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physical Assessment

Prep for physical Assessmetn

QuestionAnswer
The health assessemnt of an individual includes 2 areas: 1. Health History: Subjective data 2. Physical assessment: Objective data
Subjective Data from the individual; it is what the individual tells the nurse. this comprises about 80% data of the health assessmetn
Objective Data is the objective measurement of the health assessment. It is the data obtained by the nurse or observer through direct physical examination. It comprises about 20% data of he health assessment.
Preparation for the Physical Assessment - explanation provided to individual concerning what is about to be done - work in an organized and systematic fashion - provide for privacy - Temperature of the room should be warm enough to prevent chilling during examination - Lighting
Prep for the PA--> order of physical assessment (every system execept abdomin) 1. inspection 2. palpation 3. percussion 4. auscultation
Prep for the PA--> order of the physical assessment of the abdomen 1. Inspection 2. auscultation 3. palpation 4.percussion
Prep for the PA-->Techniques of Physical examination: INSPECTION it is the observable portion of the examinaiton and is the most revealing technique and the most underuses. It is through inspection that you will learn 90% of the information a Physical examination will yield.
Inspeciton: Patient viewed as "whole" notations should be made regarding... 1. posture 2. gait 3. stance 4. amomalities 5. motor activity 6. affect ( outward manifestions of a person's feelings or emotions 7. mood
Inspection: When concentrating on a specific area or lesion info. such as _________ can provide the nurse w/valuable information 1. color 2. edema 3. discharge 4. texture of surface
Inspection: as you proceed through inspection, it is important to be alert to signs of _________. comparing right from left Asummetry ( a difference in size b/t the sam structure or opposite sides of the body)
Sequence of Inspection Techniques: 1. General to specific 2. Cephalocaudal 3. Outside to Inside 4. Medial to lateral 5. Anterior to posterior 6. distal to proximal
Sequence of Inspection Techniques: Generl to Specific 1st! observe patient as a whole. then focus on systems, organs, and local sites of problems or complaints
Sequence of Inspection Techniques: Cephalocaudal Start from the head then proceed to the bottom of the feet
Sequence of Inspection Techniques: Outside to inside *Use this when assessing an orifice (the entrance or outlet of any cavity) *Ex: mouth- inspect lips, teeth, gums, buccal mucosa, palate, and pharynx
Sequence of Inspection Techniques: Medial to lateral *use this when inspection an organ, system, or general area *Ex: Neck-start inspection with the trachea,jugular vein, carotid artery, sternocleidomastoid muscle, and the lympatics
Sequence of Inspection Techniques: Anterior to posterior Start from the front and proceed to the back
Sequence of Inspection Techniques: Distal to proximal *Applies to the Extremities (reflects the direction of blood flow back to the heart) *Ex: Arm- start inspection with the fingers, then up the arm through hand, wrist, lower arm, elbow, upper arm, and then shoulder
True or False; you just finished your visual assessemnt(inspection), Before you begin palpations do you wash your hands? True; always wash hands and either run warm water over them or rub them together before placing them on the patient. (always= have nails clipped to prevent scratching)
Prep for the PA-->Techniques of physical examination: PALPATION to feel; used to elicit Tenderness, identify masses, detect temp. changes, and Assess vibrations
Types of Palpations: 1. Superficial or light 2. Deep
Types of Palpations: Superficial detects palable fingings on the skin surface or the area immediately below *use finger tips
Types of Palpations: Deep used to confirm superficial findings, feel organs, and elicit deep pain
Palpation: Watch patients facial expressions as you palpate b/c it will reveal pain and tenderness even if the patient is able to control muscle tensing
Palpation: Refrain from a.____ palpation until you have finished b.______ palpation; this may cause the patient to set up guarding reflexes that will hide c.________ masses and tenderness a. deep b. superficial c. superficial
4 Basic postions of Palpation: #1 1. place one hand on top of the other to begin deep or superficial. The hand on bottom will do the feeling
4 Basic postions of Palpation: #2 2. To sense temp changes--- use the dorsum of the hand on reddened, swollen, or edematous areas
4 Basic postions of Palpation: #3 Vibrations---best assessed using the metacapohalangeal joints (base of fingers) or the ulnar surface of the hand
4 Basic postions of Palpation: #4 Fingertips--- for fine tactile dicrimination
Prep for the PA--> Techniques of physical examination: PERCUSSION used to detect/elicit air, fluid, or boarders or solid mass in an underlying area
Basic Methods of Percussion: Steps using the indirect method (step #1) 1. Place your distal phalanx of the middle finger firmly against the individuals skin
Basic Methods of Percussion: Steps using the indirect method (step #2) 2. Strike only the area of the distal interphalangeal joint, using the tip of the idex or middle finger of the plexor hand
Basic Methods of Percussion: Steps using the indirect method (step #3) 3. Provide short, rapid blows using a relaxed wrist motion of the plexor hand
Basic Methods of Percussion: Steps using the indirect method (step #4) 4. Keep a 90 degree angle b/t the plexor & the pleximeter. Avoid striking with the finger pad of the plexor
"Characteristics of Percussion Notes" areas on the body where you can elicit different sounds
Characteristics of Percussion Notes: Resonant Heard over normal lung tissue that is produced by air
Characteristics of Percussion Notes: Hyperresonance Normal over a child's lung; Abnormal in the adult; Heard over areas of the lungs where air amt. are abnormally increased
An example of a patient you could elicit Hyperresonance COPD or Emphsema
Characteristics of Percussion Notes: Dull Heard over dense organs *Ex: spleen or Liver
Characteristics of Percussion Notes: Flat Heard when no air is present *Ex: Bone, muscle or tumor
An example of an area where you would elicit and hear Dull sounds spleen or liver
An example of an area where you would elicit and hear flat sounds bone, muscle, or tumor
An example of an area where you would elicit and hear resonant sounds air filled areas-Lungs
Characteristics of Percussion Notes: Tympany heard over fluid/air filled areas *Ex: stomach or intestines
An example of an area where you would elicit and hear Tympany sounds stomach or intestines
Prep for the PA--> Techniques of physical Examination: AUSCULTATION to hear; this is usually the final step in the 4 part examination. (except for the abdominal)
Ausculatation: Holding the diaphragm *flat end; hold tightly against patient's skin.Make sure to always warm stethoscope head before placing on your patient's skin
Ausculatation: Parts of the Stethoscope (diaphragm) used to assess high-pitched sounds
Ausculatation: Holding the Bell place it down lightly to avoid stretching the skin beneath, it can taut, ocluding subcutaneous sounds
Ausculatation: Parts of the Stethoscope (bell) used to assess low-pitched sounds
Examples of sounds heard by the "Bell" extra heart sounds (s3 or s4) or murmors *Low pitch sounds
Examples of sounds heard by the "Diaphragm" Breath, bowel,and normal heart sounds *High pitch sounds
Created by: ectolle
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