NUR142#5

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lwendt
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37252
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NUR142#5
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2010-09-25 16:50:08
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Nurse
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Questions from lecture#5
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  1. Ojectives of lecture
    • Differentiate between subjective and objective data.
  2. • Describe the techniques of inspection, palpation, percussion, and auscultation used in the physical assessment.
  3. • Identify methods used to obtain objective data during the physical exam.
  4. Purpose of the physical exam:
    • Provides indication of the person’s overall health status
  5. • Can provide additional information about the clinical significance of reported symptoms
  6. • Can provide indication of how person is responding to treatment already given
  7. Two types of data assessement:
    • Two Types of Data -Go Hand in Hand!
    • Subjective-something you cannot see or cannot measure, may be factual may not be

    • Objective-what you find during a physical testing, diagnostic testing, lab studies and observations
    • Difficult to have one without the other.
  8. Nursing assessment:
    • • Differs in focus from medical assessment; things in common but different jargon perhaps
    • • Holistic approach with client and family; more global
    • – physical
    • – psychosocial-can she afford the medication, can she get it and does she understand how to take it.
    • – Spiritual-does diagnose need clergy?
  9. What is a comprehensive assessment?
    • A comprehensive assessment is performed with a health history and complete physical examination.
  10. • This type of examination is done on admission to a hospital or when first meeting a client at home or in an office or clinic setting if appropriate.
  11. • This exam provides baseline data that we can use for comparison in later exams.
  12. What is an ongoing partial assessment?
    • This is conducted at regular intervals such as the beginning of each shift or at each home visit, and may be repeated as needed; pupil check, heart, respiration,
  13. • This is the type of exam you will perform each week
  14. • This assessment focuses on identified health problems as well as a general screening parameters to measure any positive or negative changes, and to evaluate the effectiveness of interventions
  15. What is a focused assessment?
    • A focused assessment is conducted to address one specific problem. Ex: lungs after nebulizer; wound check, one specific area sometimes two
  16. • This may stand alone or be a part of an ongoing assessment or a more comprehensive assessment.
  17. What is a rapid assessement?
    • A rapid assessment used to detect life threatening situations
  18. • Airway, breathing, circulation come first “ABC”
  19. • First survey is followed by a more complete assessment
  20. A few things to do in preparing for a physical assessment:
    • • Preparing the environment-privacy, warm, clean, make patient comfortable, good lighting
    • • Gathering equipment-Do it before you come in the room.
    • • Preparing the client-identify patient, introduce yourself, explain what you are going to do, sheet
    • • Maintaining cultural sensitivity-ask patient what they prefer, male nurse may make patient uncomfortable,
  21. Equipment to gather for a physical assessment:
    • • Stethoscope
    • • BP cuff
    • • Thermometer
    • • Scale
    • • Measuring Tape
    • • Reflex hammer-rare; more for neuro unit, used to assess magnesium
    • • Otoscope-pediatrics
    • • Snellen Chart-eye chart
    • • Vaginal spectulum
    • • Gloves
    • • Mask
    • • Gown
    • • Goggles
    • • Lubricant
  22. Positioning during a physical assessment:
    • • Supine
    • • Semi-fowlers

    • • Supine
    • • Dorsal recumbant
    • • Side lying
    • • Lithotomy-vaginal exam
    • • Knee chest
    • • Sims
  23. Types of techniques for physical assessment: Inspection
    • • The process of deliberate, purposeful observations performed in a systematic manner.
    • • One area at a time.
    • • Compare one side to the other-very important
    • Includes these senses; hear, smell, sight, touch
  24. Technique: Palpation
    • Uses sense of touch to gather information that cannot be obtained through inspection alone. As with touch with a fever, “Does this hurt?”
    • – Light
    • – Deep
    • Fingertips-very sensitive; moisture, texture, feel masses, pulsations, edema, crepitus (air under skin) can determine organ size,
    • Palm-vibrations,
    • Back of hand is most sensitive to temp. Use for fever

    • Palmar Surface of Hand
    • Dorsal Surface of Hand
    • Light Palpation-do not depress more than half an inch, press lightly
    • While checking abdomen, watch face for pain.
    • No deep palpation
  25. Techniques: Percussion
    • Act of tapping a person’s skin in order to set up a vibration that can be interpreted by you the health professional.

