Upload
annabelle-jackson
View
214
Download
0
Tags:
Embed Size (px)
Citation preview
Part of a general health assessment Used to gather data about the client Focuses on functional abilities and responses
to illness/stressor
The Nursing Physical Examination
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
Purposes
Comprehensive: Interview plus complete head-to-toe
examination
Focused: “Focused” on presenting problem
Ongoing: Performed as needed to assess status Evaluates client outcomes
Types of Physical Examinations
Head-to-toe◦ Starts at the head◦ Progresses “down” the body◦ System-related data found throughout:
• Heart sounds - chest• Pulses - periphery
Organizing the Examination
Body systems◦ Gathers system-related data all at once◦ May be done in a predetermined order that
mimics head-to-toe:• Neurological• Cardiovascular• Respiratory• Gastrointestinal
Organizing the Examination
Theoretical knowledge• A and P, techniques
Self-knowledge• Skill and comfort
level• Willingness to seek
help
Knowledge about client situation• Purpose of
examination• Client diagnosis
Preparing Yourself:What the Nurse Needs
Privacy is key• Draping• Use of curtains
Noise control• TV/radio off
Enable visualization• Adequate lighting• Flashlight if needed
Preparing the Environment
Promote client comfort:
Develop rapport Explain the procedure Respect cultural differences Use proper positioning
Preparing the Client
Use of sight to gather data Used throughout physical examination Tools to enhance inspection
• Otoscope• Ophthalmoscope• Penlight
Examples: Skin color, gait, general appearance, behavior
Inspection
Use of touch to gather data Begin with light pressure, moving to deep
palpation Use caution with deep palpation Parts of the hands used:
• Fingertips: Tactile discrimination• Dorsum: Temperature determination• Palm: General area of pulsation• Grasping (fingers and thumb): Mass evaluation
Examples: Edema, moisture, anatomical landmarks, masses
Palpation
Tapping on skin to elicit sound• Direct• Indirect
Useful for assessing abdomen, lungs, underlying structures
Examples: Distended bladder
Percussion
Use of hearing to gather assessment data Direct auscultation:
• Listening without an instrument Indirect auscultation:
• Use of a stethoscope to listen Diaphragm - high-pitched sounds Bell – low-pitched sounds
Examples: Heart sounds, lung sounds
Auscultation
Infants: Parents hold Attend to safety
Toddlers: Allow to explore and/or
sit on parent’s lap Invasive procedure
last Offer choices Use praise
Age Modifications for the Physical Examination
Preschoolers: Use doll for
demonstration Still may want
parental contact Allow child to help
with examination
School-Aged Children: Show approval and
develop rapport Allow independence Teach about workings
of the body
Age Modifications for the Physical Examination
Adolescents: Provide privacy Concerned that they
are “normal” Use examination to
teach healthy lifestyle Screen for suicide risk
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 activities of daily
living Provide periods of rest as needed
Age Modifications for the Physical Examination
Basic Components of a Comprehensive Examination:The General Survey
• Appearance/behavior• Grooming/hygiene• Body type/posture• Mental state
• Speech• Vital signs• Height/weight
Begins at first contact Overall impression of client Deviations lead to focused assessments
Basic Assessments: Skin, HeadIntegumentary: Skin characteristics
• Color• Temperature• Moisture
• Texture• Turgor
Lesions Hair Nails
Head: Skull and Face
• Size • Shape• Facial features
Eyes• External eye• Sclera• Pupils• Visual acuity• Vision examinations
Acuity, distance, near, color, visual fields
• Internal structures
Basic Assessments: Skin, Head
Head: Ears/hearing
• External ear• Inner ear
Tympanic membrane• Hearing
Weber’s test Rinne’s test
• Balance Romberg’s test
Nose• Smell
Mouth• Lips• Buccal mucosa• Teeth• Hard and soft palates
Basic Assessments: Ears, Nose, Mouth
Neck: Musculature Trachea Thyroid gland Cervical lymph
nodes
Breasts: Size Shape Nipple
characteristics Tissue Include axillae
Basic Assessments: Neck, Breasts
Basic Assessments: Lungs
Breath Sounds: Bronchial Bronchovesicular Vesicular
Adventitious Diminished or misplaced Abnormal vocal sounds
Chest and Lungs: Describe size and shape of chest Relate findings to landmarks
Cardiovascular–Heart:
Inspection• PMI• Heaves/Lifts
Palpation• Thrill
Heart soundsLocation:• Aortic, Pulmonic,
Tricuspid, Mitral
Components:• S1, S2, S3, S4
Murmurs
Basic Assessments: Heart, Vessels
Cardiovascular–Vessels:
Central vessels• Carotid arteries
Palpate pulsation * Special precautions Auscultate for bruit
• Jugular veins
Peripheral vessels• Blood pressure• Peripheral pulses• Signs of inadequate
oxygenation• Varicosities
Basic Assessments: Heart, Vessels
Different order for assessment skills• Inspect • Auscultate• Percuss• Palpate
Basic Assessments: Abdomen
Body shape/symmetry: Posture Gait Spinal curvature
Balance: Romberg’s test
Coordination: Finger-thumb opposition Movement
Joint mobility: Color change Deformity Crepitus
Muscle strength: Range of motion Resistance
Basic Assessments: Bones, Muscles, Joints
Staff RN Uses Focused Neuro Assessment:
Cerebral Functioning: Level of consciousness
• Arousal - response to stimuli• Orientation - time, place, person
Mental status/cognitive function• Behavior, appearance, response to stimuli, speech,
memory, communication, judgment
Basic Assessments: Neurological
Reflexes: Automatic responses Responses on a
graded scale• 0 = No response• 4 = Clonus
Example: deep tendon reflexes
Motor/Cerebellar Function:
Movement/coordination Tone Posture Equilibrium Proprioception
Basic Assessments: Neurological
Sensory Function: Light touch Light pain Temperature Vibration Position Sense
Stereognosis Graphesthesia Two-point
discrimination Point localization Extinction
Basic Assessments: Neurological
Male: Includes reproductive information External genitalia: penis, urethral opening,
scrotum, lymph nodes, pubic hair Examine for the presence of a hernia
Female: Female external genitalia: labia, clitoris, urethral
opening, vaginal orifice, pubic hair, lymph nodes
Genitourinary Assessment