ppt chapter 13

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Chapter 13

Physical Assessment

Chapter 13

Physical Assessment


QuestionQuestion

•Is the following statement true or false?

The first step of the nursing process is planning.


AnswerAnswer

False.

The first step of the nursing process is assessment.


• First step of the nursing process

– Assessment

• Physical assessment

– One method for gathering health data

Physical Assessment Physical Assessment


• Purposes

– To evaluate the client’s current physical condition

– To detect early signs of health problems

– To establish baseline for future comparisons

– To evaluate client’s responses to medical and nursing interventions

Overview of Physical AssessmentOverview of Physical Assessment


• Inspection

– Examining particular body parts

– Looking for specific normal and abnormal characteristics

– Using special instruments to inspect parts of the body inaccessible to ordinary visual inspection techniques

Overview of Physical Assessment: Four Basic Physical Assessment

Techniques


Techniques



Techniques (cont’d)


Techniques (cont’d)• Percussion

– Striking or tapping the body with fingertips to produce vibratory sounds

– Quality of sounds determines location, size, and density of underlying structures; variation in sound could mean possible pathologic change

– Pain: possible disease process or tissue injury


Inspection and PercussionInspection and Percussion





Techniques (cont’d)• Palpation

– Lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand

– Deep palpation

– Information: normal tissue and unusual masses; bilateral structures; skin temperature and moisture


Palpation TechniquesPalpation Techniques





Techniques (cont’d)• Auscultation

– Used for assessing the heart, lungs, and abdomen

– Soft sounds, loud sounds

– Nurses: practice auscultation repeatedly to gain proficiency; to ensure accuracy, eliminate or reduce environmental noise


Auscultation Auscultation


QuestionQuestion

•What is lightly touching or applying pressure to the body using fingertips, back of the hand, or palm of the hand called?

a. Inspection

b. Percussion

c. Palpation

d. Auscultation


AnswerAnswer

c. Palpation

Palpation involves lightly applying pressure to the body using fingertips, back of the hand, or palm of the hand. Inspection is looking for specific normal and abnormal characteristics. Percussion is striking or tapping the body with fingertips to produce vibratory sounds. Auscultation is listening to the sounds of the heart, lungs, and abdomen with a stethoscope.


• Equipment

– Items needed for a basic physical assessment

Overview of Physical AssessmentOverview of Physical Assessment


• Environment

– Special examination room or at bedside

– Easy access to a restroom; a door or curtain to ensure privacy

– Adequate warmth

– Lined receptacle for soiled articles

– Adequate lighting

Overview of Physical Assessment (cont’d)



• Environment (cont’d)

– Padded, adjustable table or bed

– Sufficient room for movement around client

– Facilities for hand hygiene

– Clean counter or surface for placing examination equipment




• Gather general data during first contact with client

– Physical appearance; gait; coordinated movement; use of ambulatory aids; mood and emotional tone

– Preliminary data

o Vital signs, weight, height, documentation

Performing a Physical Assessment: Basic Activities During a

Physical Assessment


Physical Assessment


Assessment of Height and WeightAssessment of Height and Weight


• Drape and position the client

– Ensure that client is covered with a drape (sheet of soft cloth or paper)

– Begin examination with the client standing or sitting


Physical Assessment (cont’d)


Physical Assessment (cont’d)


Client Is Prepared for ExaminationClient Is Prepared for Examination


• Select a systematic approach for collecting data

– Head-to-toe approach: Advantages

– Body systems approach: Advantages; disadvantages

• Examining the client: Outline procedure for performing a physical assessment

Performing a Physical Assessment: Basic Activities During a Physical

Assessment (cont’d)

Performing a Physical Assessment: Basic Activities During a Physical

Assessment (cont’d)


• Head and neck

– Mental status assessment

– Eyes: accommodation; Snellen eye chart; Jaeger chart; extraocular movements

– Ears: cerumen; Weber test; Rinne test; audiometry

– Nose: abnormalities; smelling acuity

Data Collection: 6 General Areas for Data Collection

Data Collection: 6 General Areas for Data Collection


Pupil Size Assessment GuidePupil Size Assessment Guide


Weber TestWeber Test


Rinne TestRinne Test


QuestionQuestion

•When preparing a client for the Rinne Test, which of the following equipment should the nurse keep ready?

a. Stethoscope

b. Tuning fork

c. Snellen chart

d. Jaeger chart


AnswerAnswer

b. Tuning fork

A tuning fork is required to conduct the Rinne test to determine hearing impairment. A stethoscope is used to listen to lung, heart, and abdominal sounds. A Snellen chart and a Jaeger chart are tools for assessing far and near vision respectively.


• Head and neck (cont’d)

– Mouth and oral mucous membrane

o Unusual breath odors

o Assessment of taste

– Facial skin: alterations in skin

– Hair, scalp

– Neck

Data Collection: Six General Areas for Data Collection (cont’d)



• Chest and spine

– Skin turgor

– Assess chest shape and movement; chest expansion

– Spine: lordosis, kyphosis, scoliosis

– Breasts

– Heart sounds: S1, S2, S3, S4





Data Collection: Six General Areas for Data Collection (cont’d)• Chest and spine (cont’d)

– Lung sounds

o Normal

Tracheal sounds

Bronchial sounds

Bronchovesicular sounds

Vesicular sounds




• Chest and spine (cont’d)

– Lung sounds (cont’d)

o Adventitious lung sounds

Crackles

Gurgles

Wheezes

Rubs


QuestionQuestion

•Which of the following sounds is not a normal lung sound?

a. Tracheal

b. Bronchial

c. Vesicular

d. Wheezing


AnswerAnswer

d. Wheezing

Wheezing is an adventitious lung sound; it is not normal. Tracheal sound, bronchial sound, and vesicular sound are normal lung sounds.


• Extremities

– Assessment of:

o Capillary refill

o Muscle strength

o Fingernails and toenails

o Edema: measurement

o Skin sensation




Criteria for Estimating Pitting Edema Criteria for Estimating Pitting Edema


• Abdomen

– Bowel sounds: hyperactive, hypoactive, absent

– Abdominal girth measurement

– Genitalia

• Anus and rectum

– Client positioning; trauma; hemorrhoids




• Assessment findings: basis for identifying health problems

– Clients

o Reveal situations that caused health failure

o Ask for more information

Nursing ImplicationsNursing Implications


• Nursing diagnoses

– Readiness for enhanced knowledge

– Ineffective health maintenance

– Effective or ineffective therapeutic regimen management

– Deficient knowledge; noncompliance

– Health-seeking behaviors

Nursing Implications (cont’d)Nursing Implications (cont’d)


• Explain purpose of each procedure

• Consider alterations: hearing, vision, mobility

• Ask appropriate questions

• Make appropriate adjustments: physical limitations

• Older women: modifications in pre-procedure positioning

General Gerontologic ConsiderationsGeneral Gerontologic Considerations

ppt chapter 13

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