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Week 4 Breakdown Chapter 19 physical examinationconsists of the techniquesused in a health or nursing A assessment to gather objective data about the body. Purposes of a Physical Examination To obtain baseline data. Data about the patient’...
Week 4 Breakdown Chapter 19 physical examinationconsists of the techniquesused in a health or nursing A assessment to gather objective data about the body. Purposes of a Physical Examination To obtain baseline data. Data about the patient’s physical status and functional abilities to serve as a comparison as the patient’s health status changes. To identify nursing diagnoses, collaborative problems, and wellness diagnoses. Problem statements form the basis for the plan of care and help you to address the patient’s nursing care needs. To monitor the status of a previously identified problem. To screen for health problems. Regular checkups can help to identify health problems at early stages. Types of physical examinations Comprehensive ♣ Interview plus complete head-to-toe examination ♣Focused “Focused” on presenting problem ♣System-specific Limited to one body system ♣Ongoing Performed as needed to assess status Evaluates client outcomes head-to-toe approachstarts at the head and neckand progresses down the body, A examining the feet last. body systems approachexamines each system in apredetermined order (e.g., A musculoskeletal, cardiovascular, neurological). EY POINT: Physical examination requires you to observe and touch the client’s K body, so privacy is essential. Noise.Because you need to hear the patient and listento a variety of sounds during the examination, turn off the television, radio, or other media. Lighting.You need good lighting to observe subtlechanges in skin and body contours. Temperature.Adjust the temperature of the room accordingto patient comfort. Equipment.Determine the instruments and equipmentyou will need. I n most clinical settings, you must examine a client often to evaluate a changing status, and timing will be decided by the client’s condition rather than by convenience. However, when possible, select a time when the client is comfortable and receptive to the examination. Avoid conducting the examination when the client is in pain or is hungry, tired, anxious, or unwilling to cooperate in the assessment. ake the time to establish rapport with the client; this will help the client relax and T cooperate fully in the assessment. EY POINT: Consider developmental and cultural differences.For example, some K clients may wish to have a family member present during an examination; some may require a same-sex clinician. If you and the client do not speak the same language, arrange to have an interpreter present. Four major skills used ♣ Inspection Palpation Percussion Auscultation I nspectionis the use of sight to gather data. Youbegin to use inspection the moment you meet the client and continue as you observe the person’s gait, personal hygiene, affect, and behavior during the general survey, and as you evaluate each body system. alpationis the use of touch to gather data. Usepalpation to assess temperature, skin P texture, moisture, anatomical landmarks, and such abnormalities as edema, masses, or areas of tenderness. As you move through the assessment of each body system, always inform the client that you are about to touch them. ercussionis tapping your fingers on the skin usingshort strokes. Tapping (percussing) P produces vibrations, and the resulting sound allows you to determine the location, size, and density of underlying structures. Percussion is especially useful when assessing the abdomen and lungs. Auscultationis the use of hearing to gather data.(Sethoscope) lfaction* is the use of the sense of smell to gatherdata. Some clinicians may not O consider this a formal assessment skill; however, you will certainly use this skill in the clinical setting. dults Most young and middle adults are able to cooperate during a physical A examination and do not require a modified approach. Modifications may be required if the client has acute or chronic illness or cannot understand or follow instructions. llow extra time to interview and examine older adults. They are adjusting to changes in A physical abilities and health. As part of a comprehensive examination: Assess the client’s support system and ability to perform activities of daily living (ADLs). Observe your client’s energy level during the physical examination and provide rest periods if needed. imit position changes, Work within patient’s physical abilities, Adapt your techniques L when examining older adults with impaired vision or hearing. he general survey is your overall impression of the client. It begins at first contact T and continues throughout the examination. EY POINT: Incorporate patient-centered care and culturalcompetence so that your K care meets the needs of every patient. Deviations lead to focused assessments ♣ Appearance/behavior Body type/posture Speech Mental state Dressing/grooming/hygiene Vital signs Height/weight imilar to skin color, the temperature, texture, and turgor of the skin offer clues to the S client’s health status. Although it is not technically a skin characteristic, you should also check for edema while you are assessing the skin. Skin characteristics ‒ Temperature ‒ Moisture ‒ Texture ‒ Turgor EY POINT: Evaluate all skin lesions for the possibility of malignancy, especially those K located in a site exposed to chronic rubbing or other trauma. hen assessing the hair, inspect and palpate for color, texture, distribution, and W condition of the scalp. The hair should