health assessment ppt 2.pptx

7/25/2019 health assessment ppt 2.pptx

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GENERAL SURVEY


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STEPS IN PERFORMING GENERAL

SURVEY

1. Consider the folloin!"

#. #de$%#te li!htin!

&. 'o(fort#&le roo( te()er#t%re

*. Introd%'e self #nd +erif, 'lient-s

identit,. E)l#in the )ro'ed%re/)%r)ose/ #nd ho the 'lient '#n'oo)er#te


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0. Pro+ide )ri+#', #nd #s if the,)refer to h#+e # f#(il, (e(&er ith

the( d%rin! the )ro'ed%re.

2. Perfor( 3#nd 3,!iene


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4. O&ser+e )#tient for &%ilt/ hei!ht/#nd ei!ht in rel#tion to the 'lient-s

#!e/ lifest,le/ #nd he#lth


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5. O&ser+e the )#tient-s )ost%re #nd!#it/ st#ndin!/ sittin!/ #nd #lin!.


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6. O&ser+e the 'lient-s o+er#ll!roo(in! #nd h,!iene.

7. Note &od, #nd &re#th odor


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8. O&ser+e for si!ns of distress in)ost%re or f#'i#l e)ressions

19. Note O&+io%s si!ns of he#lth orillness


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11. Assess Client-s Attit%de

1*. Note Client-s res)onses

10. Listen to $%#ntit,/ $%#lit,/ #ndor!#ni:#tion of s)ee'h

12. Listen to rele+#n'e #ndor!#ni:#tion of tho%!hts

14. ;o'%(ent Findin!s


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ASSESSMENT OF T3E

3EA; AN; NEC


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STEPS IN PERFORMING GENERAL

SURVEY

1. Consider the folloin!"



*. Introd%'e self #nd +erif, 'lient-s

identit,. E)l#in the )ro'ed%re/)%r)ose/ #nd ho the 'lient '#n'oo)er#te


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0. Pro+ide )ri+#', #nd #s if the,)refer to h#+e # f#(il, (e(&er ith

the( d%rin! the )ro'ed%re.

2. Perfor( 3#nd 3,!iene


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4. Ins)e't the s%ll for si:e/ sh#)e/ #nds,((etr,


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3,dro'e)h#l%s


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;i=erent sh#)es for he#d


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5. O&ser+e 3#ir/ in'l%din! $%#ntit,/distri&%tion #nd tet%re


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7. Ins)e't the f#'e in'l%din!s,((etr,/ f#'i#l e)ression/ f#'i#l

e)ression/ #nd fe#t%res.


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8. O&ser+e sin in'l%din! 'olor/tet%re/ h#ir distri&%tion/ #nd lesions

19. P#l)#te the he#d for nod%les or(#sses #nd de)ressions


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11. Ins)e't the ne' )osition/s,((etr,/ l%()s or (#sses


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1*. Ins)e't (o+e(ent of the ne'str%'t%res/ th,roid '#rtil#!e/ th,roid

!l#nd


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Th,roid #ssess(ent


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10. Ins)e't R#n!e of Motion


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12. Assess M%s'le stren!th


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14. P#l)#te entire ne' for enl#r!edl,()h nodes


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.


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Enl#r!ed L,()h Nodes


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15. O&ser+e the th,roid Gl#nd

16. P#l)#te the th,roid !l#nd for

enl#r!e(ent/ (#sses/ or nod%les. Ifenl#r!ed/ #%s'%lt#te o+er the th,roid#re# for &r%it.

17. ;o'%(ent


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ASSESSMENT OF T3E

3AIR/ S


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1. Asse(&le the e$%i)(ent

*. Consider the folloin!"



