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Nursing 20G - Care of the Medical Client > 3) Health Assessment And Physical Examination > Flashcards

3) Health Assessment And Physical Examination Flashcards

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1
Q

What dimensions are included in a holistic assessment of a patient’s health?

A
  • Emotional
  • Intellectual
  • Physical
  • Psychosocial
  • Spiritual
  • Cultural
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2
Q

What does the process of collecting data about a patient include?

A
  • Thorough health history
  • Physical examination
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3
Q

What aspects may be assessed during a physical exam beyond physiological function?

A
  • Cognition
  • Mood
  • Functional status
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4
Q

Why is it important for nurses to detect changes in a patient’s condition?

A
  • Nurses are often the first contact for patients.
  • Critical thinking helps interpret patient behavior and physiological status.
  • Enables timely intervention and care.
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5
Q

What are the purposes of physical assessment and examination in nursing?

A
  • Detect subtle and obvious health changes.
  • Assess patterns reflecting health problems.
  • Evaluate patient progress following therapy.
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6
Q

What is included in a complete health assessment?

A
  • Nursing history
  • Behavioural and physical examination
  • Cultural assessment
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7
Q

What is the purpose of a head-to-toe physical examination?

A
  • Provides objective information about the patient.
  • Aids in clinical judgment and nursing care planning.
  • Influences therapy choices and evaluation of responses.
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8
Q

How does continuity in health care improve through physical assessment?

A
  • Ongoing, objective, and comprehensive assessments by nurses.
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9
Q

What tools help nurses detect subtle changes in health?

A

Skills of physical assessment and examination.

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10
Q

What can health screenings focus on?

A
  • Specific physical conditions (e.g., blood pressure).
  • Cognition, mood, and functional status.
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11
Q

What is required for culturally competent health assessment?

A
  • Nurse being culturally aware and sensitive
  • Respecting patient preferences during examination
  • Recognizing how social/cultural background influences health beliefs
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12
Q

What data facilitates a culturally competent physical exam?

A
  • Integrating cultural assessment for every patient
  • Assessing gender identity, complementary therapies, dietary needs
  • Understanding caregiver relationships, past healthcare experiences
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13
Q

How does cultural assessment data inform physical assessment?

A
  • Helps think critically about patient’s contexts (political, social, economic)
  • Avoids stereotyping based on gender or ethnicity
  • Recognizes biocultural variations of normal/healthy presentations
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14
Q

What are examples of biocultural health variations?

A
  • Congenital dermal melanocytosis in some newborns
  • Higher risk of hypertension/diabetes in certain populations
  • Nurses must learn to recognize these common variations
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15
Q

What is the benefit of culturally competent care?

A
  • Leads to greater patient satisfaction
  • Improves clinical outcomes for patients
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16
Q

What guides the focus of a physical examination?

A
  • Designed to address the patient’s specific needs
  • For acutely ill, assess only the involved body system(s)
  • Comprehensive exam done when patient is more stable
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17
Q

When is a complete physical exam often performed?

A
  • As part of periodic health exams for wellness/prevention
  • To determine eligibility (insurance, military, licenses)
  • For pre-employment, new practitioner, pre-surgical assessment
  • For admission to hospital or long-term care facility
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18
Q

What purposes does a thorough physical exam serve?

A
  • Gathers baseline data on health history, status, concerns
  • Supplements, confirms or refutes data from health history
  • Confirms and identifies nursing diagnoses
  • Enables clinical judgments on changing health status/management
  • Evaluates outcomes of care provided
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19
Q

When is a complete exam not recommended?

A
  • For annual exams of asymptomatic adults
  • Research shows it does not improve health status
  • Can lead to false positives causing anxiety and unnecessary testing
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20
Q

Why review anatomy and physiology for physical assessment?

A
  • Helps identify structures and functions of the human body
  • Understand interconnectedness of physiological systems
  • Essential for assessing specific body systems/regions
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21
Q

What is needed to assess cranial nerves?

A
  • Understanding the function of each cranial nerve
  • Knowing the motor and sensory pathways innervated
  • Anatomy and physiology knowledge of the nerve pathways
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22
Q

What is the main objective when interacting with patients?

A
  • Find out their concerns
  • Help them find solutions
  • Pay close attention to their concerns
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23
Q

What is required for collecting health history and exam data?

A
  • Patience
  • Dedication to comprehensiveness and detail
  • Following principles like relational practice
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24
Q

What does the interview allow?

