Chapter 12 Physical Assessment Flashcards
SYMPTOMS
________ full description by the patient of the onset ( when did it start?), the course, the character of the problem, and any factors that aggravate or alleviate.
Encourage
DISEASE
It is any ____ of a structure or function of the body; a pathologic condition of the body.
Disturbance
How are diseases recognized?
by a set of signs and symptoms
Signs and symptoms are ___in groups to help the health care provider to make a medical diagnosis.
Clustered
What are the origins of disease?
disease of illness originates from many causes; hereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, and environmental.
A _____ factor is any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other that _____ the vulnerability of an individual or a group to illness or accident.
Risk
Increases
Risk factors for developing a disease:
Genetic and physiologic, age, environment, and life style.
Chronic
develops slowly and persists over a long period, often for a person’s lifetime.
Remission
partial or complete disappearance of clinical and subjective characteristics of a disease.
Acute
Begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment.
Organic disease
results in structural change in an organ that interferes with its functioning
Functional disease
may be manifested as organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities.
Infection
caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites
Inflammation
protective response of the body tissues to irritation, injury, or invasion by disease- producing organisms.
Cardinal signs of infection and inflammation
Erythema, edema, heat, pain, purulent drainage, and loss of function.
Assessment
process of making an evaluation or appraisal of the patient’s condition.
Medical Assessment
physical examination is conducted by the health care provider
the nurse is often expected to carry out certain functions.
Items needed to perform the nursing physical assessment
penlight, stethoscope, blood pressure cuff, thermometer, gloves, and a tongue blade.
what is the purpose of the nursing physical assessment?
to determine the patients state of health or illness.
What is the initial step of the nursing process and in forming the nursing care plan?
Nursing physical assessment
When do you perform a physical assessment?
Perform as soon after admission as possible
Initial assessment is done by an RN
ongoing assessment is the responsibility of LPN and the RN
Neurologic ( Head- to- toe assessment)
level of consciousness level of orientation hand grips vital signs glasgow coma scale
Skin and hair ( Head- to- toe assessment)
Observe skin for color, temperature, moisture, texture, turgor, and evidence of injury or skin lesions.
note color of sclera, mucous membranes, tongue, lips, nail beds, palms and soles.
determine the quantity, quality, and distribution of hair
hair should be smooth, not oil or dry.
scalp should be free from dandruff, lesions, or parasites.
head and neck mouth and throat eyes ears nose
Chest, lungs, heart, and vascular system
inspect bilateral chest expansion note rate, depth of respirations note audible sounds without stethoscope assess oxygen saturation breasts lung sounds spine heart sounds peripheral vascular system
Gastrointestinal system
abdomen
Genitourinary system
inspect labia/ genitalia and pubic hair palpate the scrotum palpate supra pubic area rectum legs and feet
Documentation
Follow institution protocol and forms used for history and physical assessment be objective, clear, complete, and concise.
Telephone consultation
Very important to follow HIPAA guidelines.
S O A P I E ( R)
Cultural considerations
culture includes: knowledge, skill, art morals, law, customs, and any other acquired habits and capabilities of a group of people.
How do you develop cultural and ethnic sensitivity?
Recognize that cultural and ethnic diversity exist
demonstrate respect for people as individuals
respect the unfamiliar
