Download presentation
Presentation is loading. Please wait.
Published byMyles Lloyd Modified over 8 years ago
1
DEFINATION: An evaluation of the health status of an individual by performing a physical examination after obtaining a health history
2
Four health assessment techniques - Inspection - Palpitation - Percussion -Auscultation Inspection is the use of two senses of vision and smell to consciously observe the patient.
3
Assessment Techniques Inspection - critical observation Take time to “observe” with eyes, ears, nose Use good lighting Look at color, shape, symmetry, position Odors from skin, breath, wound Develop and use nursing instincts Inspection is done alone and in combination with other assessment techniques
5
Palpation The second assessment technique is palpation, which is the act of touching a patient in a therapeutic manner to elicit specific information basic principles: -You should have short fingernails to avoid hurting
6
should warm your hands to placing the on the patient Encourage the patient to continue to breathe normally throughout the palpation If pain is experienced during the palpation, discontinue the palpation immediately Most significantly, inform the patient where, when, and how the touch will occur
7
Assessment Techniques Palpation - light and deep touch Back of hand to assess skin temperature Fingers to assess texture, moisture, areas of tenderness Assess size, shape, and consistency of lesions
10
Percussion is the technique of striking one object against another to cause vibrations that produce sound.The density of underlying structures produces characteristic sounds. These sounds are diagnostic of normal and abnormal findings. The presence of air, fluid, and solids can be confirmed
11
Immediate percussion
12
indirect percussion
13
Technique of Direct Left Kidney Fist Percussion
14
Technique of Indirect Fist Percussion Left Kidney
15
Auscultation Auscultation is the act of active listening to body organs to gather information on a patient's clinical status. Auscultation includes listening to sounds that are voluntarily and involuntarily produced by the body
16
Physical Assessment Techniques Inspection Vision Smell Palpation Light palpation Deep palpation Percussion Immediate, or direct, percussion Mediate, or indirect, percussion Direct fist percussion Indirect fist percussion Auscultation Immediate, or direct, auscultation Mediate, or indirect, auscultation
17
Golden Rules for Physical Assessment Stand on the right side of the patient; establishing a dominant side for assessment will decrease your movement around the patient. Perform the assessment in ahead-to-toe approach. Always compare the right- and left-hand sides of the body for symmetry.
18
Proceed from the least invasive to the most invasive procedures for each body system. Always perform the physical assessment using a systematic approach are less likely to forget some part of the assessment
19
EQUIPMENT
20
Positioning Positions used during nursing assessment, medical examinations, and during diagnostic procedures: Dorsal recumbent Supine Sims Prone Lithotomy Genupectoral See Table 28-2 for client positions
22
Complete History and Physical Nursing history is subjective - includes things like biographic data, history of present illness, past medical history, immunization history, allergies, habits (tobacco), stressors, family history, patterns of health care, and a review of the body’s systems
23
History of Present Illness Must get details of the problem, therefore must be systematic OLFQQAAT (one system – there are others): onset, location, frequency, quality, quantity, associated symptoms, treatments tried (include all treatments)
24
Pain, quality/quantity, radiation, setting, timing Rate pain from 1 to 10 Use age appropriate tools Culturally appropriate care
25
Exam Order and Documentation Date and identifying data - name, age, sex, race, place of birth, marital status, occupation, religion Source and reliability of history client complaint = reason for visit
26
Order & Documentation (subjective head-to-toe review) General - recent wt. change, fatigue, fever Skin - rashes, lesions, changes, dryness, itching, color change, hair loss, change in hair or nails Eyes - change in vision, floaters, glasses, HA, pain
27
Order & Documentation Genitalia - lesions, discharge, sexual orientation, sexual function, menstrual history, contraception, pregnancy history, TSE Peripheral vascular - intermittent claudicating, varicose veins, blood clots muscle or joint pain, redness, stiffness, warmth, swelling, family history Neuro - fainting, blackouts, seizures, weakness
28
Order & Documentation Endocrine - sweats, skin change, heat or cold intolerance, excessive thirst (polydipsia), excessive urination (polyuria), weight change, menstrual changes Psychiatric - mental illness, thoughts of harming self or others
29
Complete H&P - Objective Physical assessment is objective Objective portion of exam begins with the general survey; Each body system reviewed in text has nursing history at the beginning of the procedure for the objective exam In actual practice, you get most of the history before ever touching the client, but there are usually additional history questions to ask during the exam
30
General Survey General appearance, gait, nutrition status (NOT to be confused with nutrition history), state of dress, body build, obvious disability, speech patterns, affect (mood), hygiene, body odor, posture, race, gender, height, weight, vital signs Height up to age 2 is recumbent Add head circumference if child is less than 2 years old
31
Integumentary System Integument includes skin, hair, and nails Inspect: skin color and uniformity of color, moisture, hair pattern, rashes, lesions, pallor, edema Palpate: temperature, turgor, lesions, edema Percussion and auscultation: rarely used on skin Terminology: pallor, cyanosis, edema, ecchymosis, macule, papule, cyanosis, jaundice, types of edema, etc.