A
  • Formation of a partnership with the patient
  • Orienting the interview to the patient, not the disease
  • Referring to “a person who has X” instead of labeling
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25
Q

What should you be aware of during the interview?

A
  • Your own idiosyncrasies (e.g. wanting to be liked)
  • Potential fears (e.g. catching a disease)
  • Prevent these from affecting the therapeutic relationship
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26
Q

How does a physical assessment supplement the health history?

A
  • Can reveal information that refutes, confirms, or adds to history
  • Requires critical thinking about patient information
  • Methodically conducting the exam for a clear health picture
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27
Q

What is the importance of assessing reported symptoms?

A
  • One finding alone does not reveal the full condition
  • Need to clarify the nature of symptoms through questions
  • Examine for potential sources to rule out various conditions
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28
Q

Why group assessment findings into clusters?

A
  • Assists in revealing actual or potential nursing diagnoses
  • Abnormal findings suggest need for more information gathering
  • Allows development of individualized nursing diagnoses
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29
Q

What is the purpose of the initial baseline assessment?

A
  • Records patient’s health status and functional abilities
  • Enables comparison to future assessments for changes
  • Comprehensiveness is key for determining condition changes
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30
Q

How should the care plan be viewed?

A
  • As an ongoing process requiring updates
  • Plan changes as conditions resolve, deteriorate or new issues arise
  • Ongoing monitoring guides review of nursing diagnoses/plan
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31
Q

What enables nurses to judge patient health status?

A
  • Physical assessment skills
  • Allows directing management of patient care
  • Recognizing changes in status is key
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32
Q

How should nurses respond to changes in patient status?

A
  • Modify interventions accordingly
  • Aim for achieving most desirable outcomes
  • Revise written care plan with new interventions
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33
Q

What is challenging about performing physical assessments?

A
  • Applying critical thinking to interpret findings
  • Making appropriate care decisions based on assessments
  • Mechanics of assessments are relatively simple
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34
Q

How do physical assessments enhance nursing accountability?

A
  • Used to evaluate results of nursing interventions
  • Monitor physiological and behavioral outcomes
  • Determine if expected care outcomes are met
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35
Q

Give an example of using assessment for care evaluation.

A
  • Palpating pulse to assess a condition
  • Evaluating tolerance to an exercise plan
  • Detailed documentation aids outcome determination
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36
Q

What are the four main skills used in a comprehensive physical exam?

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
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37
Q

What other sense is an element of patient assessment?

A
  • Olfaction (sense of smell)
  • Can detect odors related to hygiene, infections, physiological processes
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38
Q

What must providers do before any patient interactions?

A
  • Thoroughly clean hands
  • Check patient identification
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39
Q

What does inspection involve?

A
  • Using vision and hearing
  • Distinguishing normal from abnormal findings
  • Recognizing healthy variations for different age groups
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40
Q

What principles should be followed for accurate inspection?

A
  • Ensure adequate lighting
  • Position/expose areas to view all surfaces
  • Inspect for size, shape, color, symmetry, position, drainage, abnormalities
  • Compare bilateral areas when possible
  • Use additional light for body cavities
  • Take time and pay attention to detail
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41
Q

What may inspection findings indicate?

A
  • The need for further examination by palpation
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42
Q

What is palpation used for?

A
  • Examining all accessible body parts using the hands
  • Assessing skin temperature, moisture, texture, turgor, tenderness, thickness
  • Checking abdomen for tenderness, distension, masses
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43
Q

How should the patient be prepared for palpation?

A
  • Help them relax and be comfortable
  • Have them take slow, deep breaths with arms at sides
  • Palpate tender areas last, ask about sensitive areas
  • Watch for nonverbal signs of discomfort
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44
Q

What is required for proper palpation technique?

A
  • Warm, clean hands with short fingernails
  • Gentle, slow, deliberate approach
  • Use light, intermittent pressure
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45
Q

What cautions should be taken during palpation?

A
  • Avoid heavy, prolonged pressure to prevent loss of sensitivity
  • Do not attempt deep palpation without supervision
  • Exercise caution to avoid injuring the patient
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46
Q

Which hand surfaces are used for specific assessments?

A
  • Palmar fingers/pads: position, texture, size, masses, fluid, crepitus
  • Dorsal surface: temperature
  • Ulnar surface: vibration
  • Fingertips: position, consistency, turgor
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47
Q

For the skin, what criteria are measured and which hand portions are used?