be clean and free of debris. A client who does not properly groom the hair may need help with other self-care tasks. Variations in color, shape, or texture of the nails may indicate health problems. Nail ColorPink nails with rapid capillary refillindicate circulation to the extremities. Half-and-half nails, in which a distal band of reddish-pink covers 20% to 60% of the nail. These occur in clients with low albumin levels or renal disease. Mees’ lines, which are transverse white lines in the nailbed. They are seen in clients who have experienced severe illnesses or nutritional deficiencies. Splinter hemorrhages, which are small hemorrhages under the nailbed, are associated with bacterial endocarditis or trauma. ail ShapeA change in nail shape may indicate underlyingdisease. Clubbing, in which N the nail plate angle is 180° or more, is associated with long-term hypoxic states, such as occurs with chronic lung disease. ail TextureNails and surrounding epidermis are normallysmooth. Chronic N nail-picking results in callus formation around the nail. Occasionally, the surrounding skin becomes inflamed. This condition, known as paronychia, is painful and may require drainage if infection is present. Head ♣ Skull and face ‒ Size ‒ Shape Eyes ‒ Visual acuity ‒ Vision examinations ♣Acuity, distance, near, color, visual fields ‒ External eye ♣Sclera ♣Pupils ‒ Internal structures Hearing ‒ Weber’s test ‒ Rinne’s test Balance ‒ Romberg’s test Ears/hearing ♣ External ear Middle ear Inner ear ‒ Tympanic membrane Mouth and oropharynx ♣ Lips Buccal mucosa Gingiva Teeth Tongue and oropharynx Chest and lungs ♣ Describe size and shape of chest. Relate findings to landmarks. ♣Breath sounds Bronchial Bronchovesicular Vesicular Adventitious Diminished or misplaced Abnormal vocal sounds he chest, or thorax, is the bony cage that protects the heart, lungs, and great vessels. T The ribs, sternum, and vertebrae form the chest. KEYPOINT: Be systematic in your assessment: always assess the areas of the chest and lungs in the same order. Cardiovascular: Heart ♣ Inspection ‒ Point of maximal impulse (PMI) ‒ Heaves/lifts Palpation ‒ Thrill Heart sounds ‒ Location ♣Aortic, pulmonic, tricuspid, mitral ‒ Components ♣S1, S2, S3, S4 ‒ Murmurs Different inspection for the abdomen Different order for assessment skills ♣ Inspect Auscultate Percuss Palpate KEY POINT: When examining the abdomen, inspect andauscultate first, before percussing and palpating. Percussion and palpation stimulate the bowel and may alter bowel sounds; therefore, the examination sequence differs from other body systems. Neurological assessments THE NEUROLOGICAL SYSTEM he neurological system controls or affects the function of all body systems and allows T interaction with the external world. Its work is carried out through the transmission of chemical and electrical signals between the brain and the rest of the body. The basic f unctions of the nervous system are cognition, emotion, memory, sensation and perception, and regulation of homeostasis. lder Adults With advanced age, the number of functioning neurons decreases. Changes O commonly observed are slower reaction time, a decreased ability for rapid problem-solving, and slower voluntary movement. However, intelligence, memory, and discrimination do not change with normal aging. eurological deficits in older adults are usually the result of adverse effects of N medications, nutritional deficits, dehydration, cardiovascular changes that alter cerebral blood flow, diabetes, degenerative neurological conditions (e.g., Parkinson or Alzheimer disease), alcohol or drug use, depression, or abuse. Level of consciousness ‒ Arousal: Response to stimuli ‒ Orientation: Time, place, person Mental status/cognitive function ‒ Behavior, appearance, response to stimuli, speech, memory, communication, judgment Cranial nerve assessment lasgow Coma Scale (GCS)Document the LOC by describingthe client’s response or G using the GCS to grade eye opening, motor responses, and verbal responses. Its limitations are that it relies heavily on vision and verbal interaction and does not evaluate brainstem reflexes. lert—Follows commands in a timely fashion. A Lethargic—Appears drowsy; easily drifts off to sleep. Stuporous—Requires vigorous stimulation before responding. Comatose—Does not respond to verbal or painful stimuli o assesssensory function, ask the client to keeptheir eyes closed as you apply various T stimuli. Ask the client to indicate when they feel a sensation. Vary your location and approach so that you test sensation, not pattern recognition. he neurological system coordinates the function of the skeleton and muscles.Motor T pathways transmit information between the brain and muscles, and the muscles control movement of the skeleton. The cerebellum helps coordinate muscle movement, regulate muscle tone, and maintain posture and equilibrium. The cerebellum is also largely responsible for proprioception, or body positioning. The Male Genitourinary System complete examination includes assessment of the external genitalia, evaluation for A hernias, and a rectal examination for prostate screening. The penis and scrotum are examined by inspection and palpation. You will assess some of the urinary system organs when examining the back (kidneys, ureters) and the abdomen (bladder). The Female Genitourinary System Female external genitalia: Labia, clitoris, urethral opening, vaginal orifice, pubic hair, lymph nodes Other ♣ Kidneys (CVA tenderness) Bladder (palpation of the abdomen) Nurse practitioner (NP)/medical doctor (MD) responsible for anus, rectum, prostate examination NP/MD responsible for pelvic examination
