Physical Assessment Patients - Essay Example

Physical Assessment Physical Assessment Introduction Physical assessment is necessary as it helps to estimate the extent of the patient’s state of well-being in order to form a correct diagnosis. It takes place after thorough history taking and involves four principle aspects: inspection, palpation, percussion and auscultation. The preferred method to perform a patient’s physical assessment is the head-to-toe method. It begins by systematically examining the patient, beginning from the head and working towards the toes (Ralph & Taylor, 2011). 1. Vital signs When a patient walks in the examination room, it is necessary for the vital signs to be measured. Temperature of a healthy individual ranges from 36-37.5 degrees Celsius and may be measured through the oral, temporal, axillary, tympanic and rectal route. For this purpose, a disposable, electronic or tympanic thermometer is required (Amugi-crouch& Meurier, 2011). Since temperature of the patient is within such a narrow range and is required to take accurately, the presence of a thermometer is essential, as it cannot be measured without it. Pulse is measured directly by the monitor that is used to measure other vital signs. However, if the machine is not available, it can be felt by palpating the pads of the first three fingers against the patient’s wrist and counting the pulse beats in one minute, starting from zero. Blood pressure is measured by using a sphygmomanometer. It comprises of two parts: systolic and diastolic and is measured in mmHg. Normal Findings: Temperature of the patient is between 36-37.5°C.Normal pulse rate is 60-100 (mean of 70) beats per minute. The systolic blood pressure normally ranges from 100-140mmHg. The diastolic blood pressure, on the other hand normally ranges from 60-90 mmHg. Abnormal Findings: Hyperthermia, pyrexia or fever occurs when the temperature exceeds 38°C. An excessively high temperature- such as above 40°C is known as hyperpyrexia. Hypothermia where in the temperature of the patient is below 35°C A pulse rate of under 60 beats per minute is termed bradycardia and may occur in hypoxia, ischemic heart disease etc. A pulse rate of over 100 beats per minute is termed as tachycardia. It may occur in stress, anxiety, pyrexia and pain (Amugi-crouch & Meurier, 2011).Hypertension occurs when the blood pressure readings remain consistently over 140mmHg for systolic and 90mmHg for diastolic blood pressure. It may result from the excess consumption of caffeine and in excessively cold environments. Hypotension occurs when the blood pressure readings fall below 100mmHg for systolic and 60mmHg for diastolic blood pressure (Talley & O’Connor, 2009). It may result because of shock, pulmonary embolus and cardiac failure (LeMone et al 2012). Nursing Plan in abnormal findings: The plan taken will be primarily to stabilize the vital signs since otherwise the patient may enter cardiac arrest. For example, a patient with high blood pressure will be given antihypertensive drugs such as ACE inhibitors to bring blood pressure back to normal. 2. The Integumentary System A thorough inspection of the skin pigmentation according to the patient’s race and nationality must be done. Notice the skin on extremities and look overall for swellings, erythema, red streaks, skin lesions, cyanosis and extreme sweating and edema. Examine the scalp for baldness Normal Findings: Skin is free of lesions, swelling of skin or lymph nodes, no erythema or red streaks. Abnormal Findings: Pallor may result because of anemia, shock and syncope. Central cyanosis of lips, earlobes, oral mucosa and tongue suggest chronic cardiopulmonary disease. 3. Cardiovascular system Palpate the precordium through the chest walls. Start the palpation from the apex, then move to the left border of the sternum and finally move towards the base of the heart. This should be followed by the auscultation using a stethoscope. This auscultation should be done in the anatomic regions corresponding to the heart sounds which include the areas of the aortic, pulmonic, tricuspid and mitral valves. Listen for S1 sound at the apex and S2 sound at the base of the heart. Inspect the contours and skin of the breast and the nipple. Palpate and examine the four quadrants for mass or swollen lymph nodes. Normal Findings: The normal heart sounds which are S1 and S2 are audible at the all the anatomic regions. Abnormal sounds of the heart like murmurs are not audible. The heart rate is between 60 to 100 beats per minute (Singh, 2012). Breast skin and contours are normal. No mass palpated. Abnormal Findings: Heart sounds may be absent or slow. Murmurs and ectopic beats may be present. Breast may either have lesions, nipple may be inverted. Mass may be palpated. Axillary lymph nodes may be swollen as often are in breast tumor patients. Differential diagnosis may include chronic congestive heart failure, atherosclerotic plaque which may cause thromboembolism. Plan of action: These conditions may be treated after further laboratory tests and giving adequate medicines. 