Week 5: Physical Assessment

This week (ok, it was actually last week but I'm writing as if it was this week since I forgot to post about week 5 last week...), we learned about physical assessments.

First, you start with the head - is it symmetrical? Is there lice on the scalp? Is the skull intact and hard? Then inspect the ears - are they symmetrical? Can the patient hear normally? Next is the face - once again, symmetrical? With the eyes, you need a penlight. Quickly shine the light in the patient's eyes and note the pupils constricting. Do they constrict equally? Are they reactive to light? Then look at the mouth. Have the patient open their mouth and shine your penlight inside - are the mucous membranes pink and moist?

Two identical heads...No other comments necessary. ;-D

Then move to the neck. Are the neck veins flat when the patient is sitting upright? Are there any masses or abnormal lumps present? Now check the carotid arteries. Make sure you only check one artery at a time or you'll knock your patient out! My partner tried to do that to me during practice today... ;-D

Hmmm...I wonder how this neck disorder would be documented...

Move on down to the lungs now. Have your patient sit forward and listen to her lung sounds on her back. Don't listen through the patient's clothes - you can't hear anything that way! You have to actually place the diaphragm of the stethoscope on your patient's bare back. There are ten spots to listen to on the back. Note if the lungs are clear and equal bilaterally (both sides). If the lung sounds aren't clear, refer to my previous blog post about lung sounds. Then listen to the eight lung areas on the front of the body. Once again, the diaphragm must be on the patient's bare skin - don't listen through the clothes!

Photobombing an x-ray!

Next is heart sounds. There are five areas to assess the heart. Note if S1 and S2 ("lub" and "dub," respectively) are present and if there are any extra heart sounds. Count the apical area of the heart for a full minute to determine the heart rate and listen for any irregularities. The heart should have a regular, steady beat between 60-100 beats per minute. While you're listening to the heart, it might be a good idea to sneakily check the respiration rate so the patient does not realize what you're doing and change their respiration rate.

After listening to the heart, examine the abdomen. Are there obvious pulsations or abnormal masses or lumps? Before you feel the abdomen, listen to all four abdominal quadrants and determine if the bowel sounds are hypoactive (sluggish), normal, or hyperactive (happily digesting). Sometimes, bowel sounds are absent but that can only be determined after listening to each quadrant for five minutes. Also ask the patient about bowel movements (we get to ask quite the questions in nursing school!) and urination.

Now move to the skin and arms. Examine the skin - is it warm, dry, and pink? How about skin elasticity - does it have good skin turgor (pinch the skin - it should go down within 3 seconds)? What about capillary refill (pinch the finger tips - the color should return within 3 seconds)? Check the radial pulses - are they equal bilaterally (on each side)? Are the pulses strong? Have the patient squeeze your fingers with both hands to determine hand strength. You can also check the rest of the vital signs (blood pressure and temperature) at this point.

You've just about completed the upper body and can now move to an assessment of the legs and feet. Check the lower legs for edema - any swelling? Feel pedal pulses on both feet - are they equal and strong? Feel the tibial pulses on the ankles - are they also equal and strong? Now check dorsiflexion (when the patient moves their feet upward toward their head) and plantarflexion (when the patient points their toes).

Finally, have the patient roll onto his or her side and examine their back and bony prominences (sacrum, heels, and elbows) to check for skin break down and pressure ulcers.

Because physical assessment practice was the first time us students got to see each other out of uniform (which is a polo shirt and scrub pants), there were lots of comments of, "Oh I didn't realize you had tattoos!"

This assessment and its variations have to be performed every day while a patient is in the hospital. It can be done with more or less steps and done in different orders. However, that's how I do my physical assessment! Here's a fun music video some nursing students made of physical assessments. :-D