Physical Assessment- Mental Health, GCS, Skin Flashcards
What is Infection control in physical assessment?
hand hygiene,
standard/additional precautions,
cleaning of equipment
Correct environment for physical assessment?
privacy & dignity,
warm, quiet, lighting, equipment
clean, working and available
e.g. Stethescope, blanket etc
A Patient- (physical & psychological) before physical assessment?
explain in appropriate terminology (therapeutic interaction), informed consent, appropriate dress, empty bladder (abdominal), assess for pain, correct position.
What does IPPA stand for?
I-Inspection (sight, sound, smell)
P-Palpation (touch)
P-Percussion (touch, sound)
A-Auscultation (sound via stethoscope)
What is inspection in physical assessment?
• Look: – collecting objective data • Inspection: – concentrated observation – Careful scrutiny – Comparing – Counting – Measuring – Smelling
What is palpation?
The act of touching a patient in a therapeutic manner to elicit specific information
What tools do you need for palpation?
Tools: Hands
– Clean
– Short nails
– Warm
What is the purpose for palpation?
- Locate organs and assess size of organs
– Assess texture/temperature/moisture/lumps
– Measure, pulsations, rigidity, swelling, tenderness
What is the technique used for palpation?
– Informative
– Slow
– Systematic
– Gentle
When do you use your fingertips for palpation?
fine tactile discrimination eg. Palpate pulses & breast examination
When do you use the Dorsum of the hand in palpation?
Temperature
When do you use the Palmar pads of the metacarpal
phalangeal joints in palpation?
for vibration (use palmar pads for thrills or vibration of the precordium)
When do you use the Palmar pads or ulnar surface in palpation?
of the hand, also for vibration (use for tactile fremitus over the thorax)
Fingertips in palpation?
grasp the skin over the sternum to assess turgor
What is percussion?
The technique of striking one object against another that
produces sound
Guidelines for percussion?
Short finger nails
What is the technique used in percussion?
o Firm, rapid, sharp strikes o Wrist only, forearm still o Remove striking finger after strike o Tapping sound o Indirect, mediate percussion
What is auscultation?
The act of listening to sounds produced by the body
Direct Auscultation: listening with unaided ear
Indirect auscultation: listening with amplification or mechanical
device
What is the diaphragm of a stethoscope used for?
flat edge, for high pitch sounds: breath, bowel, normal heart sounds
What is the bell of a stethoscope used for?
the end piece, deep hollow cup shape, low pitch, heart murmurs, extra heart sounds
What is and how to use a Doppler ultrasonic stethoscope?
Gel is placed on the body part being assessed then the doppler placed directly.. This device amplifies sounds, and tones that are unpalpable: pulses
What can interfere when auscultating?
– Hair
– Shivering
– Clothing
What is the purpose of a mental health assessment?
Assess capacity to think, sense, perceive and move
What does a mental health assessment include?
Mental and emotional status Appearance Behaviour Cognition Thought process Sensation and perception Motor function
What is a past health history in mental health assessment?
Previous problems, substance abuse
medical hx, surgical hx, medications, communicable diseases,
injuries and accidents
What is family history in mental health assessment?
Headaches, epilepsy, Alzheimer’s disease,
Huntington’s chorea, muscular dystrophies, mental illness
What is environmental hx in mental health assessment?
exposure to chemicals, travel hx
What is psychological in mental health assessment?
self-esteem and stress caused by mental or
neurological illness, support system, spouse, children, friends,
coping mechanism, recent loss, grief
What should you do before you begin a mental health assessment?
ensure privacy, consider influencing factors,
enable eye contact, ideally sit at same level
What does a integument assessment include?
Skin, hair, nails
What are the functions of the skin?
→Protect →Prevent →Sense →Regulate →Secrete →Promote
What is past health history in integument assessment?
thorough, any past skin issues, piercings,
alopecia, hair distribution
What is family health history in integument assessment?
any skin, hair or nail conditions in the family
What is social history in integument assessment?
includes alcohol, smoking, environment, products used
What equipment do you need for integument assessment?
– Magnifying glass
– Lighting: natural light & pen light
– Gloves
– Ruler
What do you inspect for examination of the skin?
Colour – Bleeding – Ecchymosis – Vascularity – Lesions – Moisture – Temperature – Texture – Turgor – Oedema
What do you palpate in the examination of the skin?
– Moisture – Temperature – Tenderness – Texture: finger pads – Turgor (elasticity): pinch – Oedema
How do you inspect and palpate the hair?
• Colour • Distribution: – Alopecia – Hirsutism. • Scalp lesions • Palpate texture
What do you inspect and palpate for the nail?
Function of nail Cleanliness Color Texture Capillary refill
