/Discomfort
• IV site
• Safety
•   Aspiration Risk
•   Fall Risk
• Skin
•   Braden Scale
•   Pressure Ulcer
• Nutrition
• Vital Signs

Assessment - based on the Med/Surg Flowsheet  6th FLOOR

• body positioning; sitting upright or hunched over?
• muscles used in breathing; accessory muscles to assist diaphragm?
• chest wall configuration:  Does the chest move in and out easily?  Does only one side move?

Observe and document and note changes in the patient's respiratory pattern.

• rate
• depth
• use of pursed lips
• stridor - crowing sound
• abdomen and chest rising together or irregularly (chest rise, abdomen draws in)
• slow or rapid respiration
• apnea
• restlessness

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Normal Breath Sounds

Fine Rales or Crackles

Medium Rales or Crackles

Course Rales or Crackles

Wheezing The wheezes are considered to be central airway sounds caused by air passing through mucus plugs in the upper divisions of the tracheobronchial tree. The sibilant wheeze is a high-pitched whining type of wheeze much like the sound that hump-back whales make as they migrate. The sonorous wheeze is a snoring type of sound.

Rhonchi

Pleural Friction Rub Pleural Friction Rubs are created when the visceral and parietal pleurae become inflammed and roughened. The inflammed membranes will stick together.

Tips:

• Put on your stethoscope so that the ear pieces are directed away from you. Adjust the head of the scope so that the diaphragm is engaged. If you're not sure, scratch lightly on the diaphragm, which should produce a noise. If not, twist the head and try again. Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to placing it on the patient's skin.

• Don't get in the habit of performing auscultation through clothing.
• Ask the patient to take slow, deep breaths through their mouths while you are performing your exam. This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detectability of any abnormal breath sounds that might be present.
• Sometimes it's helpful to have the patient cough a few times prior to beginning auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas at the lung bases.
• If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.), auscultation can be performed while the patient is lying on their side. Get help if the patient is unable to move on their own. In cases where even this cannot be accomplished, a minimal examination can be performed by listening laterally/posteriorly as the patient remains supine.
• Requesting that the patient exhale forcibly will occasionally help to accentuate abnormal breath sounds (in particular, wheezing) that might not be heard when they are breathing at normal flow rates.

Summary of Breath Sounds

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CHEST DRAINAGE AS A
THERAPEUTIC INTERVENTION

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Cardiac Assessment

Heart Sounds

David Woodruff reviews heart sounds. (10 min)

See Handout

Auscultation

1. Position the patient supine with the head of the table slightly elevated.
2. Always examine from the patient's right side. A quiet room is essential.
3. Listen with the diaphragm at the right 2nd interspace near the sternum (aortic area).
4. Listen with the diaphragm at the left 2nd interspace near the sternum (pulmonic area).
5. Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces near the sternum (tricuspid area).
6. Listen with the diaphragm at the apex (PMI) (mitral area).
7. Listen with the bell at the apex.
8. Listen with the bell at the left 4th and 5th interspace near the sternum.
9. Have the patient roll on their left side.
   • Listen with the bell at the apex.
   • This position brings out S3 and mitral murmurs.
10. Have the patient sit up, lean forward, and hold their breath in exhalation.
    • Listen with the diaphragm at the left 3rd and 4th interspace near the sternum.
    • This position brings out aortic murmurs.
11. Record S1, S2, (S3), (S4), as well as the grade and configuration of any murmurs ("two over six" or "2/6", "pansystolic" or "crescendo").

PRACTICE

• Normal sinus rhythm (at rates of ~60, ~90, ~130, and ~180 beats per minutes).

• S3
• S4
• Aortic Stenosis
• Atrial Fibrillation
• Bigeminy
• Mitral Insufficiency (regurgitation)
• Pericardial Friction Rub
• Systolic murmur

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Observe and document:

• color (cyanosis=blue) of skin, nail beds, earlobes, and mucous membranes.

Vascular

Pulses

1. Check the radial pulses on both sides. If the radial pulse is absent or weak, check the brachial pulses.
2. Check the posterior tibial and dorsalis pedis pulses on both sides. If these pulses are absent or weak, check the popliteal and femoral pulses.

