Overview
This lecture covers the principles and techniques of physical assessment, including differentiating signs and symptoms, types of data collection, disease origins, and a systematic head-to-toe examination process.
Signs vs Symptoms
- Signs are objective data observed or measured by the examiner (e.g., rash, vital signs, lab results).
- Symptoms are subjective data described by the patient (e.g., pain, nausea, anxiety).
- Always document symptoms with the patient's own words in quotes.
Attributes of a Symptom
- Location: Where is it and does it radiate?
- Quality: What is it like?
- Quantity/Severity: How bad is it?
- Timing: When did it start, how long, how often?
- Setting: Environmental, personal, or emotional context.
- Remitting/Exacerbating Factors: What makes it better or worse?
- Associated Manifestations: Other symptoms that accompany it.
Disease and Diagnosis
- Disease: Disturbance of body structure or function, recognized by clustered signs and symptoms.
- Medical diagnosis uses signs and symptoms to identify a health problem.
- Nursing diagnosis focuses on response to health problems.
Origins and Risk Factors of Disease
- Disease origins: hereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, environmental, or unknown.
- Risk factor: increases vulnerability to illness or accident (e.g., genetics, age, environment, lifestyle).
Disease Descriptions
- Chronic: develops slowly, lasts >6 months, often lifelong.
- Remission: disappearance or reduction of disease signs/symptoms.
- Acute: sudden onset, intense, resolves with treatment.
- Organic disease: structural organ changes.
- Functional disease: abnormal function without structural change.
Infection and Inflammation
- Infection: invasion by microorganisms causing tissue damage.
- Inflammation: protective tissue response (redness, swelling, heat, pain, loss of function).
- Cardinal signs: erythema, edema, heat, pain, purulent drainage, loss of function.
Assessment Overview
- Medical assessment: performed by providers to determine health status, diagnose,
and monitor effectiveness of treatment.
- Nursing assessment: establishes nurse-patient relationship, collects data, includes interview and health history.
Interview and History
- Introduce yourself, explain purpose and duration, offer to answer questions.
- Health history includes biographical data, chief complaint, present illness, past medical history, family/environmental/psychosocial/cultural history.
- Use PQRST for chief complaint: Provocative/palliative, Quality/quantity, Region/radiation, Severity, Timing.
Physical Assessment Techniques
- Inspection: visual observation.
- Palpation: touch to assess texture, temperature, or tenderness.
- Auscultation: listening to body sounds (always before palpating abdomen).
- Percussion: tapping to determine organ size, density, and borders.
Equipment for Physical Assessment
- Pen light, stethoscope, BP cuff, thermometer, gloves, tongue blade, specimen cups as needed.
- Always wash hands before and after assessment.
Vital Signs and General Survey
- Measure temperature, pulse, respiration, blood pressure, height, weight, pain, O2 saturation.
Head-to-Toe Assessment
- Neuro: level of consciousness, orientation (A/O x 1–4), Glasgow Coma Scale.
- Skin/hair: color, temperature, moisture, turgor, lesions, pallor, cyanosis, jaundice, infestations.
- Head/neck: symmetry, ROM, lymph nodes, carotids (auscultate for bruits, palpate for thrills), jugular vein distension.
- Mouth/throat: lips, mucosa, teeth, gums, breath odor.
- Eyes: symmetry, sclera, pupils (PERLA).
- Ears: symmetry, hearing, canal inspection, adjust method for adults/children.
- Nose: symmetry, patentcy, septal abnormalities.
Chest, Lungs, Heart, and Vascular
- Evaluate chest rise, symmetry, posture, and lung sounds in zig-zag pattern.
- Heart sounds: S1/S2, listen at APTM (aortic, pulmonic, tricuspid, mitral) areas.
- Peripheral pulses: grade 0–4+, assess capillary refill (<3 sec), check for varicosities and edema.
Abdomen and Genitourinary
- Inspect, auscultate (before palpation), and palpate all four quadrants.
- Note bowel sounds, palpate for tenderness.
- Inspect external genitalia, ask about urinary habits and symptoms.
- Rectal: check for hemorrhoids or lesions.
Extremities
- Palpate peripheral pulses, check for edema (grade 1+–4+), color, motion, sensation, temperature.
- Assess range of motion, use of mobility aids, gait, balance, and any deformities or amputations.
Safety and Documentation
- Check airway, breathing, circulation, pain, and safety every visit.
- Monitor IVs, catheters, drains, and dressings.
- Before leaving, ensure bed is low, brakes on, side rails as ordered, call light in reach.
- Document findings clearly on facility forms.
Key Terms & Definitions
- Sign — Objective data measurable by examiner.
- Symptom — Subjective data reported by patient.
- Risk Factor — Condition increasing likelihood of disease.
- Chronic Disease — Long-lasting, >6 months.
- Acute Disease — Rapid onset, short duration.
- Auscultation — Listening to body sounds.
- Palpation — Using touch to assess the body.
- Turgor — Skin’s elasticity reflecting hydration.
- PERRLA — Pupils Equal, Round, Reactive to Light and Accommodation.
- Capillary Refill — Time for blood to return to blanched nailbed (<3 seconds normal).
Action Items / Next Steps
- Review tables and boxes referenced in the textbook chapter for exam positioning, assessment scales, and review of systems.
- Practice head-to-toe assessments using provided checklists.
- Prepare for hands-on skill demonstration in the next lab session.