Different Approaches to Physical Assessment

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Notes

Focused assessment: Priority of assessment dictated by Pt’s chief complaint (e.g., if Pt is complaining of CP, start with OPQRST).
Head-to-toe: More complete, it assesses each body region (e.g., head and neck) before moving on to the next.
Systems assessment: More focused, it assesses each body system (e.g., cardiovascular) before moving on to the next.

Focused Symptom Analysis (OPQRST)

Onset Origin	When did symptom begin? Was onset sudden or gradual? Origin of symptom (e.g., injury, meal).
Provocation Precipitation Palliation	Activity at or before onset of symptom. Factors that worsen symptom. Factors that alleviate symptom.
Quality	Characteristics (dull, achy, sharp, etc.).
Radiation Region Related s/s	Does symptom travel to another part of body? Have Pt to point to source of symptom. Document related symptoms (e.g., nausea, fever).
Severity	If pain, rate on a scale of 0–10. Is symptom mild, moderate, or severe?
Timing	Ascertain duration of symptom. Is symptom constant or intermittent?

Cardiovascular Assessment

History	CP, palpitations, syncope, fatigue, extremity changes (numbness, tingling, cold feet or hands, leg cramps, edema, lymphedema), activity intolerance, dyspnea on exertion, shortness of breath, orthopnea, number of pillows used for sleeping, hyperlipidemia, MI, CAD, PVD, DM, HTN, CHF, DVT, stents, CABG, pacemaker.
Medication	Beta/Ca-channel blockers, nitrates, diuretics, ACE inhibitors, anticoagulants, antiarrhythmics.
Neck	Venous distention (JVD), bruits, pulsations.
Chest	Scars, symmetry, movement, deformity. Auscultate lungs for pulmonary edema. Compare apical and radial pulses for apical–radial pulse deficit. Heart valves for normal S₁, S₂ (lub, dub) heart sounds—abnormal sounds include extra beats (S₃, S₄), bruits, murmurs, pericarditic rubs, and artificial valve clicks. PMI for pulsations, thrills, or heaves.
Abdomen	Scars, edema, ascites, pulsations, and thrills.
Extremities	Color, temperature, moisture, and hair growth. Nailbeds for cyanosis and clubbing. Lower extremities for swelling and edema. Compare pulses right to left. Grade radial and pedal pulses. Grade peripheral edema. Capillary Refill Normal...............................................<3 sec Delayed..............................................>3 sec Pulse Strength Grading Scale 0..........................................................Absent 1..........................................................Weak 2..........................................................Normal 3..........................................................Full 4..........................................................Bounding