Capillary Refill

1. Press down firmly on the patient's finger or toe nail so it blanches. ++
2. Release the pressure and observe how long it takes the nail bed to "pink" up.
3. Capillary refill times greater than 2 to 3 seconds suggest peripheral vascular disease, arterial blockage, heart failure, or shock.

Edema, Cyanosis, and Clubbing

1. Check for the presence of edema (swelling) of the feet and lower legs.
2. Check for the presence of cyanosis (blue color) of the feet or hands.
3. Check for the presence of clubbing of the fingers.

Pitting Edema

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Auscultation:

What exactly are you listening for and what is its significance? Three things should be noted:

1. Are bowel sounds present?
2. If present, are they frequent or sparse (i.e. quantity)?
3. What is the nature of the sounds (i.e. quality)?

As food and liquid course through the intestines by means of peristalsis noise, referred to as bowel sounds, is generated. These sounds occur quite frequently, on the order of every 2 to 5 seconds, although there is a lot of variability.

Percussion: The technique for percussion is the same as that used for the lung exam. First, remember to rub your hands together and warm them up before placing them on the patient. Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action (see under lung exam). There are two basic sounds which can be elicited:

1. Tympanitic (drum-like) sounds produced by percussing over air filled structures.
2. Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined.

The major areas of the exam, covering the most testable components of the neurological system, include:

1. Mental status testing (covered in a separate section of this web site)

2. Cranial Nerves

3. Muscle strength, tone and bulk

4. Reflexes

5. Cerbellar Function

6. Sensory Function

7. Coordination and Gait

• Ptosis (III)
• Facial Droop or Asymmetry (VII)
• Hoarse Voice (X)
• Articulation of Words (V, VII, X, XII)
• Abnormal Eye Position (III, IV, VI)
• Abnormal or Asymmetrical Pupils (II, III)

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Typical questions might include:

1. How have you coped with medical and/or emotional crisis in the past?
2. Has your life changed recently.  What changes in your personality or behavior have you noticed?
3. How adequate is the emotional support you receive from your support systems?
4. How often do you exercise?  What types of things do you do?

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The Mental Status Exam (MSE)

In the day to day practice of medicine (and, in fact, throughout all of our interactions) we continually come into contact with persons who have significantly impaired cognitive abilities, altered capacity for memory, disordered thought processes and otherwise abnormal mental status. First and foremost, the goal is to be able to note when these abnormalities exist (you'd be surprised at how frequently they can be missed) and then to categorize them as specifically as possible. If a person seems "odd, confused or not quite right" what do we mean by this? What about their behavior, appearance, speech, etc. has lead us to these conclusions? In some instances, the patient's condition (e.g. markedly depressed level of consciousness, intoxication) will preclude a complete, ordered evaluation of mental status, so flexibility is important. Knowing when to "cut your losses" and abandon a more detailed examination obviously takes a bit of experience! The formulation of actual diagnoses, the final step in this process is, for the most part, beyond the scope of this discussion (I've included two of the most commonly encountered ones at the end of this section as examples). In fact, even if you had the experience and knowledge to generate diagnoses, this still may not be possible after a single patient encounter. The interview provides a "snap shot" of the patient, a picture of them as they exist at one point in time. Frequently, and this applies to the physical examination as well, several interactions are required along with information about the patient's usual level of function before you can come to any meaningful conclusions about their current condition. The components of the MSE are as follows:

