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RNSG 1413

CHAPTER 16 Health Assessment and Physical Exam

A complete health assessment involves Nursing history, behavioral assessment, and physical exam
Purpose of health exam To gather information about the patient's health status from the health history
What are the five skills involved in a comprehensive physical assessment? Inspection, palpation, percussion, auscultation and olfaction
Inspection The use of vision to distinguish normal from abnormal findings.
Palpation The use of the hands to touch body parts and make sensitive assessments.
Palpate skin for Temperature, moisture, texture, turgor, tenderness and thickness.
Inspect each area for Size, shape, color, symmetry, position and abnormalities.
Percussion Tapping the body with the fingertips to produce a vibration that travels through body tissues.
Auscultation Listening for sounds produced by the body.
Olfaction Smelling
Positions for examination Sitting, Supine, Dorsal recumbent, Lithotomy, Sims, Prone, Lateral recumbent, Knee-chest
Sitting Provides full expansion of lungs and better visualization of symmetry of upper body part. Used for assessing head, neck and back upper extremities.
Supine (back laying) Most normally relaxed position. It provides easy access to pulse sites.
Dorsal recumbent Position used for abdominal assessment.
Dorsal recumbent Laying on the back with knees bent and feet flat on surface.
Crackles Fine crackling, high-pitched
Rhonchi Loud, low-pitched, rumbling coarse sounds heard either during inspiration or expiration, may be cleared by coughing
Wheezes High-pitched, continuous musical sounds such as a squeak heard continuously during inspiration or expiration, usually louder on expiratation.
Pleural friction rub Dry, grating quality heard during inspiration, does not clear with cough, heard loudest over lower lateral anterior surface.
Point of maximal impulse (PMI) Fifth intercostal space at lef midclavicular. (Apex of heart is found here)
Types of assessment Comprehensive Focused
Methods of data collection Interview, Observation, Physical assessment
Components of the health history Biographical data Current health status Past health history Family history Review of systems Psychosocial profile
Created by: pdimple