Uploaded by Dr-Basma Salameh

Chapter 015-S-Health-Assessment

advertisement
Chapter 15: Health Assessment
and Physical Examination
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 1
Purposes of Physical
Examination





Gather baseline data
Supplement, confirm, or refute data
Confirm and identify nursing diagnoses
Make clinical judgments
Evaluate the outcomes of care
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 2
Cultural Sensitivity



Cultural differences influence a patient’s
behavior
Recognition of cultural diversity helps to
respect the patient
Consider a patient’s

Health beliefs
 Use of alternative therapies
 Nutritional habits
 Family relationships
 Use of personal space
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 3
Inspection

The use of vision and hearing to distinguish
normal from abnormal findings





Use adequate lighting
Position and expose body parts
Inspect for size, shape, color, symmetry, position,
and abnormalities
Side to side comparison
Pay attention to detail
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 4
Palpation



Involves using the hands
Examine accessible body parts
Palpate skin


Temperature, moisture, texture, turgor,
tenderness, and thickness
Palpate abdomen

Tenderness, distention, or masses
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 5
Percussion


Tapping the body with fingertips to produce a
vibration
Character of sound



Determines location, size, and density of
structures
Depends on the density of tissues
Abnormal sounds can be mass, air, or fluid
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 6
Auscultation




Listening to sounds produced by the body
Assess sounds heard in the heart, lungs, and
gastrointestinal systems
Requires the use of a stethoscope
Characteristics include

Frequency
 Loudness
 Quality
 Duration
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 7
Olfaction



To identify nature and source of body odors
Helps to detect abnormalities
Used in conjunction with other measurements
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 8
Preparation for
Assessment
Environment
Equipment
Physical Preparation
Positioning
Psychological Preparation
Assessment of Age-Group
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 9
General Survey



Begins when you first meet a patient
Begins with review of primary health pattern
The survey provides information regarding

Characteristic of illness
 Hygiene
 Skin condition
 Body image
 Emotional state
 Developmental status
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 10
General Appearance
and Behavior
Gender and Race
Age
Signs of Distress
Body Type
Posture
Gait
Body Movements
Hygiene and Grooming
Dress
Body Odor
Affect and Mood
Speech
Patient Abuse
Subculture Abuse
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 11
Skin


Assessment
Nursing history

Color
 Moisture
 Temperature
 Texture
 Turgor
 Vascularity
 Edema
 Lesions
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 12
Hair and Scalp


Use inspection
Assess




Distribution
Thickness
Texture
Lubrication
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 13
Nails


Inspection and palpation
Condition of nails reflects




General health
Nutritional status
Occupations
Level of self-care
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 14
Head and Neck


Inspection and palpation
Assess

Headache, dizziness, seizures, poor vision, loss
of consciousness
 Head size, shape contour of head and skull
 Facial symmetry
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 15
Eyes

Visual acuity


Visual fields


Ability to see small details
Test of peripheral vision
External and internal eye structures
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 16
Nose and Sinuses


Inspection and palpation
Assess for exposure to







Dust
Pollutants
Allergies
Nasal obstruction
Trauma
Discharge, postnasal drip
Headaches
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 17
Mouth and Pharynx





Assesses overall health
Determine oral hygiene needs
Develop therapies for dehydration
Assess oral trauma
Assess for airway trauma
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 18
Neck






Neck muscles
Lymph nodes
Carotid arteries
Jugular veins
Thyroid gland
Trachea
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 19
Thorax and Lungs



Review of ventilatory and respiratory
functions of lungs
Landmarks help to locate structures
Inspection, palpation, and auscultation




Orthopnea
Dyspnea
Adventitious breath sounds
Normal breath sounds
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 20
Heart



Compare assessment of heart function with
findings from vascular assessment
Heart function is correlated with physiological
events
Use inspection, palpation, and auscultation



Pulsations
Palpate apical pulse
Auscultate heart sounds
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 21
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 22
Vascular System

Measure blood pressure

Assess integrity of peripheral vascular system

Use inspection, palpation, and auscultation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 23
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 24
Breasts



Examine both female and male breasts
Take a health history
Use inspection and palpation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 25
Abdomen





Use landmarks to map out the abdominal
regions
Assess both anterior and posterior
Examine the liver, stomach kidneys, bladder,
and GI tract
Conduct a nursing history
Use inspection, auscultation, and palpation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 26
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 27
Female Genitalia





Examination of the genitalia includes external
and internal sex organs
Must provide privacy
Need to understand cultural sensitivity
Conduct a nursing history
Use inspection and palpation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 28
Male Genitalia



Assess the integrity of external genitalia,
inguinal ring, and canal
Conduct a nursing history
Use inspection and palpation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 29
Rectum and Anus





Perform after genital examination
Explain all steps to patient
Provide privacy
Conduct a nursing history
Use inspection and palpation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 30
Musculoskeletal System




Visualize the anatomy of bone, muscle, and
joint placement
Conduct a nursing history
Use inspection and palpation
Assess


Range of joint motion
Muscle strength and tone
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 31
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 32
Neurological System


Conduct a nursing history
Assess





Language
Intellectual function
Cranial nerve function
Sensory nerve function
Motor function
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 33
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 34
Practice Questions





1. When meeting a patient for the first time, it is
important to establish a baseline assessment that will
enable a nurse to refer back to which of the
following?
A. Physiological outcomes of care
B. The normal range of physical findings
C. A pattern of findings identified when the patient is
first assessed
D. Clinical judgments made about a patient’s
changing health status
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 35
Practice Questions (continued)





2. A patient complains of thirst and
headache. The patient appears emaciated.
On initial examination you find that the skin
does not return to normal shape. This finding
is consistent with what condition?
A. Pallor
B. Edema
C. Erythema
D. Poor skin turgor
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 36
Practice Questions (continued)





3. A patient is admitted with pneumonia.
When auscultating the patient’s chest, you
hear low-pitched, continuous sounds over the
bronchi. These sounds are identified as
which of the following?
A. Crackles
B. Rhonchi
C. Wheezes
D. Pleural Rub
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 37
Practice Questions (continued)





4. When conducting an abdominal
assessment, what is the first skill a nurse puts
to use?
A. Auscultation
B. Inspection
C. Palpation
D. Percussion
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published.
Slide 38
Download