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Questions and Answers
What is being assessed when observing a patient's posture?
What might nonverbal communication of pain include?
What aspect of the patient's appearance is evaluated when looking at hygiene and grooming?
When assessing general appearance and behavior, what might suggest neurological problems?
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What should be observed to assess body build in a patient?
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Why is it important to evaluate joint mobility during a general survey?
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What is the purpose of medication reconciliation in healthcare?
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Which condition is NOT mentioned as part of the Past history associated with Serious or Chronic Illnesses?
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What should be noted for drug allergies specifically?
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What information should be included when documenting Surgical history?
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Why do nurses incorporate review of system questions into physical examinations?
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What is the importance of an accurate family history in healthcare?
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What critical characteristics should a nurse note when summarizing any symptom?
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Why is it important to inquire about aggravating or relieving factors of a symptom?
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What is an example of a relevant past health event to inquire about in a patient's history?
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Why is past health history important in assessing a patient's current health state?
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Why should a nurse avoid recording 'usual childhood illnesses' in a patient's history?
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Why is it important to document accidents or injuries in a patient's past history?
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What does BMI stand for?
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How is BMI calculated?
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What weight status category does a BMI of 19.5 fall under?
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Which of the following is NOT one of the purposes of physical examination mentioned in the text?
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Which framework is mentioned as the most common for a comprehensive assessment?
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What should be used throughout a physical examination if patients present with infected wounds?
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What is the primary purpose of percussion in a physical examination?
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Which type of percussion involves striking a finger held against the body area to be examined?
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What does a dull percussion sound indicate?
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Which condition can be suggested by flatness in percussion?
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What is an example of a direct percussion technique?
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Study Notes
Percussion
- Percussion involves lightly tapping on the body surface to create vibrations that travel through tissues, allowing assessment of underlying tissue density.
- Types of percussion:
- Direct percussion: striking the area to be examined directly with fingertips.
- Indirect percussion: striking a finger held against the body area to be examined.
- Percussion sounds:
- Tympany: drum-like, indicating air-filled tissues (e.g., bowel).
- Resonance: hollow, clear, indicating air-filled areas with partial solidity (e.g., normal lung).
- Hyperresonance: booming, indicating large air-filled areas (e.g., lung with emphysema).
- Dullness: thud-like, indicating solid tissues (e.g., liver, heart, spleen, bladder).
- Flatness: flat and stony, indicating dense tissues (e.g., muscle, bone).
Auscultation
- Auscultation involves listening to body sounds using a stethoscope to assess heart, lung, bowel, and blood pressure.
Body Mass Index (BMI)
- BMI is a measurement of a person's weight relative to their height, indicating total body fat.
- Formula: BMI = weight (kg) / [height (m)]²
- BMI categories:
- Underweight: BMI < 18.5
- Normal weight: BMI = 18.5-24.9
- Overweight: BMI = 25.0-29.9
- Obese: BMI ≥ 30.0
Purposes of Physical Examination
- Obtain baseline data about the client's functional abilities.
- Confirm or refute data obtained in the nursing history.
- Obtain data for nursing diagnoses and plans of care.
- Evaluate physiologic outcomes and client progress.
- Make clinical judgments about the client's health status.
- Identify areas for health promotion and disease prevention.
Head-to-Toe Framework
- The most common framework for a comprehensive assessment.
Preparation for the Examination
- Infection control: use standard precautions and follow agency hand hygiene policies.
General Survey
- Involves observation of the client's general appearance and behavior, measurement of vital signs, height, and weight.
- Components:
- General appearance and behavior (e.g., signs of distress, nonverbal communication of pain).
- Posture and mobility.
- Hygiene and grooming.
Past History
- Includes:
- Serious or chronic illnesses (e.g., asthma, diabetes, heart disease).
- Hospitalizations (e.g., cause, hospital name, treatment, physician).
- Surgical history (e.g., type of surgery, date, surgeon, hospital).
- Immunizations (e.g., vaccination history).
- Allergies (e.g., medication, food, environmental agents).
- Current medications (e.g., medication reconciliation).
Family History
- Highlights diseases and conditions for which the patient may be at increased risk.
Review of Body Systems
- Incorporates review of system questions into the physical examination of each system.
History of Current Illness
- Includes:
- Location, quality, intensity, and duration of symptoms.
- Onset, frequency, and aggravating or relieving factors.
- Effect of any treatment.
- Patient's perception of symptoms and treatment.
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Description
Test your knowledge on documenting the history of a patient's current illness, focusing on key components such as symptoms, onset, duration, and frequency. Practice summarizing critical characteristics like location, quality, and intensity of symptoms.
