REIMBURSEMENT ISSUES

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CHAPTER 4Physical Assessment
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Signs and Symptoms

• Signs
• Objective data as perceived by the examiner
• Can be seen, heard, measured and can be verified
  by more than one person
• Examples rashes, altered vital signs, visible
  drainage or exudate
• Lab results, diagnostic imaging, and other studies

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Signs and Symptoms

• Symptoms
• Subjective data
• Perceived by the patient
• Examples pain, nausea, vertigo, and anxiety
• Nurse unaware of symptoms unless the patient
  describes the sensation
• Encourage a full description by the patient of
  the onset, the course, the character of the
  problem, and any factors that aggravate or
  alleviate

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Signs and Symptoms

• Disease and Diagnosis
• Disease
• It is any disturbance of a structure or function
  of the body a pathologic condition of the body.
• It is recognized by a set of signs and symptoms.
• Signs and symptoms are clustered in groups to
  help the physician to make a medical diagnosis.
• The nurse also relies on assessment of signs and
  symptoms to formulate a nursing diagnosis.

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Signs and Symptoms

• Origins of Disease
• Disease or illness originates from many causes
  hereditary, congenital, inflammatory,
  degenerative, infectious, deficiency, metabolic,
  neoplastic, traumatic, and environmental.
• Unknown etiology
• Diseases that have no apparent cause.

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Signs and Symptoms

• Risk Factors for Development of Disease
• A risk factor is any situation, habit,
  environmental condition, genetic predisposition,
  physiologic condition, and other that increases
  the vulnerability of an individual or a group to
  illness or accident.
• Risk factors do not necessarily mean that a
  person will develop a disease condition, only
  that the chances of disease are increased.
• Categories of risk factors
• Genetic and physiologic, age, environment, and
  lifestyle

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Signs and Symptoms

• Terms Used to Describe Disease
• Chronic
• Develops slowly and persists over a long period,
  often for a persons lifetime
• Remission
• Partial or complete disappearance of clinical and
  subjective characteristics of a disease
• Acute
• Begins abruptly with marked intensity of severe
  signs and symptoms and then often subsides after
  a period of treatment

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Signs and Symptoms

• Terms Used to Describe Disease
• Organic Disease
• Results in structural change in an organ that
  interferes with its functioning
• Functional Disease
• May be manifested as organic disease, but careful
  examination fails to reveal evidence of
  structural or physiologic abnormalities

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Signs and Symptoms

• Frequently Noted Signs and Symptoms
• Infection
• Caused by an invasion of microorganisms, such as
  bacteria, viruses, fungi, or parasites that
  produce tissue damage
• Inflammation
• Protective response of the body tissues to
  irritation, injury, or invasion by
  disease-producing organisms

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Signs and Symptoms

• Frequently Noted Signs and Symptoms
• Cardinal Signs of Infection and Inflammation
• Erythema
• Edema
• Heat
• Pain
• Purulent drainage
• Loss of function

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Assessment

• Process of making an evaluation or appraisal of
  the patients condition
• Medical Assessment
• Physical examination is conducted by the
  physician.
• The nurse is often expected to carry out certain
  functions.

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Assessment

• Medical Assessment
• Functions That May Be Expected of the Nurse
• Preparing the exam room
• Assisting with equipment
• Preparing the patient
• Collecting specimens

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Assessment

• Nursing Assessment
• Initiating the Nurse-Patient Relationship
• The first interview is the most challenging to
  conduct.
• Introduce yourself and state name, position, and
  purpose of the interview.
• Give an estimate of time.
• Ask if the patient has any questions and answer
  them appropriately.
• Communicate trust and confidentiality.
• Convey competence and professionalism.

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Assessment

• Nursing Assessment
• The Interview
• Provide relaxed, unhurried manner.
• Conduct in a quiet, private, well-lighted
  setting.
• Convey feelings of compassion and concern.
• Determine by what name the patient wishes to be
  addressed.
• Nurse should have an accepting posture, relaxed,
  eye level, and pleasant facial expression.

