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Nursing: Physical Assessment ch. 4 from Foundation of Nursing


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Identify the purpose of physical assessment.
Evaluates health care problems, evaluates changes in status, identifies the care that is needed.
TYpes of diseases.
hereditary, congenital, infectious, metabolic, deficiencies, neoplastic, traumatic, environmental
What is congenital disease?
appears at birth or shortly after but is NOT caused by genetic abnormalities. It is caused by a failure in development during the embryonic stage, or first 2 months of pregnancy. Contributing factors are smoking, drinking, lack of O2, radiation.
What is inflammatory disease?
The body reacts to causative agents with an inflammatory response. Bronchitis is caused by microorganisms. (allergic reaction)
What is degenerative disease?
A degeneration of various body parts. Aging process may play a role. ex. Osteoarthritis.
What is infectious disease?
Results from the invasion of microorganisms into the body. ex. AIDS, measles, pneumonia
What is deficiency disease?
Results from the lack of a specific nutrient. ex. Scurvy disease from lack of vitamin C.
What is metabolic deisease?
A dysfunction resulting from loss of metabolic control of homeostasis in the body. Diabetes results from dysfunction of the pancreas.
What is neoplastic disease?
An abnormal growth of new tissue. Mass of tissue that can be malignant or benign.
What are Traumatic conditions?
Result from physical or emotional trauma. Loss of a loved one can lead being unable to manage activities of daily living (ADL's )
Description of disease as organic or functional.
Organic is when the structural change in the organs interferes with its functioning. Functional diseases may be manifested by organic diseases. Careful examination may have failed to reveal structural or physiologic abnormalities. ex. Nervous or mental diseases.
What are the cardianl signs of an infection and inflammation?
Erythema (redess), edema (swelling), heat, pain, purulent drainage (puss), and loss of function.
The inflammatory response (signs of infection and inflammation) also serves as?
The body's defense mechanism. The erythema and heat are results of the increased blood flow. Neutrophils (white blood cells) digest microorganisms and cellular debris. The excessive fluid in the tissues (edema) causes the pain. Loss of function is the body's way of resting the injured area. Puss (neutrophils, dead cells, etc.) is then released outside the body.
Positions for examinations (8)?
Sitting, supine, dorsal recumbant, lithotomy, sims', prone, lateral recumbant, knee-chest.
Positions of examination. Areas assessed. Rationale. Limitations. "sitting"
AA: head, neck, back, lungs, breast, heart, VS, upper extremities.
Positions of examination. Areas assessed. Rationale. Limitations. "supine"
AA: head, neck, anterior thorax, lungs, breasts, heart, abdomen, pulses.
R: Normal relaxed position. Easy access to PULSE sites.
L: Patients may become short of breathe
Positions of examination. Areas assessed. Rationale. Limitations. "dorsal recumbant"
head, nech, anterior thorax, lungs, breasts, axillae, heart, abdomen.
R: Promoted relaxation of abdominal muscles.
L: Patients who might have dirorders
Positions of examination. Areas assessed. Rationale. Limitations. "lithotomy"
female genitalia, genital tract (pap smear position).
R: Maximal exposure of genitalia. Easier to insert vaginal speculum.
L: Embarassing and uncomfortable. minimizes time and patient is well draped.
Positions of examination. Areas assessed. Rationale. Limitations. "sims'"
rectum, vagina. (how i sleep at night)
R: flexion of hip and knee exposes rectal area.
L: joint deformalities may hinder patient to flex hip and knee.
Positions of examination. Areas assessed. Rationale. Limitations. "prone"
AA: musculoskeletal system (on abdomen, massaging back position
R: asses extenion of hip joint
L: may hurt patients who have respiratory difficulties
Positions of examination. Areas assessed. Rationale. Limitations. "lateral recumbant"
AA: heart (kind of like sims)
L: aids in detecting murmurs.
R: Hurt patients who might have respiratory problems.
Positions of examination. Areas assessed. Rationale. Limitations. "knee-chest"
AA: rectum (doggy style)
R: provides maximum exposure of rectum.
L: position may be embarrassing and uncomfortable
What are some physical assessment techniques?
inspection, palpation, auscultation, percussion
What is inspection?
The nurse inspects the patient's body and OBSERVES the moods, including all responses and nonverbal behaviors. Frequent used. Systematically collect data such as head to toe technique.
What is Palpation?
Examiner uses hands and TOUCh to collect data. Hands are sensitive to texture, temp, vibration, pulsation, and masses. Rule out or confirms suspicion process. The patient should be instructed to let examiner know if he feels tenderness, pain, etc. (light, moderate, deep)Nurse should have short fingernails and warm hands. Initiate social conversation to relax patient. Observe patient might imply pain.
What is auscultation?
LISTENING to sounds produced by the body. 3 systems produce sounds: cardiovascular, respiratory, gastrointestinal. Environment HAS to be quiet, close eyes if needed. Dampen area of body if hair is a problem.
What is percussion?
Tapping fingertips on body's surface. The sounds indicate the density of the tissue. A hollow organ such as the stomach produces a high pitched, drum like sound (tympany). Low pitched, thud-like called dullness comes from the liver. Flatness, soft and high pitched comes from a muscle.