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1. Delirium: Also referred to as Altered Mental Status, Delta MS, Acute Confusional State, or Toxic Metabolic State. This is a very common condition (particularly among hospitalized patients) notable for an acute, global change in mental status that can be the result of physiologic derangement anywhere within the body. Causes include: infection, hypoxia, toxic ingestion, impaired ability of the body to handle endogenously produced toxins (e.g. liver or kidney failure), etc. There is a wide spectrum of presentations, ranging from unarousable to extremely agitated. Patients may appear quite ill, with markedly abnormal vital signs that in themselves can suggest the cause of the delirium (e.g. hypotension, infection). They are frequently confused, disoriented, agitated and uncooperative. Formal evaluation of mood, affect, memory, judgment or insight can be hopeless. Thought process is disordered and content notable for delusions, paranoia and hallucinations. In general, the diagnosis is suggested by the time course of the illness (i.e. the change is acute). Treatment is dictated by the underlying insult, which can generally be determined after a detailed history (usually with the help of others who are familiar with the patient), review of medications, thorough examination, and appropriate use of lab and radiologic testing. The elderly as well as those with multiple medical problems (conditions which frequently coexist) are at the highest risk for developing this condition. Delirium in this patient sub-set can be provoked by seemingly minor precipitants. Initial presentation of psychotic disorders as well as dementia can be mistaken for delirium (and vice versa). This can only be sorted out with time and appropriate testing, though these distinctions are extremely important.
2. Dementia: A final common pathway for multiple disorders characterized by its slow, progressive nature, taking months to years to develop. While quite uncommon under 50, the incidence increases markedly with age. Patient's appearance and behavior vary with the extent of involvement. This ranges from well groomed, alert and cooperative to agitated, unable to care for themselves and incapable of answering even simple questions. Mood and affect can range widely, and may or may not be appropriate for the given situation. Thought process and content have similar variability. Memory, judgment and higher cortical function deteriorate with time. As this is a progressive disease, presentation will depend on the level of advancement. Contributions from other acute, reversible medical problems must be ruled out on the basis of history, examination and laboratory testing.

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1. Appearance: How does the patient look? Neatly dressed with clear attention to detail? Well groomed?
2. Level of alertness: Is the patient conscious? If not, can they be aroused? Can they remain focused on your questions and conversation? What is their attention span?
3. Speech: Is it normal in tone, volume and quantity?
4. Behavior: Pleasant? Cooperative? Agitated? Appropriate for the particular situation?
5. Awareness of environment, also referred to as orientation: Do they know where they are and what they are doing here? Do they know who you are? Can they tell you the day, date and year?
6. Mood: How do they feel? You may ask this directly (e.g. "Are you happy, sad, depressed, angry?"). Is it appropriate for their current situation?  Mood swings may indicate a physiologic disorder.  Medications, or disease may influence mood changes.  After childbirth and during menopause women may experience profound depression.
7. Affect: How do they appear to you? This interpretation is based on your observation of their interactions during the interview. Do they make eye contact? Are they excitable? Does the tone of their voice change? Common assessments include: flat (unchanging throughout), excitable, appropriate. Check lability of affect (rapid dramatic fluctuation in emotions), flat affect (unresponsive range of emotions), or inappropriate affect (inconsistency between expression and mood).
8. Thought Process: This is a description of the way in which they think. Are their comments logical and presented in an organized fashion? If not, how off base are they? Do they tend to stray quickly to related topics? Are their thoughts appropriately linked or simply all over the map?
9. Thought Content: A description of what the patient is thinking about. Are they paranoid? Delusional (i.e. hold beliefs that are untrue)? If so, about what? Phobic? Hallucinating (you need to ask if they see or hear things that others do not)? Fixated on a single idea? If so, about what. Is the thought content consistent with their affect? If there is any concern regarding possible interest in committing suicide or homicide, the patient should be asked this directly, including a search for details (e.g. specific plan, time etc.). Note: These questions have never been shown to plant the seeds for an otherwise unplanned event and may provide critical information, so they should be asked!
10. Memory: Short term memory is assessed by listing three objects, asking the patient to repeat them to you to insure that they were heard correctly, and then checking recall at 5 minutes. Long term memory can be evaluated by asking about the patients job history, where they were born and raised, family history, etc.
11. Ability to perform calculations: Can they perform simple addition, multiplication? Are the responses appropriate for their level of education? Have they noticed any problems balancing their check books or calculating correct change when making purchases? This is also a test of the patient's attention span/ability to focus on a task.
12. Judgment: Provide a common scenario and ask what they would do (e.g. "If you found a letter on the ground in front of a mailbox, what would you do with it?").
13. Higher cortical functioning and reasoning: Involves interpretation of complex ideas. For example, you may ask them the meaning of the phrase, "People in glass houses should not throw stones." A few common interpretations include: concrete (e.g. "Don't throw stones because it will break the glass"); abstract (e.g. "Don't judge others"); or bizarre.

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FLACC Scale

Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which results in a total score between zero and ten.