A
  • Temperature - Dorsum of hand/fingers
  • Moisture - Palmar surface
  • Texture - Palmar surface/pads of fingertips
  • Turgor and elasticity - Grasping with fingertips
  • Tenderness - Palmar surface/pads of fingertips
  • Thickness - Palmar surface/pads of fingertips
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48
Q

For organs like the liver and intestines, what criteria are measured and which hand portions are used?

A
  • Size - Entire palmar surface or palmar fingers
  • Shape - Palmar surface/pads of fingertips
  • Tenderness - Entire palmar surface or palmar fingers
  • Absence of masses - Palmar surface/pads of fingertips
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49
Q

For glands like thyroid and lymph nodes, what criteria are measured and which hand portions are used?

A
  • Swelling - Pads of fingers
  • Symmetry and mobility - Palmar surface/pads of fingertips
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50
Q

For blood vessels like carotid or femoral arteries, what criteria are measured and which hand portions are used?

A
  • Pulse amplitude - Palmar surface/pads of fingertips
  • Elasticity - Palmar surface/pads of fingertips
  • Rate - Palmar surface/pads of fingertips
  • Rhythm - Palmar surface/pads of fingertips
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51
Q

For the thorax, what criteria are measured and which hand portions are used?

A
  • Excursion - Palmar surface
  • Tenderness - Finger pads/palmar surface of fingers
  • Fremitus - Palmar or ulnar surface of entire hand
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52
Q

Give an example of a situation requiring caution during palpation.

A
  • If the patient has a fractured rib
  • Locate the painful area very gently and carefully
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53
Q

Why is it important to avoid obstructing blood flow?

A
  • Applying too much pressure on vital arteries
  • Can temporarily block/obstruct necessary blood flow
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54
Q

What is the purpose of percussion?

A
  • Tapping the body with fingertips to produce vibrations
  • Determining location, size, and density of underlying structures
  • Verifying abnormalities assessed by palpation and auscultation
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55
Q

How does percussion work?

A
  • Vibrations are transmitted through body tissues
  • Sound character depends on density of underlying tissue
  • Different densities influence the sound produced
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56
Q

What can percussion help identify?

A
  • Location of organs or masses
  • Mapping boundaries of organs/masses
  • Determining size of organs/masses
  • Presence of air or fluid within organs/cavities
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57
Q

What does an abnormal percussion sound suggest?

A
  • Indicates a mass or abnormal substance present
  • Such as air or fluid within an organ or body cavity
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58
Q

What is required for proper percussion technique?

A
  • Dexterity and skill
  • Usually performed by advanced practitioners
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59
Q

What is auscultation used for?

A
  • Listening to body sounds
  • Detecting variations from normal sounds
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60
Q

What sounds should be learned first?

A
  • Normal sounds from cardiovascular, respiratory, and GI systems
  • Such as blood flow through arteries
  • Abnormal sounds are recognized after learning normal variations
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61
Q

What should one know to become proficient at auscultation?

A
  • Types of sounds made by each body structure
  • Locations where sounds are best heard
  • Areas that normally do not emit sounds
62
Q

What is required for proper auscultation?

A
  • Good hearing ability
  • Quality stethoscope
  • Knowing how to use stethoscope properly
  • Amplified stethoscope if hearing impaired
63
Q

How is the stethoscope used?

A
  • Placed directly on skin, not over clothing
  • Bell for low-pitched sounds like heart/vascular
  • Diaphragm for high-pitched sounds like lungs/bowels
64
Q

What should be done before using the stethoscope?

A
  • Become familiar with it
  • Practice using it
  • Recognize extraneous sounds from tubing/chestpiece
65
Q

What characteristics of sounds should be recognized?

A
  • Frequency (pitch)
  • Loudness (amplitude)
  • Quality (blowing, gurgling, etc.)
  • Duration (short, medium, long)
66
Q

What is required for effective auscultation?

A
  • Concentration and practice
  • Considering the body part being auscultated
  • Understanding the cause of the sound
67
Q

Give an example of the cause of a heart sound.

A
  • Closure of the mitral valve causes the first heart sound
68
Q

Where is the first heart sound best heard?

A
  • Left fifth intercostal space along the midclavicular line
69
Q

Why is it important to learn normal sound characteristics?

A
  • To recognize abnormal sounds and their origins
  • First heart sound has “lub” quality
  • Second heart sound has “dub” quality
70
Q

What makes it easier to identify abnormal sounds?

A
  • Understanding the cause and character of normal sounds
  • Familiarity with normal allows detection of abnormalities
71
Q

What is the purpose of olfaction during patient assessment?