0. Introd%'e self #nd +erif, 'lient-s identit,.E)l#in the )ro'ed%re/ )%r)ose/ #nd hothe 'lient '#n 'oo)er#te

2. Pro+ide Pri+#', #nd #s if the, )refer toh#+e # f#(il, (e(&er ith the( d%rin!the )ro'ed%re


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5. 3#+e the 'lient re(o+e #ll 'lothin!#nd )%t on e#(in#tion !on or dr#)e

6.As the'lient to sit

in #n

%)ri!ht )osition ith #r(srel#ed #t

the sides.


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7. Ins)e't sin for 'olor

8. Ins)e't #nd )#l)#te #n, sin lesions

#nd 'h#r#'teri:e


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.


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19. O&ser+e #nd #ssess the folloin!"sin te()er#t%re/ (oist%re/ #nd

tet%re.11. Press sin o+er ti&i# #nd #nle


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1*. Assess sin for (o&ilit, #nd t%r!or


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.


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10. Ins)e't h#ir for 'olor/ #(o%nt/ #nddistri&%tion


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12. Assess for )resen'e of P#r#sites

14. Ins)e't for )resen'e of s'#l)lesions


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.


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.


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15. Ins)e't tet%re/ 'olor/ #nd sh#)e ofn#ils

h di i f h il & d


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16. Ins)e't the 'ondition of the n#il &eds

17. ;o'%(ent Findin!s


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ASSESSMENT OF T3EEYES/ EARS/ NOSE/ AN;

T3ROAT


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1. Asse(&le E$%i)(ent

*. Consider the folloin!"



0. Introd%'e self #nd +erif, 'lient-s identit,.E)l#in the )ro'ed%re/ )%r)ose/ #nd hothe 'lient '#n 'oo)er#te

2. Pro+ide Pri+#', #nd #s if the, )refer toh#+e # f#(il, (e(&er ith the( d%rin!the )ro'ed%re

f d i d l


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4. Perfor( 3#nd 3,!iene don !lo+es#nd o&ser+e other #))ro)ri#te

infe'tion 'ontrol )ro'ed%res

5 h li i i i h


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5. Let the 'lient sit in #n %)ri!ht)osition

6. Ins)e't the %))er #nd the loere,elids

7 I l d > i d


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7. Ins)e't s'ler# #nd 'on>%n'ti+# #ndnote for e%d#tes/ lesions/ #nd forei!n

&odies


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.

8 I t il i h d


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8. Ins)e't )%)il si:e/ sh#)e/ #ndre#'tion

19 I t th d th t i


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19. Ins)e't the 'orne# #nd the #nterior'h#(&er ith the %se of the )enli!ht


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.

11 A l l t


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11. Assess o'%l#r (%s'le (o+e(ents&, #sin! the 'lient to follo #n o&>e't

ith his e,es thro%!h the 5 ?elds of!#:e

1* I t th l i l t f


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1*. Ins)e't the l#'ri(#l #))#r#t%s for#n, sellin! #nd dis'h#r!e

10 I t th ti l t t &


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10. Ins)e't the retin#l str%'t%res &,the %se of #n o)th#l(os'o)e

12. Che' for +is%#l #'%it,#. Position the 'lient in sittin! or

st#ndin! )osition *9 feet fro( the

snellen-s 'h#rt&. instr%'t to re(o+e !l#sses if #n,

#nd to 'o+er the left e,e ith theo''l%der


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' Instr%'t to re#d #s (#n, lines on the


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'. Instr%'t to re#d #s (#n, lines on the'h#rt #s )ossi&le #nd re'ord the +is%#l

#'%it, of the l#st line here (ore th#nh#lf of the letters ere re#d 'orre'tl,.

d. Mo+e the 'lient 'loser to the 'h#rt ifthe 'lient is %n#&le to re#d #nd notethe dist#n'e here the 'lient is #&le tore#d to the to) line

e. Re)e#t the test on the ri!ht e,e

14 P#l)#te the l#'ri(#l s#' for


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14. P#l)#te the l#'ri(#l s#' foro&str%'tion &, )ressin! the inde

?n!er ne#r the inner '#nth%s #nd notefor #n, dis'h#r!es.