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Assessment

• Nursing Health History
• The initial step in assessment process
• Information on patients wellness, changes in
  life patterns, sociocultural role, and mental and
  emotional reaction to illness
• Biographical Data
• Date of birth, sex, address, family members,
  marital status, religious preference,
  occupations, source of health care, and insurance

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Assessment

• Nursing Health History
• Reasons for Seeking Health Care
• Chief complaint
• Document information in patients own words.
• The nurse can use the PQRST method
• P provocative/palliative
• Q quality/quantity
• R region/radiation
• S severity
• T timing

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Assessment

• Nursing Health History
• Present Illness or Health Concerns
• The data collected relate to the progression of
  the present illness from the onset of the current
  signs and symptoms.
• Past Health History
• Previous hospitalizations
• Allergies
• Habits and lifestyle patterns
• Ability to perform ADLs
• Patterns of sleep, exercise, and nutrition

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Assessment

• Nursing Health History
• Family History
• Immediate and blood relatives
• Includes health or cause of death, as well as
  history of illness
• Objective is to determine patients risk for
  illnesses of a genetic or familial nature
• Provides information about family structure,
  interaction, and function

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Assessment

• Nursing Health History
• Environmental History
• Provides data about patients home environment
• Psychosocial and Cultural History
• Data about primary language, cultural groups,
  educational background, attention span, and
  developmental stage
• Coping skills and family support
• Identify major beliefs, values, and behaviors
  when treating them

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Assessment

• Nursing Health History
• Review of Systems
• Systematic method for collecting data on all body
  systems.
• Record in clear and concise manner with
  appropriate terminology.
• Ask specific questions relating to functioning of
  each system.

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Assessment

• Nursing Physical Assessment
• The purpose is to determine the patients state
  of health or illness.
• Initial step of the nursing process and in
  forming the nursing care plan
• When to Perform a Physical Assessment
• Perform assessment as soon after admission as
  possible.
• Initial assessment is done by an RN.
• Ongoing assessment is the responsibility of LPN
  and RN.

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Assessment

• Nursing Physical Assessment
• Where to Perform a Nursing Assessment
• Comfortable, private setting
• In most cases, the patients own room works very
  well and is convenient.
• Methods of Nursing Physical Assessment
• Head-to-toe
• System-by-system
• Focused

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Assessment

• Nursing Physical Assessment
• Performing the Nursing Physical Assessment
• Items needed penlight, stethoscope, blood
  pressure cuff, thermometer, gloves, and a tongue
  blade
• Nurse also makes use of the senses of touch,
  smell, sight, and hearing.
• Always wash your hands before beginning
  assessment.

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Figure 4-1
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Equipment used during a physical examination.
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Assessment

• Performing the Nursing Physical Assessment
• Head-to-Toe Assessment
• Neurologic
• Level of consciousness
• Level of orientation
• Hand grips

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Assessment

• Head-to-Toe Assessment (continued)
• Skin and hair
• Observe skin for color, temperature, moisture,
  texture, turgor, and evidence of injury or skin
  lesions.
• Note color of sclera, mucous membranes, tongue,
  lips, nail beds, palms, and soles.
• Determine the quantity, quality, and distribution
  of hair.
• Hair should be smooth, not oily or dry.
• Scalp should be free of dandruff, lesions, or
  parasites.

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Figure 4-3
(From Elkin, M.K., Perry, A.G., Potter, P.A.
2004. Nursing interventions and clinical
skills. 3rd ed.. St. Louis Mosby.)
Assess skin turgor by grasping fold of skin on
back of patients hand, sternum, forearm, or
abdomen.
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Assessment

• Head-to-Toe Assessment (continued)
• Head and neck
• Note facial expression.
• Note symmetry of features.
• Assess arteries, veins, and lymph nodes.
• Palpate beneath the jaw and down each side of the
  neck to feel for enlarged lymph nodes.
• Palpate carotid arteries.
• Assess jugular vein distention.
• Auscultate the carotids for bruits.