A
  • Become familiar with nature and source of body odors
  • Detect abnormalities that cannot be recognized by other means
72
Q

Give an example of when olfaction can indicate an abnormality.

A
  • If a patient’s cast has a sweet, heavy, thick odor
  • This indicates an underlying infection
73
Q

What should findings from olfaction prompt the nurse to do?

A
  • Investigate the origin of the odor
  • As it may indicate abnormalities or underlying conditions
74
Q

What does proper preparation ensure for a physical examination?

A
  • A smooth examination process
  • Few interruptions during the exam
75
Q

What can result from a disorganized approach to preparation?

A
  • Errors in the examination
  • Incomplete findings
76
Q

What three areas require preparation for an examination?

A
  • The environment
  • Equipment
  • The patient
77
Q

What precautions should be taken for patients with open skin lesions or weeping wounds?

A
  • Use standard precautions and routine practices
  • Wear gloves during palpation and percussion
  • Reduces contact with microorganisms
78
Q

What additional protective equipment is needed for excessive wound drainage?

A
  • Wear a gown
  • Wear other personal protective equipment as needed
  • Prevents exposure to spray from the wound
79
Q

When should hand hygiene be practiced during a physical assessment?

A
  • Before initiating the assessment
  • After completing the assessment
80
Q

What is the odor associated with the oral cavity and what are its potential causes?

A
  • Alcohol odor - ingestion of alcohol, diabetes
  • Sweet, fruity ketone odor - diabetic acidosis
  • Halitosis - poor dental/oral hygiene, gum disease
81
Q

What is the odor associated with urine and what are its potential causes?

A
  • Ammonia odor - urinary tract infection, renal failure
  • Stale urine odor on skin - uremic acidosis
82
Q

What are the odors associated with the skin and what are their potential causes?

A
  • Body odor - poor hygiene, excess perspiration (hyperhidrosis), foul-smelling perspiration (bromhidrosis)
  • Wound site odor - wound abscess
83
Q

What are the odors associated with vomitus and feces and what are their potential causes?

A
  • Vomitus odor - abdominal irritation, contaminated food
  • Fecal odor in vomitus/oral cavity - bowel obstruction
  • Fecal odor in rectal area - bowel incontinence
  • Foul-smelling stools in infant - malabsorption syndrome
84
Q

What are the odors associated with wounds/infections and what are their potential causes?

A
  • Sweet, heavy, thick odor from draining wound - Pseudomonas bacterial infection
  • Musty odor from casted body part - infection inside cast
  • Fetid, sweet odor from tracheostomy or mucous secretions - infection of bronchial tree (Pseudomonas bacteria)
85
Q

What is required for a physical examination? (Environment)

A
  • Privacy
  • Well-equipped examination room or space
86
Q

What is necessary for proper illumination during an examination?

A
  • Adequate lighting of body parts
87
Q

What helps patients feel comfortable discussing their conditions?

A
  • Soundproof examination room
  • Eliminating noise sources
  • Preventing interruptions
  • Warm room temperature
88
Q

What makes examinations easier when the patient is in bed?

A
  • Raising the bed height
  • Using proper body mechanics
89
Q

What precautions are needed with examination tables?

A
  • Carefully assisting patients on/off the table
  • Not leaving confused/combative patients unsupervised
  • Raising head of table and using pillow for comfort
90
Q

What equipment is typically used for a complete physical assessment?

A
  • Cervical devices (brush, broom, spatula)
  • Cotton applicators
  • Disposable pads/paper towels
  • Drapes
  • Eye chart
  • Flashlight and spotlight
  • Forms (physical, laboratory)
  • Gloves (sterile and clean)
  • Patient gown
  • Ophthalmoscope
  • Otoscope
  • Pap slides/fixative or liquid cytology
  • Percussion hammer
  • Pulse oximeter
  • Ruler
  • Scale with height rod
  • Specimen containers
  • Sphygmomanometer and cuff
  • Sterile swabs
  • Stethoscope
  • Tape measure
  • Thermometer
  • Tissues
  • Tongue depressors
  • Tuning fork
  • Vaginal speculum
  • Water-soluble lubricant
  • Watch with second hand/digital display
91
Q

What should be done before starting a physical examination?

A
  • Ask if the patient needs to use the washroom
  • Ensure empty bladder and bowel for abdominal/genital/rectal exams
  • Collect urine or stool specimens if needed
  • Explain proper specimen collection method
  • Label specimens per laboratory policies
92
Q

How should the patient be prepared for the examination?

