K & E Ch 30, Assessment (1).ppt

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Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder
Health Assessment
Learning Outcomes
Explain the four methods used in physical examination: inspection, palpation, percussion, and auscultation
Identify expected outcomes of health assessment.
Learning Outcomes (cont'd)
Assessing appearance and mental status
Assessing the skin
Assessing the hair
Assessing the eye structures and visual acuity
Assessing the ears and hearing
Assessing the nose and sinuses
Assessing the mouth and oropharynx
Assessing the neck
Assessing the heart and central vessels
Assessing the peripheral vascular system
Assessing the breasts and axillae
Assessing the abdomen
Assessing the female genitals and inguinal area
Assessing the male genitals and inguinal area
Assessing the anus
Describe suggested sequencing to conduct a physical health examination in an orderly fashion.
Discuss variations in examination techniques appropriate for clients of different ages.
Recognize when it is appropriate to delegate assessment skills to unlicensed assistive personnel.
Demonstrate appropriate documentation and reporting of health assessment.
Purposes of the Physical Examination
Obtain baseline data
Evaluate physiologic outcomes and progress
Make clinical judgments
Purposes of the Physical Examination (cont'd)
Identify areas for health promotion and disease prevention
Health Assessment of the Adult
Be aware of normal physiologic changes
Be aware of stiffness of muscles and joints from aging changes or history of orthopedic surgery
Expose only areas to be examined
Permit ample time to answer questions and assume desired positions
Be aware of cultural differences
Health Assessment of the Adult (cont'd)
Arrange for an interpreter if needed
Ask clients how wish to be addressed
Adapt techniques to any sensory impairment
Methods Used in Physical Examination
Inspection
Palpation
Percussion
Auscultation
Inspection
Shape, position, size, symmetry of the body
Palpation
Texture
Temperature
Vibration
Distention
Pulsation
Palpation (cont'd)
Deep palpation
Light palpation
Percussion
Direct—striking body directly
Determine size, shape, borders of internal organs
Indirect percussion
Direct percussion
Auscultation
Direct—use of unaided ear
Indirect—use of stethoscope
Pitch, intensity, duration, quality
Suggested Sequencing for
Integument
Skin
Lifespan Considerations: Assessing the Skin
Lifespan Considerations: Assessing the Skin
Integument (cont'd)
Lifespan Considerations: Assessing the Hair
Integument (cont'd)
Lifespan Considerations: Assessing the Nails
Head
Skull and face
Lifespan Considerations Assessing the Skull and Face
Head
Lifespan Considerations Assessing the Eyes and Vision
Head
Lifespan Considerations Assessing the Ears and Hearing
Head
Lifespan Considerations Assessing the Nose and Sinuses
Head
Mouth and oropharynx
Inspection and palpation
Lips, oral mucosa, tongue and floor of the mouth, teeth and gums, hard and soft palate, uvula, salivary glands, tonsillar pillars, and tonsils
Lifespan Considerations Assessing the Mouth and Oropharynx
Neck
Muscles
Lifespan Considerations Assessing the Neck
Thorax and Lungs
Lifespan Considerations Assessing the Thorax and Lungs
Lifespan Considerations Assessing the Thorax and Lungs
Cardiovascular and Peripheral Vascular System
Heart
Lifespan Considerations Assessing the Heart and Central Vessels
Lifespan Considerations Assessing the Peripheral Vascular System
Breasts and Axillae
Lifespan Considerations Assessing the Breasts and Axillae
Lifespan Considerations Assessing the Breasts and Axillae
Abdomen
Skin
Lifespan Considerations Assessing the Abdomen
Lifespan Considerations Assessing the Abdomen
Musculoskeletal
Muscles
Musculoskeletal (cont'd)
Lifespan Considerations Assessing the Musculoskeletal System
Lifespan Considerations Assessing the Musculoskeletal System
Neurological
Neurological (cont'd)
Cranial nerves
Lifespan Considerations Assessing the Neurologic System
Lifespan Considerations Assessing the Neurologic System
Female Genitals and Iguinal Area
Vagina
Urethra
Lifespan Considerations Assessing the Female Genitals and Inguinal Lymph Nodes
Male Genitals and Iguinal Area
Testicles
Lifespan Considerations Assessing the Male Genitals and Inguinal Lymph Nodes
Anus
Lifespan Considerations Assessing the Anus
Delegation
Due to the substantial knowledge and skill required, assessments are not delegated to UAP
Many aspects are observed during usual care
Documentation
Use forms or checklists
Question 1
Which is a normal finding on auscultation of the lungs?
Tympany over the right upper lobe
Resonance over the left upper lobe
Hyperresonance over the left lower lobe
Dullness above the left 10th intercostal space
Question 1 Answer
Which is a normal finding on auscultation of the lungs?
Tympany over the right upper lobe
Resonance over the left upper lobe
Hyperresonance over the left lower lobe
Dullness above the left 10th intercostal space
Question 1 Rationales
Hyperresonance is never a normal finding
Dullness would be heard below (not above) the 10th intercostal space.
Question 2
After auscultating the abdomen, the nurse should report which finding to the primary care provider?
Bruit over the aorta
Question 2 Answer
After auscultating the abdomen, the nurse should report which finding to the primary care provider?
Bruit over the aorta
Correct. A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified.
In order for absence of bowel sounds to be considered abnormal, they must be silent for 3 to 5 minutes.
Continuous bowel sounds are normally heard over the ileocecal valve following meals.
Bowel sounds are more commonly irregular than they are regular.
Question 3
If unable to locate the client’s popliteal pulse during a routine examination, what should the nurse perform next?
Check for a pedal pulse.
Check for a femoral pulse.
Take the client’s blood pressure on that thigh.
Ask another nurse to try to locate the pulse.
Question 3 Answer
If unable to locate the client’s popliteal pulse during a routine examination, what should the nurse perform next?
Check for a pedal pulse.
Check for a femoral pulse.
Take the client’s blood pressure on that thigh.
Ask another nurse to try to locate the pulse.
Correct. If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located.
Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point.
Taking a thigh BP requires locating the popliteal pulse.
Since the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate.
Question 4
Which of the following is an expected finding during assessment of the older adult?
Facial hair becomes finer and softer
Decreased peripheral, color, and night vision
Increased sensitivity to odors
Question 4 Answer
Which of the following is an expected finding during assessment of the older adult?
Facial hair becomes finer and softer
Decreased peripheral, color, and night vision
Increased sensitivity to odors
Correct. Visual acuity often lessens with age.
The sense of smell becomes less, rather than more acute.
The respiratory rate and rhythm is regular at rest. However, both may change quickly with activity and be slow to return to the resting level.
Question 5
If the client reports loss of short-term memory, the nurse would assess this using which one of the following?
Have the client repeat a series of three numbers, increasing to eight if possible.
Have the client describe his or her childhood illnesses.
Ask the client to describe how he or she arrived at this location.
Ask the client to count backwards from 100 subtracting seven each time.
Question 5 Answer
If the client reports loss of short-term memory, the nurse would assess this using which one of the following?
Have the client repeat a series of three numbers, increasing to eight if possible.
Have the client describe his or her childhood illnesses.
Ask the client to describe how he or she arrived at this location.
Ask the client to count backwards from 100 subtracting seven each time.
Recalling childhood events tests remote (long-term) memory.
Correct. Recent memory includes events of the current day.

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K & E Ch 30, Assessment (1).ppt