Physical Assessment

Physical Assessment

Systematic Approach
■ Always observe standard precautions.
■ Listen to your Pt. Provide a comfortable environment.
■ If there is an obvious problem, start at that point.
■ Work from head to toe and compare right to left.
■ Let your Pt know your findings and use this time to teach.
■ Leave sensitive or painful areas until the end of the exam.
■ Techniques used for physical assessment include (1st) inspection, (2nd) palpation, (3rd) percussion, and (4th) auscultation and, except for the abdomen, are carried out in this order.
■ Document: All assessments, interventions, and outcomes.

Documenting Vital Signs

Heart Rate:
Document: Rate, rhythm, strength, and any differences from R–L

Respirations:
Document: Rate, depth, effort, rhythm, and any sounds, noting whether they were heard on inspiration, expiration, or both.

Blood Pressure:
NEVER perform a BP on an arm with a dialysis shunt, injury, or same side mastectomy or axilla surgery! Avoid arms with IV/VAD if possible.
Document: Point at which sound is first heard (systolic) over the point at which sound completely ceases (diastolic).

Temperature:
Document:Temperature reading and route

Adult Vital Signs Normal Ranges

HR                                RR                               SBP                       DBP          Temp

60—100                    12—20                          95—140                          60—90                     *See below

Tympanic Temperature                                    37.0_—38.1_C (98.6_—100.6_F) Oral Temperature                                              36.4_—37.6_C (97.6_—99.6_F) Rectal Temperature                                           37.0_—38.1_C (98.6_—100.6_F) Axillary Temperature                                        35.9_—37.0_C (96.6_—98.6_F)

Factors Affecting Vital Signs

	HR	RR	SBP	Temp
Fever	↑	↑	Normal	↑
Anxiety	↑	↑	↑	Normal
Pain, acute	↑	↑	↑	Normal
Pain, chronic	↓	Normal	Normal	Normal
Acute MI	↓	↑	↓ (Late)	Normal
Spinal Injury	↓	↓	↓	Norm / ↑
Tamponade	↑	↑	↓	Normal
CHF	↑	↑	↑ (Early)	↑
Pulm. Embolism	↑	↑(Dyspnea)	↓	↑
Exercise	↑	↑	↑	↑
↑H&H	↑	↑	↓	↓
↓ Blood Sugar	Norm / ↑	Normal	Norm / ↑	↓
↑Blood Sugar	↑	↑/Deep	↓	↑
↑WBC	↑	↑	↓(Sepsis)	↑
↑K +	↓	Shallow	Norm/↑	Normal
↓K +	↑	Shallow	↓	Normal
↑Ca +	↓	Normal	↓	Normal
↓Ca +	↓	Varies	↓	Normal
↑Na +	↑	Norm/↑	↑	↑
↓Na +	↑	Norm/↑	↓	Normal
Narcotics	↓	↓	↓	↓
Beta-blockers	↓	↓	↓	Normal
Ca Chan-Blockers	↓	↓	↓	Normal