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Physical Assessmentt

QuestionAnswer
What are the two parts of an assessment? Nursing History and Physical Assessment (physiological, psychological, socio cultural, spiritual and developmental)
Purpose of Assessment identify the clients health care needs determne priorities of care and expected outcomes establish a nursing care plan communicate the clients health status
Nursing History and Physical Assessment..which is subjective and objective? history-subjective physical-objective
Physical Exam use of senses
Equipment for Bedside -non sterile gloves -stethoscope -pen light -bandage scissors -2x2 gauze -tape measure -tongue blade -doppler -conducting gel -alcohol pads -pen and paper -V/S equipment -safety pin or needle
Bell and Diaphragm of Stethoscope Bell= low pitched sounds hear abnormal heart sounds, bruits lay lightly on skin Diaphragm=high pitched sounds breath sounds, normal heart sounds, bowl sounds, press firmly on skin
Inspection visual observation
Palpation determine-position, size, fluid, mass, temp use- palmar surface of fingers and pads. ulnar surface of hand and fingers. dorsal surface of hands
Percussion tones over air is loud over fluid less loud over solid soft
Auscultation listening for sounds produced by body stethoscope over bare skin
Terms to describe sound duration pitch intensity quality(subjective: whistling, gurgling or snapping) location
Rules to Physical Exams Check V/S first systematic approach look at all equip make sure equip is functioning right
Circulation= Inspection and Palpation Inspect= skin color, cap refill, JVD Palpate= skin temp, pulses, quality of pulses, edema
Grading Pulses 0 absent 1+ barely palpable, difficult to feel 2+ normal, detected readily, cant feel with strong pressure 3+ bounding, very easy to find, difficult to obliterate
Grading Edema 1+ barely detectable 2+ indentation <5mm 3+ indent of 5-10mm 4+ indent >10mm
Auscultation sites aortic pulmonic tricuspid mitral
Heart Sounds S1- mit and tri valves close S2 - aortic and pul valves close S3- abnormal s123 ken tucky S4- abnormal S412 tenn es see
Murmurs disruption in flow of blood in, through or out of heart. from valvular regurgitation or stenosis
Aeration inspect-skin color, shape of chest, breathing effort, position of trachea palpate- tender bulges unusal movements, thoracic expansion, crepitus
Lung Fields look at pics in book
Lung Auscultation in front and back and side look at notes
Elimination palpate bladder, urethra, kidney percus, color clarity and odor or urine, BUN and Creatine levels
Elimination and Bowl inspect, auscultate each quad,
Auscultating Abd active-every 5-15 sec hypo and hyper over or below active listen for 5 mins if u think they are absent
Pulsations in Abd Do not palpate! distention- measure at level of umbilicus
Percussion and Palpation oF ABD percus sev. areas in each quad tympany over stomach and intestine dullness over fluid and masses palpate light to deep
Nutrition/Metabolism height/weight I and O tube feedings and diet oral cavity lab values IVF skin tugor
Sensation/Perception Inspect- gait, orientation, attitude, affect/mood and speech skin integrity(incisions, dressings, lesions, decub) IV sites Skin sensation(numb tingle itch) vision hearing
Sensation/Perception Pain assessment and pain med Pain assess.- intensity, location, description, what makes it worse or better Pain med.- when last given, how much, how effective, LOC and V/S
Pupil PERRLA head injurys- open eyes spontaneously or to name or to painful stimuli or follow u around room
Mobility assess mobility, ROM and use of assitive devices hand and leg strength bilat. how they move all 4 extremities(spont. to command, w/o purpose) ADL can do and cant do
Anxiety level, behavior, cog. function, support, family lifestyle, spirituality
Sexuality physical exam on genitals Hx of self exams and STDs intimate relationships children
Created by: jackiejackie211
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