A
  • Patient should be properly dressed/draped (hospital gown or undressed with gown)
  • Provide privacy and time for undressing
  • Have patient sit/lie on exam table with drape over lap/trunk
  • Eliminate drafts, control room temperature, provide warm blankets
  • Routinely ask if patient is comfortable
93
Q

What should be considered for patient positioning?

A
  • Ask patient to assume positions for accessible body parts
  • Explain positions and assist patient
  • Adjust drapes to expose only area being examined
  • Organize exam to minimize position changes
  • Use extra care when positioning older patients
94
Q

How can you help patients feel more comfortable during an examination?

A
  • Provide a thorough explanation of the purpose and steps
  • Use simple, understandable terms
  • Encourage patients to ask questions and mention discomfort
  • Give detailed explanations for each body system
  • Convey an open, professional, and relaxed approach
95
Q

When should a chaperone be present during an examination?

A
  • When the patient and nurse are of opposite genders
  • The chaperone provides protection and reassurance
  • The chaperone witnesses the conduct of both parties
96
Q

How should you respond to a patient’s emotional responses during an exam?

A
  • Watch for signs of fear, concern, or anxiety
  • Remain calm and clearly explain each step
  • Stop the exam and ask how the patient feels
  • Do not force the patient to continue if uncomfortable
  • Postpone for better accuracy when the patient can relax
97
Q

What should you do if a patient’s fears stem from misconceptions?

A
  • Clarify the purpose of the examination
  • Before each element, verbalize what you will assess
  • Ask for the patient’s consent to proceed
98
Q

How should histories be gathered for infants and children?

A
  • Gather all or part of the histories from parents or guardians
99
Q

What approach should be taken when examining children?

A
  • Perform the examination in a non-threatening area
  • Provide time for play to become acquainted
  • Offer support to parents and do not pass judgment
100
Q

How should children and parents be addressed?

A
  • Call children by their first name
  • Address parents as “Mr.”, “Mrs.”, or “Ms.” rather than first names
101
Q

What questioning technique helps gather more information from parents?

A
  • Use open-ended questions to allow sharing more details
  • Enables observation of parent-child interactions
102
Q

How should adolescents be treated during the examination?

A
  • Treat adolescents as adults for best response
  • Remember adolescents have a right to confidentiality
  • Speak alone with adolescents after discussing history with parents
103
Q

What areas are assessed in the sitting position?

A
  • Head and neck
  • Back
  • Anterior and posterior thorax and lungs
  • Breasts
  • Axillae
  • Heart
  • Vital signs
  • Upper extremities
104
Q

What is the rationale for the sitting position?

A
  • Sitting upright provides full expansion of lungs
  • Provides better visualization of symmetry of upper body parts
105
Q

What is a limitation of the sitting position?

A
  • A physically weakened patient may be unable to sit
  • Use supine position with head of bed elevated instead
106
Q

What areas are assessed in the supine position?

A
  • Head and neck
  • Anterior thorax and lungs
  • Breasts
  • Axillae
  • Heart
  • Abdomen
  • Extremities
  • Pulses
107
Q

What is the rationale for the supine position?

A
  • Most normally relaxed position
  • Provides easy access to pulse sites
108
Q

What is a limitation of the supine position?

A
  • If patient becomes short of breath easily, raise head of bed
109
Q

What areas are assessed in the dorsal recumbent position?

A
  • Head and neck
  • Anterior thorax and lungs
  • Breasts
  • Axillae
  • Heart
  • Abdomen
110
Q

What is the rationale for the dorsal recumbent position?

A
  • For abdominal assessment
  • Promotes relaxation of abdominal muscles
111
Q

What is a limitation of the dorsal recumbent position?

A
  • Patients with painful disorders are more comfortable with knees flexed
112
Q

What area is assessed in the lithotomy position?

A
  • Female genitalia and genital tract
113
Q

What is the rationale for the lithotomy position?

A
  • Provides maximal exposure of genitalia
  • Facilitates insertion of a vaginal speculum
114
Q

What are the limitations of the lithotomy position?

A
  • Can be embarrassing and uncomfortable for patient
  • Examiner should minimize time patient spends in this position
  • Patient should be kept well draped
115
Q

What areas are assessed in the modified left lateral recumbent position?

A
  • Rectum and vagina
116
Q

What is the rationale for the modified left lateral recumbent position?

A
  • Flexion of hip and knee improves exposure of rectal area
117
Q

What is a limitation of the modified left lateral recumbent position?

