CHAPTER 16 Health Assessment and Physical Exam
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| A complete health assessment involves | Nursing history, behavioral assessment, and physical exam
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| Purpose of health exam | To gather information about the patient's health status from the health history
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| What are the five skills involved in a comprehensive physical assessment? | Inspection, palpation, percussion, auscultation and olfaction
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| Inspection | The use of vision to distinguish normal from abnormal findings.
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| Palpation | The use of the hands to touch body parts and make sensitive assessments.
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| Palpate skin for | Temperature, moisture, texture, turgor, tenderness and thickness.
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| Inspect each area for | Size, shape, color, symmetry, position and abnormalities.
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| Percussion | Tapping the body with the fingertips to produce a vibration that travels through body tissues.
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| Auscultation | Listening for sounds produced by the body.
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| Olfaction | Smelling
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| Positions for examination | Sitting, Supine, Dorsal recumbent, Lithotomy, Sims, Prone, Lateral recumbent, Knee-chest
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| Sitting | Provides full expansion of lungs and better visualization of symmetry of upper body part. Used for assessing head, neck and back upper extremities.
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| Supine (back laying) | Most normally relaxed position. It provides easy access to pulse sites.
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| Dorsal recumbent | Position used for abdominal assessment.
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| Dorsal recumbent | Laying on the back with knees bent and feet flat on surface.
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| Crackles | Fine crackling, high-pitched
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| Rhonchi | Loud, low-pitched, rumbling coarse sounds heard either during inspiration or expiration, may be cleared by coughing
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| Wheezes | High-pitched, continuous musical sounds such as a squeak heard continuously during inspiration or expiration, usually louder on expiratation.
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| Pleural friction rub | Dry, grating quality heard during inspiration, does not clear with cough, heard loudest over lower lateral anterior surface.
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| Point of maximal impulse (PMI) | Fifth intercostal space at lef midclavicular. (Apex of heart is found here)
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| Types of assessment | Comprehensive
Focused
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| Methods of data collection | Interview, Observation, Physical assessment
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| Components of the health history | Biographical data
Current health status
Past health history
Family history
Review of systems
Psychosocial profile
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