Health Assessment Flashcards
The Nursing Physical Examination
- Used as part of a general health assessment
- Used to gather data about the client
- Focuses on functional abilities and responses to illness/stressor
___ assessments focus on the client’s functional abilities and physical responses to illness and other stressors
Nursing
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Is an assessment of the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community
General health assessment
The nurse performs a physical examination to;
- Establish baseline data
- Identify nursing diagnoses, collaborative problems, or wellness diagnoses
- Monitor the status of an identified problem
- Screen for health problems
A comprehensive physical assessment includes a health history interview and a complete head-to-toe examination of every body system
Types of Physical Examinations
- Comprehensive physical exam or physical assessment
* Interview plus complete head-to-toe examination (i.e. annual physical, on admission) - Focused
* “Focused” on presenting problem
Types of Physical Examinations
- System-specific
* Limited to one body system - Ongoing
* Performed as needed to assess status
* Evaluates client outcomes
Preparing Yourself: What the Nurse Needs
- Theoretical knowledge
- Self-knowledge
- Knowledge about client situation
Preparing the Environment
- Privacy is key
- Noise control
- Enable visualization
- Temperature
- Equipment
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- A&P, techniques, therapeutic communication, & documentation
Theoretical knowledge
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- Skill and comfort level
- Willingness to seek help
Self-knowledge
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- Skill and comfort level
- Willingness to seek help
Self-knowledge
Preparing the Client
* Promote client comfort
- Develop rapport
- Explain the procedure
- Respect cultural differences
Preparing the Client cont’d
- Use proper positioning (know when to use each position)
- Standing
- Sitting
- Supine
* Fowlers (HOB elevated 60°) & Semi-Fowlers (HOB elevated 30-45°) - Dorsal recumbent
- Lithotomy
- Sims’
- Prone
- Lateral recumbent
- Knee-chest
Physical Assessment Techniques
* Four major skills used
- Inspection
- Palpation
- Percussion
- Auscultation
Additional clinical skill
- Olfaction (sense of smell)
___ is listening without using an instrument
If you’ve heard wheezing or chest congestion without the use of a stethoscope, you have already performed ___
Direct auscultation
___ is listening with the help of a stethoscope
Indirect auscultation
Age Modifications for the Physical Examination
Infants
* Have parents hold
* Attend to safety
Age Modifications for the Physical Examination
Toddlers
* Allow to explore and/or sit on parent’s lap
* Perform invasive procedure(s) last
* Offer choices
* Use praise
Age Modifications for the Physical Examination
Preschoolers
* Use doll for demonstration
* Child may still want parental contact
* Allow child to help with examination
Age Modifications for the Physical Examination
School-age children
* Show approval and develop rapport
* Allow independence
* Teach about workings of the body
Age Modifications for the Physical Examination
Adolescents
* Provide privacy
* Address concerns that they are “normal”
* Use examination to teach healthy lifestyle
* Screen for suicide risk
Age Modifications for the Physical Examination
Young/middle adults
* Modify in presence of acute or chronic illness
Age Modifications for the Physical Examination
Older adults
* May need special positioning related to mobility
* Adapt examination to vision and hearing changes
* Assess for change in physical ability
* Assess for ability to perform ADLs
* Provide periods of rest as needed
“SPICES”
S = Sleep disorders
P = Problems with eating or feeding
I = Incontinence
C = Confusion
E = Evidence of falls
S = Skin breakdown
Basic Components of a Comprehensive Examination: The General Survey
* Begins at first contact
* Overall impression of client
* Deviations lead to focused assessments
- Appearance/behavior
- Body type/posture
- Speech
- Mental state (LOC and interaction)
- Dressing/grooming/hygiene
- Vital signs
- Height/weight (calculate BMI)
Basic Assessments: Skin, Head
Integumentary
* Color
* Skin characteristics
- Temperature - warm to touch
- Moisture - oily, diaphoresis, dry and scaly
- Edema - assessing for edema and grading scale
- Texture - smooth, coarse, cracked, rough, dry, shiny
- Turgor - tenting versus increased turgor
* Lesions
- Malignant lesions (Asymmetry, Border, Color, Diameter, Evolving)
* Hair
* Nails
Basic Assessments: Skin, Head (HEENT)
Head (Head, eyes, ears, nose, throat)
* Skull and face
- Size
- Shape
* Eyes
- Visual acuity
- Visual examinations (acuity, distance, near, color, visual fields)
- External eye (sclera, pupils)
- Internal structures
Basic Assessments: Ears, Nose, Mouth
* Ears/hearing
- External ear
- Middle ear
- Inner ear (tympanic membrane)
- Hearing (Weber’s test, Rinne’s test)
- Balance (Romberg’s test)
Basic Assessments: Ears, Nose, Mouth cont’d
* Nose
- Smell
* Mouth and oropharynx
- Lips
- Buccal mucosa
- Gingiva
- Teeth
- Tongue and oropharynx
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Place a vibrating tuning fork on the center of the client’s head. He should be able to sense the vibration equally in both ears. Record a positive test if the vibration is louder in one ear.
Weber’s test