Assessing Health PhysicalExaminationMetro Community CollegeNancy Pares RN MSNNursing Programs.
Health Assessment Performinga Physical ExaminationAn Overview The Nursing PhysicalExamination.
Part of a general health assessment Used to gather data about the client Focuses on functional abilities and responsesto illness stressorThe nurse performs a physical examination to .
Establish baseline data Identify nursing diagnoses collaborativeproblems or wellness diagnoses Monitor the status of an identified problem Screen for health problems.
Types of PhysicalExaminationsComprehensive Interview plus complete head to toeexamination.
Focused on presenting problem Performed as needed to assess status Evaluates client outcomes Organizing theExamination.
Head to toe Starts at the head Progresses down the body System related data found throughout Heart sounds chest.
Pulses periphery Organizing theExamination Body systems Gathers system related data all at once.
May be done in a predetermined order thatmimics head to toe Neurological Cardiovascular Respiratory.
Gastrointestinal Preparing Yourself What the Nurse Needs Theoretical Knowledge aboutknowledge client situation.
A and P techniques Purpose ofexamination Self knowledge Client diagnosis Skill and comfort Willingness to seek.
Preparing the Environment Privacy is key Enable visualization Draping Adequate lighting Use of curtains Flashlight if needed Noise control.
TV radio off Preparing the ClientPromote client comfort Develop rapport Explain the procedure.
Respect cultural differences Use proper positioning Physical Assessment SkillsFour major skills used Inspection.
Palpation Percussion Auscultation Inspection Use of sight to gather data.
Used throughout physical examination Tools to enhance inspection Otoscope Ophthalmoscope Penlight.
Examples Skin color gait generalappearance behavior Palpation Use of touch to gather data Begin with light pressure moving to deep palpation.
Use caution with deep palpation Parts of the hands used Fingertips Tactile discrimination Dorsum Temperature determination Palm General area of pulsation.
Grasping fingers and thumb Mass evaluation Examples Edema moisture anatomical landmarks Percussion Tapping on skin to elicit sound Direct.
Indirect Useful for assessing abdomen lungs underlying structures Examples Distended bladder Auscultation.
Use of hearing to gather assessment data Direct auscultation Listening without an instrument Indirect auscultation Use of a stethoscope to listen.
Diaphragm high pitched sounds Bell low pitched sounds Examples Heart sounds lung sounds Age Modifications for thePhysical Examination.
Infants Toddlers Parents hold Allow to explore and or Attend to safety sit on parent s lap Invasive procedure Offer choices.
Use praise Age Modifications for thePhysical ExaminationPreschoolers School Aged Children Use doll for Show approval and.
demonstration develop rapport Still may want Allow independenceparental contact Teach about workings Allow child to help of the bodywith examination.
Age Modifications for thePhysical ExaminationAdolescents Young Middle Adults Provide privacy Modify in presence of Concerned that they acute or chronic illness.
are normal Use examination toteach healthy lifestyle Screen for suicide risk Age Modifications for the.
Physical ExaminationOlder Adults May need special positioning related to Adapt examination to vision and hearing Assess for change in physical ability.
Assess for ability to perform activities of daily Provide periods of rest as needed Basic Components of a Comprehensive Examination The General Survey Begins at first contact.
Overall impression of client Deviations lead to focused assessments Appearance behavior Speech Grooming hygiene Vital signs Body type posture Height weight.
Mental state Basic Assessments Skin Integumentary Skin characteristics Temperature Texture.
Moisture Turgor Lesions Basic Assessments Skin Skull and Face Eyes Size External eye.
Shape Sclera Facial features Pupils Visual acuity Vision examinations Acuity distance near .
color visual fields Internal structures Basic Assessments Ears Nose Mouth Ears hearing Nose External ear.
Inner ear Tympanic membrane Mouth Hearing Lips Weber s test Buccal mucosa.
Rinne s test Balance Teeth Romberg s test Hard and soft palates Basic Assessments Neck Neck Breasts .
Musculature Size Trachea Shape Thyroid gland Nipple Cervical lymph characteristicsnodes Tissue.
Include axillae Basic Assessments LungsChest and Lungs Describe size and shape of chest Relate findings to landmarks.
Breath Sounds Bronchial Adventitious Bronchovesicular Diminished or misplaced Vesicular Abnormal vocal sounds.
Basic Assessments Heart Cardiovascular Inspection Heaves Lifts Heart sounds Palpation Location .
Aortic Pulmonic ThrillTricuspid MitralComponents S1 S2 S3 S4.
Basic Assessments Heart Cardiovascular Vessels Peripheral vessels Central vessels Blood pressure Carotid arteries Peripheral pulses.
Palpate pulsation Signs of inadequate Special precautions oxygenation Auscultate for bruit Varicosities Jugular veins Basic Assessments .
Different order for assessment skills Inspect Auscultate Percuss Palpate.
Basic Assessments Bones Muscles Body shape symmetry Joint mobility Posture Color change Gait Deformity Spinal curvature Crepitus.
Romberg s test Muscle strength Range of motionCoordination Resistance Finger thumb opposition Movement.
Basic Assessments Neurological Staff RN Uses Focused Neuro Assessment Cerebral Functioning Level of consciousness.
Arousal response to stimuli Orientation time place person Mental status cognitive function Behavior appearance response to stimuli speech memory communication judgment.
Basic Assessments Neurological Automatic responses Responses on agraded scale Motor Cerebellar.
0 No response Function 4 Clonus Movement coordination Example deep tendon Tonereflexes Posture Equilibrium.
Proprioception Basic Assessments NeurologicalSensory Function Light touch Stereognosis.
Light pain Graphesthesia Temperature Two point Vibration discrimination Position Point localization.
Extinction Genitourinary Assessment Includes reproductive information External genitalia penis urethral opening scrotum lymph nodes pubic hair.
Examine for the presence of a hernia Female external genitalia labia clitoris urethralopening vaginal orifice pubic hair lymph nodes Genitourinary Assessment Kidneys CVA tenderness .
Bladder palpation of the abdomen NP MD responsible for anus rectum prostateexamination NP MD responsible for pelvic examination.
Health Assessment: Performinga Physical Examination. Part of a general health assessment. Used to gather data about the client. Focuses on functional abilities and responses to illness/stressor. The Nursing Physical Examination. The nurse performs a physical examination to:

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