Quick Summary- 2000 Infusion Nursing Standards of Practice
(PDF, 146KB)

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Aspiration Risk

See hospital Policy

Aspiration pneumonitis

• Aspiration of gastric contents results in a chemical pneumonitis

• Most commonly seen in apical segments of right lower lobe

• If unrecognised or inadequately treated it can result in a secondary bacterial infection

• Secondary infection is usually with gram-negative and anaerobic organisms

10 Best Practices for Skin Care

Nutrition Assessment

Diabetic Food Pyramid

Unfortunately, recent studies have suggested that the recording of the amount of food eaten in hospitals is highly inaccurate.

Nurse’s aides can be trained to be more accurate in estimating the amount of food ingested, but doing so requires a substantial time investment.

Vital Signs

Best Practice-Vital Signs

General Considerations

• The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the exam.
• Ideally the patient should be sitting with feet on the floor and their back supported. The examination room should be quiet and the patient comfortable.
• History of hypertension, slow or rapid pulse, and current medications should always be obtained.
• Observation: Before diving in, take a minute or so to look at the patient in their entirety, making your observations, if possible, from an out-of-the way perch. Does the patient seem anxious, in pain, upset? What about their dress and hygiene? Remember, the exam begins as soon as you lay eyes on the patient.

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Temperature

Temperature can be measured is several different ways:

• Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C) [1]
• Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)
• Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)
• Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)

Of these, axillary is the least and rectal is the most accurate.

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Oxygen Saturation: Over the past decade, this non-invasive measurement of gas exchange and red blood cell oxygen carrying capacity has become available in all hospitals and many clinics. While imperfect, it can provide important information about cardio-pulmonary dysfunction and is considered by many to be a fifth vital sign. In particular, for those suffering from either acute or chronic cardio-pulmonary disorders, it can help quantify the degree of impairment.

Respiration

1. Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations. [p129, p237] [2]
2. Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored?
3. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.
4. In adults, normal resting respiratory rate is between 14-20 breaths/minute. Rapid respiration is called tachypnea.

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Pulse

1. Sit or stand facing your patient.
2. Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left). There is no reason for the patient's arm to be in an awkward position, just imagine you're shaking hands.
3. Compress the radial artery with your index and middle fingers.
4. Note whether the pulse is regular or irregular:
   • Regular - evenly spaced beats, may vary slightly with respiration
   • Regularly Irregular - regular pattern overall with "skipped" beats
   • Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately
5. Count the pulse for 15 seconds and multiply by 4.
6. Count for a full minute if the pulse is irregular. [3]
7. Record the rate and rhythm.

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Orthostatic Vital Signs

Orthostatic (a.k.a. postural) measurements of pulse and blood pressure are part of the assessment for hypovolemia.

What is Orthostatic Hypotension?
Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person assumes a standing position. It may be caused by hypovolemia (a decreased amount of blood in the body), resulting from the excessive use of diuretics, vasodilators, or other types of drugs, dehydration, or prolonged bed rest.

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Interpretation

• A normal adult heart rate is between 60 and 100 beats per minute (see below for children).
• A pulse greater than 100 beats/minute is defined to be tachycardia. Pulse less than 60 beats/minute is defined to be bradycardia. Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning). Tachycardia is a normal response to stress or exercise.

Blood Pressure

1. Position the patient's arm so the anticubital fold is level with the heart. Support the patient's arm with your arm or a bedside table.
2. Center the bladder of the cuff over the brachial artery approximately 2 cm above the anticubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow. [4]
3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure. [5]
4. Place the stetescope over the brachial artery. [6]
5. Inflate the cuff to 30 mmHg above the estimated systolic pressure.
6. Release the pressure slowly, no greater than 5 mmHg per second.
7. The level at which you consistantly hear beats is the systolic pressure. [7]
8. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure. [8]
9. Record the blood pressure as systolic over diastolic ("120/70" for example).

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Interpretation

• Higher blood pressures are normal during exertion or other stress. Systolic blood pressures below 80 may be a sign of serious illness or shock.
• Blood pressure should be taken in both arms on the first encounter. If there is more than 10 mmHg difference between the two arms, use the arm with the higher reading for subsequent measurements.
• It is frequently helpful to retake the blood pressure near the end of the visit. Earlier pressures may be higher due to the "white coat" effect.
• Always recheck "unexpected" blood pressures yourself.

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