HEALTH ASSESSMENT AND PHYSICAL EXAMINATION
Purpose: Use physical examination to do the following 1. Gather baseline baseline data data about the clients clients health status status 2. Supplement, Supplement, confirm confirm or refute refute data obtaines obtaines in the history history 3. Confirm Confirm and identify identify nursing nursing diagnos diagnoses es 4. Make clinical clinical judgements judgements about about a clients changing changing health status and management 5. Evaluate Evaluate the outcomes outcomes of care SKILLS OF PHYSICAL ASSESSMENT
1. INSPECTIONINSPECTION- to inspect inspect the patient patient properly properly use the following tips a. Make sure sure there is adequate adequate lighting lighting b. Position Position and expose expose body parts parts so that all surfaces surfaces can can be viewed c. Inspect Inspect each area for for size, shape, shape, color, color, symmetry symmetry,, position and abnormalities d. When possible possible compare compare each each area ins[ected ins[ected with the same area on the opposite side of the body e. Use additional additional light light (ex: a penlight penlight)) to inspect body body cavities
f. DO NOT NOT RUSH. RUSH. BE BE VERY VERY DETAIL DETAILED ED 2. PALPATIONPALPATION- usings usings the hands hands to touch body body parts to make make sensitive assessments. a. Examine Examine all accessib accessible le parts of the body body
b. Use different parts of the hands to detect characteristics such as texture, temperature and perception of movement c. Have the client relax before you begin palpation(muscle tension during palpation impaires the assessment)
d. PALPATE TENDER AREAS LAST e. Perform palpations slowly, gently and deliberately f. Light palpation determines areas of tenderness, deep palpation is used to examine the condition of and organ
g. LIGHT INTERMITTENT PRESSEURE IS BEST FOR PALPATION..HEAVY PROLONGED PRESSURE CAUSE LOSS OF SENSITIVITY IN THE HAND h. Use palmar surface of fingers and finger pads to determine: position, texture, size, consistency, masses, fluid and crepitus. i. Measure temperature using dorsal side of the hand j. use fingertips to determine skin turgor
k. DO NOT PALPATE WITHOUT CONSIDERING CLIENTS CONDITION l. DO NOT PALPATE A VITAL ARTERY WITH PRESSURE THAT OBSTRUCTS BLOOD FLOW 3. PERCUSSION- tapping the body with the fingertips to produce a vibration that travels through body tissues a. The character of the sound determines the location size and density of underlying structures. b. Assists in verifying abnormalities assessed by palpation and auscultation
c. Character of the sound depends on the density of the underlying tissue. d. Abnormal sound suggests mass or substance within and organ or body cavity. e. ** this technique is normally used by advanced practicioners** 4. AUSCULTATION- listening to sounds the body makes to detect variations from normal. a. Learn the normal sounds produce by the different body cavities as well as their location and variation b. Learn and know how to use stethoscope properly and have good hearing c. Always place stethoscope on skin. Clothing obscures sound. d. Know the following characteristics of sound: Frequency, Loudness, Quality, Duration
e. *Proper auscultation requires concentration and practice 5. Olfaction- using the sense of smell to determine abnormal body odors a. Become familiar with the normal odor of the body and the source of the odor
PREPARING FOR THE EXAMINATION
FOLLOW THESE STEPS WHEN PREPARING FOR THE PHYSICAL EXAM 1. Ensure proper infection control
2. Prepare the environment: this includes temperature in the room, lighting, moving unnecessary equipment out of the way etc 3. Prepare the proper equipment and arrange it in order of use to help the assessment go more smoothly 4. Physically prep the client: talk to and assist them into the position(s) they are going to be in for the exam, make sure they are draped properly etc 5. Physiologically Prep the Client: give them a thorough explanation of what you are about to do, explain the procedure so that they can understand exactly what is about to happen and answer any questions they may have.
6. DO NOT RUSH!! 7. Asses the clients age group to determine your approach and assist in data collection
GENERAL SURVEY 1. General appearance and behavior- assess the following at the start of the exam. a. Gender and race b. Age c. Signs of distress d. Body type e. Posture f. Gait g. Body movement h. Hygiene and grooming
i. Dress j. Body odor k. Affect and mood l. Speech m.
Client abuse
n. Substance abuse 2. Vital signs- properly assess, measure and record the following: a. Temperature b. Respirations c. Blood pressure d. Temporal, carotid, apical, brachical, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis pulses.**NOTE** normally for vital signs you only have to record the measurement of the radial and apical pulse but for assessment all pulses should be measured and assessed to ensure all are normal.
e. ** KNOW THE NORMAL RANGES FOR ALL VITAL SIGNS IN ALL AGE GROUPS 3. Height and Weight
