copyright © 2011 delmar, cengage learning. all rights reserved. chapter 27 physical assessment
TRANSCRIPT
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Purposes of Physical Examination
• Determine client’s level of health and functioning
• Identify risk for problems
• Determine areas of preventive nursing
• Confirm issues to perform ADLs
(continued)
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Purposes of Physical Examination
• Identify needs for testing or examinations
• Evaluate outcomes of treatment
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Preparation for Physical Examination
• Environment
• Equipment
• Positioning and draping
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Environment
• Accommodate special needs
• Place equipment on clean, immovable surface
• Keep room quiet, warm, and well-lit
• Ensure privacy
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Equipment
• Wash hands
• Collect necessary equipment
• Gather assessment forms
• Secure supply of clean gloves
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Positioning and Draping
• Position client to access body part being assessed
• Drape client to prevent unnecessary exposure
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General Survey
• Signs of distress
• Health, stature, and sexual development
• Weight, height, and vital signs
• Posture, motor activity, and gait
• Dress, grooming, and personal hygiene
• Facial expressions and behaviors
• Reactions to people and environment
(continued)
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General Survey
• Quality of speech
• Level of consciousness
• Sexual history
• Older adults
• Disabled clients
• Abused clients– Sexual assault nurse examiner (SANE)
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Assessment Techniques
• Inspection
• Palpation
• Percussion
• Auscultation
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Head and Neck
• Skull and face
• Eyes
• Ears
• Nose and sinuses
• Mouth and pharynx
• Neck
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Thorax and Lungs
• Normal breath sounds– Vesicular
– Bronchovesicular
– Bronchial
(continued)
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Thorax and Lungs
• Adventitious breath sounds– Crackles
– Rhonchi
– Wheezes
– Pleural friction rub
– Stridor
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Heart and Vascular System
• Heart– Aortic area
– Pulmonic area
– Erb’s point
– Tricuspid area
– Mitral area
(continued)
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Heart and Vascular System
• Vascular system– Skin temperature
– Color
– Sensation
– Pulses
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Breasts and Axillae
• Inspection
• Palpation
• ACS Guidelines for Breast Cancer Screening (2003)– Breast self-examination (BSE)
– Clinical breast examination (CBE)
– Mammogram
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Abdomen
• Inspection
• Auscultation of four quadrants
• Percussion
• Light palpation
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Musculoskeletal System
• Inspection
• Palpation
• Range of motion (ROM)
• Muscle testing
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Neurologic System
• Mental status– Physical appearance and behavior
– Communication
– Level of consciousness
• Cognitive abilities and mentation
• Sensation
(continued)
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Neurologic System
• Cranial nerves
• Motor function
• Cerebellar function– Coordination
– Balance and gait
• Reflexes
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Reproductive System
• Female genitalia
• Male genitalia
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Anus and Rectum
• Position
• Gloves
• Lubricant
• Prostate gland palpation
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Post Assessment Care of the Client
• Outpatient setting
• Inpatient setting