    • • The sound wave produced is called a percussion tone-ex:sinuses. You are looking for fluid or consolidation.
    • • Characteristics of these sounds can be described
    • • Indirect Percussion
    • • pleximeter (non-dominant hand middle finger)
    • • plexor (dominant hand middle finger)
    • We have better technology now so this is not used much
  26. Percussion tones:
    • Flatness Soft Thigh

    • Dullness Medium Liver

    • Resonance Loud Normal Lung

    • Hyperresonance Very Loud Emphysema

    • • Tympany Loud Air in Abdomen
    • (drum like)
  27. Auscultation of heart, lung, and BS sounds:
  28. Use of stethoscope to listen to body sounds.
    • Listen for:
    • • Pitch-high to low, not where it should be
    • • Loudness-volume
    • • Quality-characteristic of a sound. Wheezing, gurgling, swishing,
    • • Duration-end of expiration for example
    • Refer to webers
  29. First part of exam: general survey
    • • First Component of any exam
    • • Most important of all parts of exam
    • • Can get most information from initial meeting
    • • Uses inspection technique including sight, smell, and, hearing
    • • Includes observation of appearance and behavior, taking vital signs, and measuring height and weight
  30. Exam: general appearance
    • • Level of Consciousness
    • – awake and alert, or lethargic, or stuporous, or comatose

    • • Orientation
    • – time,place,person

    • Vital Signs, Height, Weight
  31. Other things to see when performing a physical exam:
    • Body build, posture, gait

    • Hygiene, grooming

    • Signs of Illness-color, coughing, sclera color, sometimes it is not obvious, color of skin, rashes,

    • Affect, attitude, mood

    • Cognitive process
  32. Assessing skin, nails, and teeth:
    • • Inspect
    • – overall condition, color, vascularity, lesions, be descriptive, where is it, what does it look like.
    • – body odors
    • • Palpate-wear gloves
    • – temperature, moisture, turgor, texture
    • – nails-capillary refill, abnormalities
    • –Capillary refill-check in feet and fingers, side to side pulses and capillary refill. You can read the back of the finger or toe if there is fungus or whatever on the nail
  33. Abnormalities in skin:
    • Abnormalities in Skin Color
    • • Erythema redness,flushed
    • • Cyanosis gray or blue
    • • Jaundice yellow: light to dark
    • • Pallor pale, ashen (people of color)
    • Get a Pulse Ox
    • Look at mucus membranes of colored people, they will turn a dull color
  34. Abnormalities in skin turgor:
    • • Turgor-fullness or elasticity of skin; delayed turgor doesn’t necessarily mean anything “tenting” “elastic”
    • • Normal finding-skin returns to normal shape immediately after pinching
    • • In elderly client-decreased turgor MAY be normal finding
    • • Dehydration-turgor delayed
    • • Edema-difficulty in lifting skin fold
  35. Age variations in performing a physical assessment:
    • Age Variations
    • • Infant /child
    • – Jaundice (yellowing of skin, eyes and darkening of urine) milia
    • – milia (whiteheads)
    • – Fine downy hair (lanugo) 1st two weeks
    • – Pubic hair development at the onset of puberty
    • • Older Adult (no need to memorize)
    • – Wrinkles, dryness, scaling, decreased turgor
    • – Raised dark areas (senile keratosis)
    • – Small flat age spots (senile lentigines)
    • – Small round red spots (cherry angioma)
    • – Fine brittle gray or white hair
    • – Hair loss
    • – Coarse facial hair women
    • – Decreased body hair
    • – Thick, yellow toenails
  36. Nail angles:
    Clubbing-chronic poor oxygenation, heart and lung disease patient, down syndrome (heart anamolies)
  37. Things to check on head and neck:
    • • Inspect
    • • Palpate
    • • Percussion
    • • Auscultate
  38. Things to check for eyes:
    • • Inspect external eye
    • • Inspect internal eye- go from outside and in
    • – use of light source to check for
    • • reaction to light
    • • consensual reflex- should constrict together,
    • • accommodation-ability to focus near and far
    • • convergence
    • • extraocular movements=EOM
    • • peripheral vision
    • •convergence- object getting closer
    • One way to test the cranial nerves.
    • PERLA- pupils equal reactive light accomadation
    • • Inspect internal eye-advanced assessment- use opthalmoscope
    • Snellen Eye Chart
    • Muscles of Eye Controlling Movement
  39. Things to check on ears:
    • • Inspect external ear
    • • Inspect internal structures with otoscope (advanced assessment).
    • • Assess for hearing loss (conductive, sensorineural, or combination)
    • •symmetry
  40. Testing for hearing acuity:
    • • Whisper Test
    • • Weber’s Test-
    • • Rinne’s Test
    • • Both tests with tuning fork for hearing acuity- compare air conduction of sound to bone conduction
    • • Normal finding is that air conduction is better than bone conduction
  41. Nose and mouth inspection:
    • • This is the beginning of the respiratory and the GI systems
    • • Inspect nares
    • • Percuss the sinuses
    • • Inspect with tongue blade and flashlight (gloves, of course!).
    • • Palpate if needed
    • • Patency
    • •Good way to access oral health.

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