PHYSICAL NURSING EXAMINATION

PHYSICAL ASSESSMENT NOTES

HEALTH HISTORY
bio data
chief complaint
medical history
family history
immunization
medication history
nutrition history
psychosocial history ADL
review body systems

MEMORY TEST
-What is your name
orientation to person
-whats your mothers name
orientation to other people
-whats todays date
orientation to time
-what year is it
orientation to time
-how old are you
memory
-where were you born
remote memory
what did you have for breakfast
recent memory
-who is prime minister of Canada
gen knowledge
-can you count backwards from 20
attention span and calculation skills
-why are you here
recent memory

palliative or provocative question
-what provokes,relieves, triggers Sx
quality/quantity question
-what does Sx look,feel like
region/radiation
-where is Sx
severity/scale
-how severe 1~10scale
timing
-Sx when how long
understand pt perception

INTEGUMENTARY SYSTEM
SKIN pigment dry/oily itchy condtion
turgor=pinch skin turgor is skin returning to its shape
HAIR loss texture color distribution
alopecia/hirutism
NAILS clubbing brittle blanch shape bed color tissues around nail test/color return less than 2 second
DIGESTIVE SYSTEM
frenulum tissue connecting tongue to floor of mouth
ABDM auscultate before percussing abdomin
RUQ=liver-gallbladder-duadium-pancreas-rt kidney-ascending transverse colon
LUQ=liver-stomach-spleen-pancreas-lt kidney-transverse colon
RLQ=cecum-appendix-rt kidney-rt ovary-fallopian tube-
LLQ=lt kidney-descending colon-sigmoid colon-lt ovary-fallopian tube
girth =level of umbilicus
assess skin integrity,contour symmetry,movement,
-bowel sounds should be heard 1 every5~30seconds in a 3~5 minutes period hyperactive high pitched increased motility
,,fluid masses,pain,
-mouth-symmetry,color,texture-mucuses,teeth,gums,tongue,
oropharnyx and tonsils
-Anus color integrity lesions
MUSCULOSKELETAL SYSTEM
-crepatation=grating sound
MOVEMENTS- Flexion=bend limb at joint-extension=straighten at joint
abduction=move limb away from mid line body -adduction=move limb toward mid line of body-pronation=turning forearm so palm is down -supination=turning forearm so palm is up-circumduction=arm in circle from shoulder-inversion=sole of foot inward at ankle-e version=sole of foot outward at ankle,rotation=move head around an axis-protraction=move a body part forward and parallel to the ground-retraction=move a body part backward parallel to ground
elevation=raising body part-depression=lowering body part
MUSCLE GRADE
-5=100% 4=75% 3=50% 2=25%
1=10% 0=0%
SEE NERVES
SENSORY SYSTEM
-penlight test reaction to light
-near vision test newspaper
-distant vision snellen lger #poorer vision both eyes then each eye
accommodation test pencil/distance pupil constriction
-convergence finger/nose Xeyed
peripheral how many fingers
ocular movement up/down lt/rt
EYES lacrimal gland lubricates tears
HEARING whispered voice -use otoscope to check for cerumen /wax
NOSE/SINUS patency smell
ENDOCRINE SYSTEM
-thyroid examine lower neck for masses and symmetry
REPRODUCTIVE SYSTEM
-breast exam-genital
-testicular exam
CARDIOVASCULAR SEE HEART
LYMPHATIC SYSTEM
cervical-axillary-inguinal nodes are not observed or palpable
SEE NOTES RESPIRATORY SYSTEM
URINARY SYSTEM
bladder at mid line symphysis pubis
-unable to palpate
VITAL SIGNS
T=35.9-37.4 P=76 R=20 BP=110-140/60-90
temp=hypothalamus
surface temp=temp of skin
-rectal/tympani c temp=.5C higher
axillary=.5C lower
-tachycardia=100-180beats
-bradacardia=below60 beats
PULSES-apical.brachial,carotid,
dorsalis pedis-femoral,popliteal,posterior tibial,radial,temporal,ulna
BP marked systolic with a V and diastolic with upside down V on graph
OXYGEN
-pulse oximetry measure O2 saturation of arterial blood
-O2 saturation = amt of O2 bound to hemoglobin in tge blood is expressed as %…95-98%

HT / WT2.2lbs=1kg and 2.5cm = 1 inch

INSPECTION
PALPATION
PERCUSSION
-resonate clear hollow
-hyper resonate booming
-tympani drum like
-dull muffled thud
-flat dead stop of sound
AUSCULTATION
-pitch high/low
-loudness soft/loud
-quality gurgling /swishing
-duration short/med/long