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Figure 4-4
(From Seidel, H.M., Ball, J.W., Dains, J.E.,
Benedict, G.W. 2003. Mosbys guide to physical
examination. 5th ed.. St. Louis Mosby.)
Palpation of carotid artery.
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Assessment

• Head-to-Toe Assessment (continued)
• Mouth and throat
• Inspect the lips and mucous membranes with tongue
  blade and penlight.
• Note condition of teeth and gums.
• Note breath odor.
• Eyes
• Note symmetry.
• Assess for exudates.
• Assess sclera.
• Observe pupillary reflex.

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Assessment

• Head-to-Toe Assessment (continued)
• Ears
• Note symmetry.
• Assess ear canal.
• Note ability to hear and follow commands.
• Note use of hearing aids if applicable.
• Nose
• It should be symmetrical.
• Assess patency.
• Observe for bleeding or drainage.
• Assess nares.

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Assessment

• Head-to-Toe Assessment (continued)
• Chest, lungs, and heart and vascular system
• Inspect for bilateral chest expansion.
• Note rate and rhythm of respirations.
• Breathing should be QUIET.
• Note posture.
• Breasts
• Examine and encourage monthly self-exams.

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Assessment

• Head-to-Toe Assessment (continued)
• Lung sounds
• Instruct patient to breath through mouth quietly
  and more deeply and slowly than a usual
  respiration.
• Place stethoscope firmly but not tightly on the
  skin and listen for one full inspiratory/expirator
  y cycle at each point.
• Systematically auscultate using a zig-zag pattern.

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Assessment

• Head-to-Toe Assessment (continued)
• Spine
• Note the curvature while in a sitting and a
  standing position.
• Heart sounds
• Auscultate with stethoscope.
• Listen for intensity of the sound, faint to
  strong.
• Determine the regularity of the rhythm.

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Figure 4-8
(From Seidel, H.M., Ball, J.W., Dains, J.E.,
Benedict, G.W. 2003. Mosbys guide to physical
examination. 5th ed.. St. Louis Mosby.)
Sequence of patient positions for auscultation of
heart sounds.
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Assessment

• Head-to-Toe Assessment (continued)
• Peripheral vascular system
• Palpate peripheral pulses.
• Rate the strength on a 0-to-4 scale.
• Assess extremities for symmetry, color, and
  varicosities.
• Assess temperature of hands and feet.
• Perform capillary refill or blanch test.

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Figure 4-9
(From Seidel, H.M., Ball, J.W., Dains, J.E.,
Benedict, G.W. 2003. Mosbys guide to physical
examination. 5th ed.. St. Louis Mosby.)
Palpation of arterial pulses.
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Assessment

• Head-to-Toe Assessment (continued)
• Abdomen
• Inspect for shape, contour, lesions, scars,
  lumps, or rashes.
• Auscultate for bowel sounds in all quadrants.
• Perform palpation and percussion.
• Genitourinary system
• Inspect labia/genitalia and pubic hair.
• Palpate the scrotum.
• Palpate suprapubic area.

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Figure 4-11
(From Thompson, J.M., Wilson, S.F. 1996. Health
assessment for nursing practice. St. Louis
Mosby.)
Palpation of the abdomen to assess for
distention, masses, or tenderness using light
palpation.
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Figure 4-12
(From Seidel, H.M., Ball, J.W., Dains, J.E.,
Benedict, G.W. 2003. Mosbys guide to physical
examination. 5th ed.. St. Louis Mosby.)
Palpation of the liver using moderate palpation.
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Assessment

• Head-to-Toe Assessment (continued)
• Rectum
• Spread buttocks and assess for hemorrhoids or
  lesions.
• Legs and feet
• Palpate femoral, dorsalis pedis, popliteal, and
  posterior tibial pulses.
• Observe and palpate for edema.
• Test for range of motion.
• Check color, motion, sensation, and temperature
  of both feet.