32
SKIN
33
Inspect and palpate the skin & note -Color Look for increased pigmentation Redness Pallor Cyanosis Yellowing of the skin -Moisture Ex. Dryness.sweating,and,oiliness
34
Temperature : Assessment generalized warmth and coolness of the skin note temperature of any red area. Texture : Roughness and smoothness. Mobility and turgor: lift a fold of skin note the ease with which it lifts up (mobility) and the speed with which it returns into place (turgor)
35
Lesions: Anatomic location and distribution. Pattern and shapes. Annular (in ring) linear,clusterd The type of skin lesion eg. Macules,papules Evaluating the bed bound patient.
36
HEAD EXIMINATION The hair : Quantity. Distribution. Texture. Pattern of loss. If you may see loose flakes of dandruff.
37
The scalp. Part the hair in several place and look for scaliness, lumps, nevi,or other lesion. The skull: General size, note any deformities, depression, lumps,or tenderness The face: Facial expression and contours A symmetry, involuntary movements, edema, and mass
38
Anatomy of eye
39
Examination of The eye Visual acuity.
40
with Snellen chart: ○ 20/20 - first number (numerator) is distance from chart ○ Second number is distance at which a normal eye could have read that line (OU, OD, OS) ○ Always record if tested cc (with correction
41
Visual field by confrontation : Screening Position and A ligment of the eye: Eyebrows : quantity and distribution and any scaliness of under ling skin. Eye lid : color,edema, width of the palpebral fissures condation and direction of eyelashes. Lacrimal Apparatus: swelling,excessive tearing or drayness of the eyes.
42
Conjunctiva and sclera: Color, vascular pattern against white sclera nodules or swelling. Cornea and lens. Opacities Iris: Pupils: size(0.5-0.3mm), shape, and symmetry of the pupils Pupillary reaction to light Direct reaction(pupillary construction in the same eye)
43
The consensual reaction(pupillary construction in the opposite eye) Extra ocular muscles: normal conjugate movement of the eye in each direction, or any devotion of normal nystagmus
44
Ear Anatomy of ear
45
Techniques of examination The uricle and surrounding tissue for deformatities,lumps,and lesion. Ear canal and drum by otoscop
46
Normal ear drum
47
Auditory acuity Air and bone conduction: Test for lateralization (weber test) Compare air conduction (AC) bone conduction(BC)(rinne test)
48
The nose and par nasal sinuses
49
Techniques of examination Inspect the anterior and inferior surfaces of the nose: Note any asymmetry or deformity of the nose Test for nasal obstruction. Inspect the inside of the nose with an otoscope The nasal mucosa that covers the septum and any abnormalities The nasal septum : perforation deviation or any inflammation. Any abnormalities such as ulcers or polyps. Palpate for sinus tenderness.
50
Mouth and pharynx
51
Techniques of examination The lips: color and moisture, and note any lumps, ulcers, cracking or scaling. The oral mucosa: Color, ulcers, white patches, and nodules The gums and teeth : Color of the gums normally pink,patchy brownnes may be present, The roof of the mouth: inspect the color and architecture of the hard palate.
52
The tongue and the floor of the mouth : Color texture, and symmetry Inspect the side of the tongue, and palpate it with your gloves. Pharynx: Color,symmatry and look exudates,swelling,ulceration,tonsillar enlargement
53
The neck
54
Techniques of examination Inspect the neck noting (symmetry and any masses or scars. Look for enlargement of the parotid or submandibular glands, and note any visible lymph nodes The lymph nodes.
56
Neck Inspect Thyroid gland for enlargement Any visible lymph nodes and masses
57
REFERENCES Boyce, J. M., & Pittet, D. (2008). Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory.
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.