4. Respiratory System Inspect the chest walls for symmetry. Inspect the spine to be in the center. Spinal column inspection along with shoulders and hips for general symmetry. Palpate the chest for tenderness. Auscultate to listen to breath sounds with normal and deep breathing. Examine color of sputum (if present) and send to laboratory (Amugi-crouch & Meurier, 2011). Normal Findings: Chest is in line with shoulders and hips and is symmetrical. No breathing abnormalities. Abnormal Findings: Kyphosis, scoliosis, coughing, wheezing, dyspnea, excessive sputum due to infections or other diseases(Amugi-crouch & Meurier, 2011). 5. Abdomen Ensure the patient has an empty bladder and is asked to lie in a supine posture. Inspect the contours and skin for striae, rashes and dilated veins on the abdomen. Look for scar marks. Palpate superficially through all nine quadrants and then deeply. Percuss all four quadrants to assess dullness and tympany. Auscultate to listen to gut sounds. (Bickley et al 2009) Normal findings: The color of the skin is consistent and no other lesions are seen. Scars or striae or scar may be visible in a few patients because of previous surgery. The abdomen can be flat or round or have a scaphoid shape. Thin people may have peristalsis and show the pulsation of the aorta. Abdominal breathing is evident. The liver usually cannot be palpated in a normal adult Abnormal Findings: Abdomen may be generally distended because of flatulence. Striae are seen in obesity or pregnancy. Gut sounds are absent in cases of obstruction or inflamed peritoneum. Routine Health Screenings and Immunization: Blood pressure: Get patient tested every two years if it remains in normal range between 18-65 years and once a year if any other disease may have possibly caused it. If more, discuss monitoring with patient. Bone Mineral density: Discuss if this test is required before 60 years, after which get it screened for females. Cholesterol: Between 20-35 years of age get patient screened if there is increased risk of heart disease. From 45 years onwards get screened regularly. Breast Cancer: Discuss with patient if there is requirement before 40 years. After 50 years, get screened every two years especially for females. Cervical Cancer: Get a Pap smear done of 21 year old female or those who have been sexually active for 3 years. Until 50 years get a smear done every three years. Diabetes: Get screened before 40 years if there is patient history of hypertension. After which discuss screening plan with patient. Gonorrhea/Chlamydia and HIV: Get post pubertal patients screened if there is increased risk of either of these diseases. (Buttaro, 2008) Conclusion With routine examination of clients and patients, nurses can suggest differential diagnosis. In emergencies the plan of care is required to be prompt. However, in long term or less severe cases, advice from the physicians can be sought in order to proceed with the line of treatment. This is true especially in cases of medical anomalies or diseases that require surgical intervention. The physical assessment therefore should be able to provide adequate information with which prompt and proper plan of care can be established. References Altman, G. (2004). Delmars physical assessment skills. Clifton Park, NY: Delmar Learning. Amugi-crouch, A., & Meurier, C. (2011). Vital Notes for Nurses: Health Assessment. Oxford: John Wiley & Sons. Bickley, L. S., Szilagyi, P. G., & Bates, B. (2009). Bates guide to physical examination and history taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Buttaro, T. M. (2008). Primary care: A collaborative practice. St. Louis, Mo: Mosby/Elsevier. LeMone, P., Burke, K. M., Bostick, J. E., & LeMone, P. (2012). Clinical handbook for medical-surgical nursing: Critical thinking in patient care. Boston: Pearson. Ralph, S. S., & Taylor, C. M. (2011). Sparks & Taylors nursing diagnosis reference manual. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Singh, N. R. (2012). Nursing: The ultimate study guide. New York: Springer. Talley, N. J., & OConnor, S. (2009). Clinical examination: A systematic guide to physical diagnosis. Chatswood, N.S.W: Elsevier Australia. Read More