15 Ins)e't the etern#l e#r #nd note


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15. Ins)e't the etern#l e#r #nd notethe )osition/ 'olor/ si:e/ #nd sh#)e

16 Note #n, defor(ities nod%les


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16. Note #n, defor(ities/ nod%lesin@#((#tions/ #nd lesions

17. Note 'olor/ #(o%nt/ #nd'onsisten', of ser%(en

18 P#l)#te the #%ri'le &eteen the


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18. P#l)#te the #%ri'le &eteen theth%(& #nd inde ?n!er/ notin! #n,

tenderness/ lesions/ #nd )resen'e of)#in

*9 P#l)#te the (#stoid ti)s %sin! the


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*9. P#l)#te the (#stoid ti)s %sin! theinde #nd (iddle ?n!er #nd note for

#n, tenderness

*1 A%ditor, S'reenin! Test" Voi'e


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*1. A%ditor, S'reenin! Test" Voi'ehis)er test

#. Instr%'t 'lient to o''l%de e#r ithone ?n!er

&. e#(iner st#nds * feet &ehind the

'lient #nd his)er # * s,ll#&le ord

'. re)e#t ith the other e#r

** A%ditor, s'reenin! test" EBER


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**.A%ditor, s'reenin! test" EBERTEST

#. hold h#ndle of # t%nin! for #ndstrie the line on the %ln#r &order of,o%r )#l( to #'ti+#te it.

&. )l#'e the ste( of thet%nin! for #!#inst the

(iddle of the

'lient-s forehe#d #t the(idline or the front

of the teeth.

h li if h d i h d


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'. #s the 'lient if the so%nd is he#rd'entr#ll, or to#rds one side.

*0 A%ditor, S'reenin! test" RINNE


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*0. A%ditor, S'reenin! test" RINNETEST

#. st#nd &ehind or to one side of the'lient #nd strie the t%nin! for

& )l#'e the ste( of the t%nin! for


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&. )l#'e the ste( of the t%nin! for#!#inst the 'lient-s ri!ht (#stoid

)ro'ess to test &one 'ond%'tion

'. instr%'t the 'lient

to indi'#te if theso%nd is he#rd.

d. #s the 'lient totell hen the so%nd sto)s.

e Mo+e the t%nin! for for#rd


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e. Mo+e the t%nin! for for#rdinfront of the ri!ht #%ditor, (e#t%s

hen the so%nd h#s sto))ed/ ithtines f#'in! for#rd.

f. #s the 'lient if the so%nd is stillhe#rd #nd note the len!th of ti(e he

he#rs the so%nd


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*2 Otos'o)i' Assess(ent


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*2. Otos'o)i' Assess(ent

#. #s the 'lient to ti) ##, fro( the

e#r &ein! #ssessed

&. Sele't the s)e'%l%( th#t ill

'o(fort#&l, ?t the )#tient

'. slol, insert the s)e'%l%( into

the '#n#l #ssessin! the '#n#l forin@#((#tion/ e%d#tes/ lesions/ #ndforei!n &odies


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d Contin%e to insert the s)e'%l%( %ntil


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d. Contin%e to insert the s)e'%l%( %ntilthe t,()#ni' (e(&r#ne is +is%#li:ed/#nd identif, the 'olor/ the li!ht re@e/ #nd

note for the )resen'e of )erfor#tions&%l!in! or retr#'tions/ &%&&les or @%ids.

e. #s the 'lient to 'lose the (o%th)in'h the nose 'lose/ #nd &lo !entl,hile o&ser+in! the (o+e(ent of the

t,()#ni' (e(&r#ne.

f. !entl, ithdr# the s)e'%l%( #ndre)e#t the )ro'ess ith the other e#r.

