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Presentation to participants of the 'Acute Care Nursing Program' - Canberra Hospital, 2005
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Physical Assessment
Acute Care Nursing Program 2005
Outline
Assessment Process Respiratory Assessment Cardiac Assessment Neurological Assessment Abdominal Assessment Neurovascular Assessment
Assessment Process
Inspection Palpation Percussion Auscultation
Gather information – base line Record trends
Respiratory Assessment
Inspection Palpation Percussion Auscultation
Respiratory Assessment
Inspection General
appearance, colour
Scaring Symmetry Shape Position of trachea Work of breathing
Rate Rhythm Cough –
productive?
Respiratory Assessment
Palpation Chest excursion Tactile and vocal fremitus
Respiratory Assessment
Percussion Normal – resonant, hollow sound Solid - dull Percussion is done in the intercostal
spaces Percussion is done both on the
posterior chest and lateral chest
Respiratory Assessment
Auscultation Systematic approach Note adventitious (extra)
Crackles Wheeze Friction rub
Respiratory Assessment
Cardiac Assessment
Inspection Palpation (Percussion) Auscultation
Cardiac Assessment
Inspection JVP Oedema Colour
Cardiac Assessment
Palpation Pulse Oedema Capillary refill Blood pressure
Cardiac Assessment
Auscultation Normal
S1 S2
Abnormal S2 split S3 S4
Cardiac Assessment
Neurological Assessment
Glasgow Coma Scale Cranial Nerves
Glasgow Coma Scale
Assess neurological status Assessment of best response
Eyes Verbal Motor
Glasgow Coma ScaleScor
eBest Eye Best Verbal Best
Motor6 ----------- ----------- Obeys5 ---------- Orientated Localises
pain4 Spontaneou
sConfused Withdraws
3 To speech Inappropriate Flexion
2 To Pain Incomprehensible
Extension
1 None None None
Cranial Nerves
12 cranial nerves 3rd – 12th within brainstem
(Midbrain, Pons, Medulla)
Cranial NerveFunction: Sensory Smell
Assessment: Recognition of
odor
IOlfactory
Cranial NerveFunction: Sensory Information
from the retina
Assessment: Visual acuity
IIOptic
Cranial NerveFunction: Motor Four of the six
extra-ocular muscles
Assessment: Response to
light Moves eye Elevates upper
eyelid
IIIOculomotor
Cranial NerveFunction: Motor Controls the
oblique eye muscle
Assessment: Moves eye
right, left, up and down
IVTrochlear
Cranial NerveFunction: Mixed Three sensory
Corneal Reflex One motor
Assessment: Normal facial
sensation Blinks Clenches teeth
VTrigeminal
Cranial NerveFunction: Motor Lateral rectus
muscle of eye
Assessment: Moves eye
laterally
VIAbducens
Cranial NerveFunction: Mixed Sensory
Tongue Motor
Eyelids
Assessment: Elevates
eyebrows Puffs checks Recognizes
tastes
VIIFacial
Cranial NerveFunction: Sensory Hearing
Assessment: Whisper in
each ear
VIIIVestibulocochle
ar
Cranial NerveFunction: Mixed Sensory
Taste buds Motor
Gag reflex
Assessment: Taste testing Test gag
IXGlossopharynge
al
Cranial NerveFunction: Mixed Motor branches
to the pharyngeal and laryngeal muscles
Viscera of the thorax and abdomen
Assessment: Same as IX
XVagus
Cranial NerveFunction: Motor Innervates the
sternocleidomastoid and trapezius muscles
Assessment: Shrugs shoulders
XIAccessory
Cranial NerveFunction: Motor Tongue
muscles
Assessment: Sticks out
tongue
XIIHypoglossal
Abdominal Assessment
Inspection Auscultation Percussion Palpation
Abdominal Assessment
Inspection Asymmetry Engorged veins Intestinal movements Lesions Scars Swelling
Abdominal Assessment
Auscultation Systematic Bowel sounds
Abdominal Assessment
Percussion All four quadrants
Tympanic- air filled structures Dull – solid structures
Bowel Liver Bladder
Abdominal Assessment
Palpation Light and Deep
Tenderness, guarding, rigidity Define organs Kehr’s sign McBurney’s point Murphy’s sign
Neurovascular Assessment
Colour Temperature Capillary Refill Peripheral Pulses Swelling Movement Sensation
References A Practical guide to clinical assessment
http://medicine.ucsd.edu/clinicalmed/ Smith SF, Duell DJ & Martin BC, 2005,
Clinical Nursing Skills, Prentice Hall, New Jersey.