Evaluate level of responsiveness if the patient is not alert.

If your patient is not alert but appears to be sleeping or even comatose.

• Does he respond to your voice?
  • If he does not, see if he will respond to touch by pressing or rubbing his arm or shoulder. Some patients who do not respond to gentle touch will respond to pain.
  • Test for a pain response by pressing a pen across a nailbed or rubbing a knuckle over the bony part of the patient’s sternum.

AVPU

Alert, Verbal stimulus response, Pain stimulus Response, and Unresponsive.

Components of the general survey include:

• Observe skin color, respiratory effort, and presence or absence of distress.
• Evaluate mood and affect (smiling, pleasant, anxious, apprehensive, depressed, angry, hostile).
• Assess posture.
• Observe hygiene, grooming, and dress.
• Check for odors.
• Measure height, weight, and body mass index (BMI).
• Note mobility aids.

General patient survey

• Are the patient’s lips pink and moist or are they bluish or purple in color
  • The bluish discoloration may be cyanosis, which indicates decreased oxygenation.
• Are his respirations regular and unlabored or is he using accessory muscles?
• Does the patient appear to be comfortable or does he have other signs of pain or distress?
• Is he smiling and pleasant?
• Does he appear anxious or apprehensive?
• Depressed?
• Is he angry or hostile?
• If the patient is standing, is his posture erect? If he is seated or in bed, look for evidence that he can change position independently. Note his facial expression.
• Is there any evidence of pain or distress?
• Observe hygiene, grooming, and dress. Is he dressed appropriately for the season and the situation? Pay attention to any noticeable odors as well.
• Is your patient thin? Obese?

BMI Calcualtion

multiply the patient’s weight in pounds by 703, then divide that result by the patient’s height in inches squared.

30+ = obese

25-29 = overweight

18.5-24 = healthy

18.4 and below = underweight

Components of vital signs include:

• Assess pain.
• Measure temperature.
• Assess pulse.
• Evaluate respirations.
• Check for odors.
• Determine if oxygen saturation is necessary.
• Measure blood pressure.

Components of integument assessment include:

• Inspect the skin systematically from head to toe for color (pink, tanned, pale, ruddy, jaundiced, consistent with ethnicity), color variation, hair distribution, and lesions.
• Palpate and inspect the skin from head to toe for temperature, texture, and moisture.
• Palpate and inspect the skin overall for skin turgor, edema, and lesions.
• Assess any lesions for location, distribution, size, shape, color, texture, surface characteristics, exudate, and tenderness.
• Inspect and palpate the hair for quantity, distribution, texture, color, and parasites.
• Inspect and palpate the nails for color, shape, thickness, adhesion to the nailbed, lesions, clubbing, and capillary refill.

Head, nose, and throat

-

Respiratoy

-

Cardiac

-

Abdomen

-

Musculoskeletal

-

Neurological

-

When performing a complete, head-to-toe physical examination, which physical-assessment technique should you perform first?

Inspection

Inspection is the process of observation. You will first inspect the body systematically, observing for normal as well as abnormal physical signs. When assessing most body systems, the recommended order is inspection, palpation, percussion, and auscultation. Abdominal assessment is an exception, since any manipulation of or pressure on the abdomen may stimulate peristalsis, the waves of contraction that propel contents through the gastrointestinal tract, and thus alter the patient’s bowel sounds. So, when assessing the abdomen, inspection is still first, but auscultation comes before percussion and palpation.

You are performing a physical examination of the spine for an older adult. Which of the following findings is common with aging?

kyphosis

Kyphosis, a pronounced “hunchback” curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging. This pronounced convexity of the thoracic spine is also common in older patients who have had vertebral fractures.

While performing an abdominal assessment, you place your fingertips over the patient's painful area and gradually increase pressure, then quickly release it. The patient reports increased pain on release of pressure, so you document that your patient has positive

rebound tenderness

This procedure elicits rebound tenderness – an increase in pain when deep palpation over a tender area is released. Rebound tenderness in the right lower quadrant at McBurney’s point (one third the distance from the anterior iliac crest to the umbilicus) is a sign of acute appendicitis.

While performing a head-to-toe assessment, you perform the Romberg test. You do this to test the patient's

balance

The most common test of balance is the Romberg test. Ask the patient to stand about 2 feet in front of you, with her feet together, toes pointed forward, and her hands at her sides. While you extend your hands so that one is on either side of the patient, ask her to close her eyes. Watch to see how well she can maintain balance in that position. A minimum of swaying is normal, but if the patient sways more than a couple of inches, stop the test and document that the patient demonstrated difficulty maintaining balance on Romberg testing.

When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory phase of each respiratory cycle. These sounds are best identified as

crackles

Crackles, which are sometimes called rales, are wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration. They are most common at the end of inspiration.

When using and maintaining your stethoscope, it is important to

insert the earpieces at an angle toward your nose

Angling the earpieces toward your nose helps ensure that sounds are effectively transmitted to your eardrums.

When assessing peripheral vascular status of the lower extremities, you place your fingertips on the top of your patient's foot between the extensor tendons of the great toe and those of the toes next to it. Which pulse are you palpating?

Dorsalis pedis

In the lower extremities, the most common pulse tested is the dorsalis pedis pulse, found on the dorsum of the foot between the extensor tendons to the great toe and the toe next to it.

As part of your general patient survey, you find that your patient has a body mass index (BMI) of 23. From this finding, you can conclude that your patient

has a body mass index within normal limits

BMI is a measurement of an adult’s body fat based on height and weight. Generally, a BMI between 18.5 and 24.9 reflects a normal weight with a normal amount of body fat. A patient with a BMI below 18.5 is considered underweight; a patient with a BMI of 25 or above is considered overweight; and one with a BMI of 30 or above is considered obese.

What is your primary goal in performing a comprehensive physical assessment?to develop a plan of care

To develop a plan of care

Remember the nursing process: assessment, diagnosis, planning, implementation, evaluation. Assessment is the first part of the process. It generates the database from which you will make nursing decisions. Your objective in interacting with patients is to identify their needs and concerns and help find solutions. That is the nursing process in action – and your map is the nursing care plan you establish for each patient. Analyzing and synthesizing data will provide the basis for each nursing diagnosis and for the selection of nursing interventions to manage actual or potential health problems.

While examining your patient's head and face, you determine that cranial nerve I is intact when the patient follows your instructions and successfully

identifies a minty scent

Cranial nerve I, the olfactory nerve, controls the sense of smell. To test this nerve’s function, ask the patient to identify a nonirritating aroma, such as mint or coffee.

Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate?

RLQ, Right lower quadrant

To the right of the umbilicus in the right lower quadrant is the ileocecal valve. This is where the small intestine connects to the large intestine, and it is normally very active with bowel sounds. Many nurses begin listening here for that reason. For the average adult, you’ll hear five to 30 bowel sounds per minute.

While performing a cardiovascular assessment, you might encounter a variety of pulsations and sounds. Which of the following findings is considered normal?

A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line

This is where you would inspect and palpate for the point of maximal impulse. Also called an apical pulsation, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is a normal and expected finding when you are preparing to auscultate an apical pulse.