Physical Assessment ch 19 Flashcards
Purposes of a physical examination
- To obtain baseline data, for comparison.
- To identify nursing diagnoses, collaborative problems, and wellness diagnoses.
- To monitor status of previously identified problems.
- To screen for health problems.
Comprehensive physical examination
Health history interview. Complete examination of all body systems.
Done at outpatient annual checkup, admission to inpatient setting, and initial home visit.
Focused physical assessment
Pertains to a particular issue.
Such as an emergency situation, to “focus on a presenting problem”
Ongoing assessment
Performed as needed to assess status, evaluation of client outcomes.
Ex med surg rounds
What are the two examination approaches for a physical exam?
Head to toe —Progress down the body so as not to miss anything. Systematic approach
Body system— each system in a predetermined order. Can mimic head to toe
How to prepare for examination of client?
Theoretical—nursing school related info
Self-knowledge—examine your weakness
Familiarize yourself with the client—
Purpose of examination/client diagnosis
Review the nursing plan of care if this is not an initial assessment. So u can modify plan based on findings.
How to promote client comfort ?
Develop rapport.
Explain the procedure.
Respect cultural differences.
Use proper positioning.
What are the physical assessment skills and order used?
- Inspection— immediately observe clients gait, personal hygiene, affect, and behavior during general survey.
- Palpation— assess temperature, skin texture, edema, masses, etc by touch. Move to sensitive areas last.
- Percussion— use tapping to evaluate underlying masses location, size, and density.
- Auscultation—use of hearing
Direct- is without an instrument
Indirect- with stethoscope - Olfaction— maybe use smell on occasion
What to exam in sitting, supine, and dorsal recumbent position(supine with knees flexed up)?
Sitting—vital signs, head and neck, chest, cardiovascular system and breasts.
Supine— abdomen, breasts, extremities, and pulses. Raise to Fowler or semi fowler for breathing issues
Dorsal recumbent— abdominal assessment if client has abdominal or pelvic pain
When to examine in lithotomy, sims, prone, lateral recumbent and knee-chest position?
Lithotomy— female pelvic examination
Sims—flexion of knees in side-lying position for rectal or instead of lithotomy (don’t if client has full hip replacement)
Prone— examine musculoskeletal system, hip extension, back and butt.
(Difficult for client with respiratory problems)
Lateral Recumbent- lying on side in straight line. On left to evaluate heart murmur, bring heat closer to chest wall.
(Or have client sit and bend forward)
Knee-chest— for rectum but not used often
Tools to enhance visual inspection
Otoscope- ears
Ophthalmoscope- internal eye exam
Penlight- examine eyes, mouth, highlighting a skin lesion
Using touch for palpation, parts of hand?
Fingertips- tactile discrimination
Dorsum- temperature determination
Palm- general area of pulsation
Grasping(fingers and thumb)- mass evaluation
Parts of stethoscope use?
Diaphragm- high pitched sounds
Bell- low pitched sounds
Age modification of exam for infants?
Allow parent to hold infant against chest or on lap without support if child is able.
Otherwise place on padded table with rail raised to prevent falling. Don’t let infant out of sight on table.
Modification of exam for toddlers?
Allow to explore the environment or sit on parents lap.
Invasive procedures last.
Offer choice to child to promote cooperation.
Use praise to promote positivity with healthcare.
Preschooler examination modifications?
Combat fears with a doll or have parent demonstrate.
Allow to have parent hold them.
Allow child to help with the examination.
Always give reassurance and compliment cooperation
School aged children exam modifications ?
Develop rapport, supportive of independence, allow time to teach about equipment and how the body works.
Modifying adolescent exam?
Provide privacy, and address concerns that they are normal regarding puberty.
Be aware of peer influence on them. Emphasis on lifestyle habits. Education of STI’s and testicular cancer and HPV.
Prepare for pelvic and breast examination.
Screen for depression and suicide risk.
Modification for older adults in examination?
Spices common problems
Asses clients support system, and ADL abilities.
Limit position changes, work with there physical abilities. Provide rest breaks.
Be aware of hearing and vision issues and if they are following you.
S—sleep disorder
P—problems with eating or feeding
I—incontinence
C—confusion
E—evidence of falls
S—skin breakdown
What is analyzed in a general survey open first impression of the client?
Appearance and Behavior
Dress, Grooming, hygiene
Body Type and Posture
Speech
(Inappropriate or illogical responses, rapid or slow speech, vocabulary & sentence structure, accent or hesitancy to speak)
Mental State- in regards to dementia or medication, as well as mental health
Height/weight/BMI
Integumentary system
(Skin evaluation characteristics)
Color—pallor, cyanosis, jaundice, flushing, erythema, ecchymosis, petechiae, mottling
Temperature—consistent with room and activity level
Moisture— excess could mean thyroid hyperactivity, hyperthermia, or hyperhidrosis. Dry could mean dehydration or chronic renal failure etc
Skin texture— exposure, age, hyperthyroidism and other endocrine disorders can thicken skin, or impaired circulation.
Turgor— indicates hydration, edema(excessive hydration) can be a sign of issues.
Skin lesions— evaluate all skin lesions for malignancy, especially on exposed rubbing spots or other trauma.
Integumentary system
(Hair evaluation)
Color, texture, distribution
Alopecia— normal, chemotherapy, nutritional deficiencies, endocrine disorders, perimenopausal period, or immune disorders
Hirsutism- excess facial or trunk hair(endocrine disorders)
Scalp— smooth, firm, symmetrical, and w/o lesions
Pediculosis— lice
Integumentary system
(Nail evaluations)
Color— pink indicates rapid capillary refill for circulation
Shape— nail plate angle of 180* or more is sign of hypoxia states(chronic lung disease)
Texture— should be smooth
The Head
(HEENT)
Head
Eyes
Ears
Nose
Throat