*4 Ins)e't the nose notin! #n,


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*4. Ins)e't the nose/ notin! #n,tr#%(#/ &leedin!/ lesions/ (#sses/sellin!/ #nd #s,((etr,/

*5 Note for )#ten', of the nostrils &,


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*5. Note for )#ten', of the nostrils &,o''l%din! one nostril ith # ?n!er #nd#sin! the )#tient to &re#the in #ndo%t

*6. Ins)e't the intern#l #s)e't of thenose ith the %se of #n otos'o)e ithn#s#l s)e'%l%(/ #ssessin! e#'h nostrilse)#r#tel,

*7 Ins)e't the (%'%s (e(&r#nes for


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*7. Ins)e't the (%'%s (e(&r#nes for'olor #nd dis'h#r!es

*8. Ins)e't the (iddle #nd inferiort%r&in#tes #nd the (iddle (e#t%s for'olor/ sellin!/ dr#in#!e/ #nd )ol,)s


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09. O&ser+e the n#s#l se)t%( for de+i#tion/

)erfor#tion/ lesions/ #nd &leedin!

01. O&ser+e the 'lient-s f#'e for #n,


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01. O&ser+e the 'lient s f#'e for #n,sellin! #ro%nd the nose #nd the e,es.

0*. P#l)#te the n#s#l sin%ses &, !entl,)ressin! the th%(&s %nder the &on,rid!e of the %))er or&its #nd o&ser+e

the )resen'e of )#in

00. P#l)#te the (#ill#r, sin%ses &,


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#))l,in! !entle )ress%re in the #re# %nderthe intr#or&it#l rid!e %sin! the th%(& or

(iddle ?n!er #nd o&ser+e for the )resen'eof )#in.

02. Per'%ss the front#l sin%ses %sin!


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02. Per'%ss the front#l sin%ses %sin!the (iddle or inde ?n!er %sin! thedo(in#nt h#nd #nd note for the so%nd

04. Per'%ss the (#ill#r, sin%ses %sin!the do(in#nt (iddle or inde ?n!er

#nd note for the so%nd

05. Ins)e't the (o%th &, st#ndin!


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05. Ins)e't the (o%th &, st#ndin!infront of the 'lient #nd s(ell the&re#th

06. O&ser+e the li)s for 'olor/(oist%re/ sellin!/ lesions/ #ndin@#((#tion

07. Instr%'t the 'lient to o)en the(o%th #nd %se # ton!%e &l#de toins)e't the (e(&r#nes th#t 'onne'tthe %))er #nd loer li)s/ #nd the !%(s

for 'olor in@#((#tion lesions #nd

.


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.

08. ith the 'lient-s ton!%e ' in the


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!(o%th/ #s the 'lient to )ress it#!#inst the 'hee/ #nd )ro+ideresist#n'e ith ,o%r ?n!er )#ds heldon the o%tside of the 'hees #nd notefor stren!th #nd 'o()#re &il#ter#ll,.

29. As the 'lient to o)en the (o%th#s ide #s )ossi&le #nd %sin! # ton!%e

&l#de #nd # )enli!ht/ #ssess the inner'hees #nd Stensen-s d%'ts #ndo&ser+e for 'olor/ in@#((#tion/

h,dr#tion/ #nd lesions.

21. O&ser+e the dent%res #nd


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orthodonti's for ?t

2*. Co%nt the %))er #nd the loerteeth #nd note for dis'olor#tion/ loose#nd (issin! teeth/ #nd (#lfor(#tion.

20. As the 'lient to tilt the he#d '


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#nd #l'e the ton!%e &l#de on the(iddle thid of the ton!%e #nd shine #li!ht #t the ' of the 'lient-s thro#t#nd #s the 'lient to s#, AAA3D

22. O&ser+e the )osition/ si:e/ 'olor/


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) / / /#nd !ener#l #))e#r#n'e of the tonsils#nd %+%l#/ #nd note for !#! re@e #nd)resen'e of sellin! #nd e%d#tes

24. ;o'%(ent ?ndin!s in the 'lient-s

re'ords

.


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health assessment ppt 2.pptx

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