A
  • Joint deformities hinder the patient’s ability to bend hip and knee
118
Q

What area is assessed in the prone position?

A
  • Musculoskeletal system
119
Q

What is the rationale for the prone position?

A
  • For assessing extension of hip joint, skin, and buttocks
120
Q

What is a limitation of the prone position?

A
  • Patients with respiratory difficulties do not tolerate this well
121
Q

What area is assessed in the left lateral recumbent position?

A
  • Heart
122
Q

What is the rationale for the left lateral recumbent position?

A
  • Aids in detecting murmurs
123
Q

What is a limitation of the left lateral recumbent position?

A
  • Patients with respiratory difficulties do not tolerate this well
124
Q

What area is assessed in the knee-chest position?

A
  • Rectum
125
Q

What is the rationale for the knee-chest position?

A
  • Provides maximal exposure of rectal area
126
Q

What is a limitation of the knee-chest position?

A
  • This position can be embarrassing and uncomfortable
127
Q

What makes up a complete physical examination?

A
  • Assessments for each body system
128
Q

When do patients typically require a focused examination?

A
  • Patients with specific symptoms or returning for follow-up care
  • Focused on relevant body systems related to their symptoms
129
Q

Give an example of when a focused examination would be performed.

A
  • A patient with severe chest cold symptoms requires focused assessment of ears, nose, throat, respiratory and cardiovascular systems
  • Would not routinely require a neurological assessment
130
Q

When is a complete examination performed?

A
  • When a patient is admitted to the hospital
131
Q

What guides the preventive screenings for a routine health promotion examination?

A
  • The patient’s age or health risk factors
132
Q

What do nurses need to use to ensure proper examination?

A
  • Judgement to assess relevant body systems
  • Document correct observations
133
Q

What tools help assess the health of older persons?

A
  • Tools that identify functional, cognitive, and affective status
  • Tools that screen for health risks like falls, polypharmacy, and elder abuse
134
Q

What is functional independence?

A
  • The ability to perform basic personal care
  • The ability to perform activities that support independent living (ADLs and IADLs)
135
Q

Who are functional assessment tools used for?

A
  • Can also be used for younger individuals with functional limitations like spinal cord or traumatic brain injuries
136
Q

What do functional status assessment tools help nurses assess?

A
  • A person’s independence in the home
  • A person’s level of functioning on return home from the hospital
137
Q

Give an example of a tool to assess independence with ADLs.

A
  • The Katz Index is a common screening tool
138
Q

Give an example of a tool to assess independence with IADLs.

A
  • The Lawton-Brody IADL scale assesses tasks necessary for independent community functioning
139
Q

Name some other examples of functional assessment tools.

A
  • Functional Analysis Screening Tool (FAST)
  • Global Assessment of Functioning (GAF) Scale
  • Barthel Index
140
Q

Why is screening for elder abuse important?

A
  • An important consideration when working with older persons
141
Q

Give examples of tools to screen for elder abuse/maltreatment.

A
  • Elder Abuse Suspicion Index (EASI)
  • Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST)
  • Vulnerability to Abuse Screening Scale (VASS)
142
Q

What is a good online resource for geriatric assessment tools?

A
  • The Hartford Institute for Geriatric Nursing (https://hign.org/consultgeri/resources)
143
Q

How should a complete health assessment be performed?

A
  • Follows the format of the nursing history interview review of body systems
  • Obtain information from history to focus on specific examination areas
  • Findings from history reveal patterns of related signs and symptoms
  • Physical examination supplements history to confirm or refute data
144
Q

Why is it important for nurses to be systematic during an examination?

A
  • To avoid missing important assessment findings
  • A head-to-toe approach includes all body systems
  • Helps anticipate each step of the examination
145
Q

How does an adult examination typically begin?

A
  • By assessing head and neck structures, including hair and skin
  • Then progressing methodically down the body to incorporate all systems
146
Q

What tip helps keep the examination organized?

A
  • Compare both sides of the body for symmetry
  • Some asymmetry is normal (e.g. dominant arm muscle development)
147
Q

For a seriously ill patient, what should be done first?

A
  • Assess the body systems most at risk of being abnormal first
  • For example, chest pain patient gets cardiovascular assessment first
148
Q

What should be offered if the patient becomes fatigued?

A
  • Offer rest periods between assessments
149
Q

When should painful procedures be performed?

A
  • Perform painful procedures near the end of the examination
150
Q
A

Nursing 20G - Care of the Medical Client (3 decks)

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