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Assessment include: (in order)
- inspection
- palpation
- percussion
- auscultation
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Inspection uses the senses of __
deliberate, purposeful, and systematic visual examination
vision and smell
moisture, color, texture of body surfaces
shape, body, position, size, symmetry of the body
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Palpation uses the sense of ____
touch. warm hands before touching client.
Identify tender areas and palpalte them LAST.
Start with light palpation to detect surface characteristics, then perform deeper palpation.
assess texture, temp., and moisture of teh skin, as well as organ location and size.
Assess for swelling, vibration or pulsation, rigidity, or spasticity, and crepitation.
Assess for the presence of lumps or masses, as well as presence of tenderness or pain.
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Percussion involves _____
tapping the client's skin.
provides info related to presence of air, fluid, or solid masses as well as organ size, shape and position.
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Auscultation involves___
listening to sounds produced by the body, such as heart, lung or bowel sounds.
- direct: use of unaided ear
- indirect: use of stethoscope
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cyanosis
mottled bluish coloration
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pallor
pale, whitish coloration
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jaundice
yellow coloration
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4 types of health assessment:
- comprehensive
- ongoing/ partial
- focused
- emergency
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3 types of physical assessment
- complete assessment
- examination of a body system
- examination of a body area
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Purpose of the physical examination:
to obtain baseline data
to supplement, confirm, or refute data obtained in nursing history
to obtain data that will help establish nursing diagnoses and plan of care
to evaluate the progress of a clients health problem
to make clinical judgements about client's health status
to identify areas for health promotion and disease prevention
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during preparation:
instruct the client that all information gathered and documented during the assessment is kept confidentioal in accordance with the HIPPA. this means that only those health care providers who have a legitimate need to know the client's information will have access to it.
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be sure to prepare the:
- patient
- environment
- be sensitive to culture!
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A health history and physical examination provides a means of detecting any existing problems.
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a physical assessment helps the nurse establish
nursing diagnoses
plan the client's care
evaluate the outcomes of nursing care
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Steps in examination procedure
planning
obtain appropriate equipment
prepare the client
implementation of procedures
evaluation of findings
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Sequence for physical exam
General survey
vital signs
head to toe
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Assessment of the head:
•Hair, scalp, cranium, face
•Eyes and vision
•Ears and hearing
•Nose and sinuses
•Mouth and oropharynx
•Cranial nerves
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Assessment of the Neck
•Muscles
•Lymph nodes
•Trachea
•Thyroid gland
•Carotid arteries
Neck veins
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Assessment of Upper extremities
•Skin and nails
•Muscle strength and tone
•Range of motion
•Brachial and radial pulses
•Biceps and triceps reflexes
•Sensation
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Assessment of Chest and Back
•Skin
•Chest shape and size
•Lungs
•Heart
•Spinal column
•Breasts and axilla
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Abdomen
skin
abdominal sounds
specific organs
femoral pulses
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