How to initiate0patient relationship?
State name, position, and purpose of interview. Give estimated time. Ask what name the patient wants to be addressed. Use approving nods and gestures.
What is "P" in PQRST method in physical assessment?
P: PROVOCATIVE; What causes illness? What makes it better? What makes it worse? ETIOLOGY, causes?
What is "Q" in PQRST method in physical assessment?
Quality/ quantity: How does it feel, look or sound? How much of it is there?
What is "R" in PQRST method in physical assessment?
Region/ radiation. Where is it? Does it spread?
What is "S" in PQRST method in physical assessment?
Severity scale. Does it interfere with ADL's? How does it rate on severity scale of 0-10?
What is "T" in PQRST method in physical assessment?
Timing. When did it begin? How often? Is it sudden or gradual?
Review of systems (General constitutional systems)
fever, chills, malaise, fatigue, change apetite, weight, night sweats
Review of systems (skin)
rashes, redness, eruptions, puss, abnormal nail, hair growth
Review of systems (skeletal)
joint stiffness, pain, restriction of motion, edema, erythema, bone deformity
Review of systems (head)
1. general: headaches, dizziness, fainting
2. eyes: blurr vision, dilation, use of eyedrops, sensitivty, pain 3. ears: hearing loss, pain, discharge 4. nose: sense of smell, sinus pain, postnasal discharge, bleeding 5. throat and mouth: change in voice, tooth abcess, edema of gums, bleeding
Review of systems (endocrine)
thyroid enlargement, heat or cold tolerance, excessive thirst, unexplained weight hain, changes in facial or body hair
Review of systems (hematologic)
anemia, tendency to bruise of blees, abnormality of blood disorders?
Review of systems (gastrointestinal)
apetite, jaundice, digestion, nausea, vomitting, heart burns, BMs
Review of systems (genitourinary)
flank or suprapubic pain, urgency, nocturia, hernias, STDs, edema of face, stress incontinence
Physical Assessment guide: 1. Neurologic
Assess LoC (alert, drowsy, lethargic, or oriented) x1 (person) x2(person, place) x3(person, place, time) x4(person, place, time, purpose)
Physical Assessment guide
2. Integumentary
Look at skin condition, color, temp, turgor (elasticity), skin impairments, moist, or dry
Physical Assessment guide
3. Cardiovascular
Take apical pulse, capillary refill (less than 3 sec./ press on skin see how long white spot stays) Pitting edema (indentation of skin in swollen area)1+ to 4+, pedal pulses +1 to +4, type of IV rate, site condition
Physical Assessment guide
4. respiratory
auscultate for crackles, wheezes, pleural friction rub, tachypnea(abnormal fast breathing), dyspnea (slow, flaired nostril, shortness of breath), orthopnea(The inability to breathe easily unless one is sitting up straight or standing erect), liters of )2 flow
Physical Assessment guide
5. Gastrointestinal
x4(active, hypoactive, hyperactive, absent by quadrants)nasogastric suction (color amount), apetite, digestion, fluid intake, BM
Physical Assessment guide
6. Urinary
Urine amount, color, odor, presents of a catheter, voiding
Physical Assessment guide
7. Mobility
What is the activity level? bedrest, chair, up and lib, walker, cane crutches?
When checking head to toe in physical assessment what systems do you look in to?
1. neurologic
2. integumentary
3. cardiovascular
4. respiratory
5. gastrointestinal
6. urinary
7. mobility
When aucultating the abdomen what do you listen for?
Listen to 4 quadrants RUQ, LUQ, RLQ, LLQ (1 minute each) if no sound listen for up to 5 minutes). Normal rate is 4-32 sounds per min. Bowel soundfs should occur every 15-60 secs.
What are the 2 significant alterations in bowel sounds?
1. absence of sounds 2. increased sounds with a high pitched loud rushing sound.
Both light and deep palpations are used.
What happens if edema is not pitting?
Check for range of motion (RoM). Enlarged veins should not be shown. Check for CMST (color, motion, sensation, temp) of both feet. Touch patient's toes for sensation.
Pitting edema scale
1+ trace (2mm), 2+ mild (4mm), 3+ moderate (6mm), 4+ severe (8mm)
What is ABC, in and out, PS?
Used for follow up assessment.
A= airway: patient getting enough air? position need to be changed?
B= breathing: assess ease and rate
C= Circulation: Check general color & quickly palpate extremeties. Assess pulse & skin temp.
In: What is going in? Look at machine settings. IV sites
Out: coming out? check dressings, tubes, catheters.
P= pain
S= safety: side rails, chairs locked, clutter free, cleanliness
Difference between focused assessment & head to toe?
Head to toe is usually upon admitting patient whereas focus can be assessed when a nurse observes a patient's change in condition post admittance.
When you document information what do you include?
Patient's OWN words in quotations. Every bit of info from patient counts.
What is teh first area to be assessed after taking vital signs?
Level of conscience (LOC) person, place, time, purpose
What is turgor?
The elasticity of the skin.
What is a thrill?
Vibration along the artery.
What positions can assess the female genitalia?
lithotomy, dorsal recumbant, Sims

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