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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 111
CHAPTER 4Physical Assessment
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 2
OBJECTIVE DATA DEFINED OBJECTIVE DATA DEFINED
Objective data as Objective data as OBSERVED by OBSERVED by the examiner the examiner
Can be seen, heard, & measured Can be seen, heard, & measured –– Examples: rashes, altered vital signs, Examples: rashes, altered vital signs,
visible drainage or SWELLING/EDEMA visible drainage or SWELLING/EDEMA –– Lab results, diagnostic imaging, and Lab results, diagnostic imaging, and
other studiesother studies
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 3
WHAT DO YOU OBSERVE? WHAT DO YOU OBSERVE?
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 4
OBJECTIVE VERSES OBJECTIVE VERSES SUBJECTIVE SUBJECTIVE
–– Subjective data is what the Subjective data is what the patient patient says it issays it is
–– Examples: Examples: painpain, nausea, vertigo, and , nausea, vertigo, and anxietyanxiety
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 5
Signs and SymptomsSigns and Symptoms
DiseaseDiseaseIt is any disturbance of a It is any disturbance of a structure or function of the body.structure or function of the body.It is recognized by a set of signs It is recognized by a set of signs and symptoms.and symptoms.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 6
Signs and SymptomsSigns and SymptomsRisk Factors for Development of Risk Factors for Development of
DiseaseDisease–– A risk factor is any situation, lifestyle, A risk factor is any situation, lifestyle,
habit, environmental condition, genetic habit, environmental condition, genetic predisposition, physiologic condition, predisposition, physiologic condition, and other that increases the and other that increases the vulnerability of an individual or a group vulnerability of an individual or a group to illness or accident.to illness or accident.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 7
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 8
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 9
Signs and SymptomsSigns and Symptoms
Terms Used to Describe DiseaseTerms Used to Describe Disease–– ChronicChronic
––6 months and longer, often for a 6 months and longer, often for a personperson’’s lifetime s lifetime
–– AcuteAcuteBegins abruptly, severe signs and Begins abruptly, severe signs and symptoms and then often subsides symptoms and then often subsides after a period of treatmentafter a period of treatment
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 10
AssessmentAssessment
Process of making an Process of making an evaluationevaluation or or appraisalappraisal of the patientof the patient’’s conditions condition
Collection of subjective (pt. feels) Collection of subjective (pt. feels) and objective data (what the and objective data (what the caregiver observes)caregiver observes)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 11
AssessmentAssessment
Medical AssessmentMedical Assessment–– Functions That May Be Expected of the Functions That May Be Expected of the
PT PT –– Preparing the exam roomPreparing the exam roomAssisting with equipmentAssisting with equipmentPreparing the patientPreparing the patientCollecting specimensCollecting specimens
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 12
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 13
Initiating the Initiating the NurseNurse--Patient Patient Relationship Relationship (remember it helps (remember it helps reduce potential liability)reduce potential liability)
Introduce yourself and state name, Introduce yourself and state name, position, and purpose of the position, and purpose of the interview.interview.Convey competence and Convey competence and professionalism.professionalism.Convey empathy Convey empathy
AssessmentAssessment
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 14
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 15
Guess what ? Time to put you in Guess what ? Time to put you in the driver seat.the driver seat.
Break into twoBreak into two’’ss Grab your mind Grab your mind Shy ones are going to have an anxiety Shy ones are going to have an anxiety
attack!attack! Practice makes perfect Practice makes perfect Perform a nursing introduction to your Perform a nursing introduction to your
partner partner
We will discuss the process after the We will discuss the process after the exerciseexercise
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 16
AssessmentAssessment
Nursing Health HistoryNursing Health History–– Reasons for Seeking Health CareReasons for Seeking Health CareChief complaintChief complaint
––Document information in patientDocument information in patient’’s s own words.own words.
––““I have been having a lot of I have been having a lot of breathing problems for last two breathing problems for last two weeksweeks””
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 17
SOAP:SOAP:
SSubjective dataubjective dataOObjective data, bjective data, AAssessment, ssessment, PPlan. lan.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 18
AssessmentAssessment
–– Psychosocial and Cultural HistoryPsychosocial and Cultural HistoryData about primary language, cultural Data about primary language, cultural groups, educational background, groups, educational background, attention span, and developmental attention span, and developmental stagestageCoping skills and family supportCoping skills and family supportIdentify major beliefs, values, and Identify major beliefs, values, and behaviors when treating thembehaviors when treating them
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AssessmentAssessment
Nursing Physical AssessmentNursing Physical Assessment–– Performing the Nursing Physical Performing the Nursing Physical
AssessmentAssessmentItems needed:Items needed:
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 20
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 21
Figure 4Figure 4--11
Equipment used during a physical examination.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 22
AssessmentAssessment
–– HeadHead--toto--Toe AssessmentToe AssessmentNeurologicNeurologic
––Level of consciousnessLevel of consciousness––Level of Level of orientationorientation––Hand gripsHand grips
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 23
Figure 4Figure 4--33
Assess skin turgor by grasping fold of skin on back of patient’s hand, sternum, forearm, or abdomen.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 24
AssessmentAssessment
–– HeadHead--toto--Toe Assessment (continued)Toe Assessment (continued)Head and neckHead and neck
––Note facial expression.Note facial expression.––Note symmetry of features.Note symmetry of features.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 25
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 26
Figure 4Figure 4--99
Palpation of arterial pulses.
(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 27
TIME FOR YOUR PHYSICAL TIME FOR YOUR PHYSICAL
““My name is weeMy name is wee--wee and I will be wee and I will be doing your head to toe assessment doing your head to toe assessment todaytoday””