Lecture 2 Flashcards
- Summarize the purpose of the patient
interview and physical assessment.
- identify/confirm nursing diagnosis
- identify actual or potential health problems
- make clinical decisions about patients changing health status and management
- evaluate outcomes of care
- To determine the patients overall level of physical, psychological, sociocultural, developmental, functional, and spiritual health
- health history is subjective
- physical assessment is objective
- Describe techniques of physical
assessment
- inspection
- palpation
- percussion
- auscultation
Describe inspection?
- Inspection: perform deliberate, purposeful observations in a systemic manner. Observe visually, listen, and smell to gather data. Assess appearance, behavior, and movement. Inspect each area of body for size, color, shape, position, movement, and symmetry. Note normal findings and deviations from normal.
- adequate lighting to insect body cavities, only expose the needed area and then cover to maintain privacy. Check side to side symmetry.
- Validate findings with patient
Describe palpation?
(touch) , back of hand can measure temperature. Palmar
(front) surfaces of fingers assess firmness, contour, shape, tenderness, and consistency. Fingerpads locate pulse, lymphnodes, and small lumps, skin texture, and edema. Vibration is detected by ulnar (outside) surface of hand. Hands should be warm, and fingernails short. Start with light palpation and end with deep. If you know an area will be painful then save that for last.
Describe percussion?
striking one object to another to produce sound. Tapping over certain body tissues produce vibrations and sound waves. Abnormal sounds suggest a mass.
Describe auscultate?
heart, lung, abdomen, and cardiovascular sounds. Sound assessment include pitch/frequency, loudness, quality, and duration.
- Bell: low pitched sounds like heart and vascular (bruits)
- Diaphragm: high pitched sounds like lung and bowel
- Determine strategies to prepare a patient
physically and psychologically for a physical
assessment examination.
- Physical prep: ask patient if they need to use restroom before initiating. Position patient comfortably and appropriately.
- Psychologically: explain to the patient what you are going to do then explain in further detail when you are doing the exam.
- Describe the components of a general
Survey.
- first component of physical assessment
- observe overall appearance/ behavior
- do this while preparing patient for physical examination.
- This general survey includes; gender and race, age, signs of distress, body type, posture, gait, body movement, hygiene and grooming, dress, body odor, affect and mood, speech, signs of patient abuse, substance abuse
- take vital signs
- measure height/ weight/ waist circumference/ calculate BMI
- provides clues to overall health
- health history: history of changes in weight, history of pain/ discomfort, sleeping patterns, difficulty sleeping
- Appearance/ behavior: do this during health history. Inspect: body build, posture, gait, proportion of height to weight, illness, skin color, respirations, short attention span, hygiene, cognitive processes
- Height and weight:
- BMI/ waist circumference: measure waist circumference at umbilicus
- Vital signs
- Pain
- Describe the specific techniques for
physical examination of the Integumentary?
(skin, nails, hair, and scalp): assess hygiene, skin cancer. Ask during health history but they fall under integumentary: rashes, bruising, allergies, sun exposure, bathing routines, lesions, inspect skin color,
Cyanosis: bluish/ grayish due to inadequate oxygenation, exposed areas (ears, lips, inside of mouth, hands and feet, nailbeds). Possible cause: cold environment, cardiac or respiratory disease.
Jaundice: elevated bilirubin in blood (liver/ gallbladder disease or anemia). Assess overall skin, mucous membranes, and sclera (eye)
Pallor: paleness of skin, face lips, conjunctivae, and mucous membranes. Caused by anemia (decreased hemoglobin), shock (decreased blood volume).
-Inspecting skin vascularity and lesions:
Ecchymosis: blood in subcutaneous tissues, causing purplish discoloration.
Petechiae: small hemorrhagic spots caused by capillary bleeding
Vitiligo: assess skin, lips, nail beds, conunctivae. Possible causes, depigmentation (congenital or autoimmune conditions)
Tanned of Brown: assess sun exposed areas, possible cause is overexposure (increased melanin production) or pregnancy causing brown spots.
-Palpating temp, texture, moisture, and Turgot (elasticity): skin is normally warm and dry. Diaphoresis is excessive amounts of sweating.
-Turgor: normal means it returns to normal shape when released. Dehydration means the skin returns its shape slowly.
-Edema: swelling with taught and shiny skin. An indentation may remain after pressure is released. Edema may result from overhydration, heart failure, kidney failure, trauma, or peripheral vascular disease.
-Inspecting hair and scalp: assess color, texture, distribution, lubrication, thickness, quantity.
Abnormal findings: balding (alopecia), excessive amounts of hair on face and body (hirsutism). Nits will be attached to hair shaft. If lumps or masses are palpated note size, location, tenderness, and mobility. Thyroid disease can cause fine brittle hair.
-Nails: color, length, symmetry, cleanliness, configuration.
-Normal age related variations for integumentary: decreased turgor, raised dark areas, flat brown age spots, small round red spots, hair loss, coarse facial hair in women, decreased body hair for men, thick yellow toenails.
Describe the specific techniques for
physical examination of the head and neck?
-Eyes: use a snellen chart for distant vision. Jaeger chart for near
Vision.
-Assess eye structures, pupillary reaction, accommodation, convergence, extraocular movements, peripheral vision,
-Ears: palpate external ear, assess hearing (whisper test), refer out if needed.
-Nose: examine external nose, assess patency (occlude one at a time). Look inside nose with a light.
-Palpate sinuses: assess frontal and maxillary sinuses. Frontal- push above each eye. Maxillary- push on upper cheek. Check for pain and edema
-Palpate the Neck: assess trachea, lymph nodes, and thyroid glands
Describe the specific techniques for
physical examination of the thorax and lungs.
- Health History: trauma, pillows, chest pain, persistent cough/sputum, allergies, smoking, history of lung disease, respiratory infections.
- Physical Assessment: inspection, palpation, percussion, auscultation. Percussion is usually done by advanced health person.
- Inspecting the Thorax: inspect color, shape, and contour, breathing patterns, muscle development. Transverse diameter should be greater than anterior posterior diameter. Greater anterior posterior diameter means barrel chest (lung disease).
- Palpating Thorax: detect sensitivity, chest expansion of respirations, and vibrations. Use palmar to to palpate thoracic landmarks for temp, moisture, muscular development, tenderness, masses, vibrations. Abnormal findings: cool/excess dry/or moist skin, muscle asymmetry, tenderness, masses, and vibrations
- Auscultating Breath Sounds: listen with diaphragm to same thoracic landmarks (5 front and 9 back) and auscultate breath sounds. Listen for duration, pitch, and intensity of sounds. Adventitious breath sounds are abnormal breath sounds.
What is a functional assessment?
assessing patients ability to perform activities of daily living
What are psychosocial factors?
as about support, sleep, nutrition, interpersonal relationships, drugs, alcohol, smoking, sexual history, mental health,
