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physical Assessment
Prep for physical Assessmetn
| Question | Answer |
|---|---|
| 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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