Nursing 100Tonights Plan - PowerPoint PPT Presentation

Title: Nursing 100Tonights Plan


1
Nursing 100-Tonights Plan

• Last Week Covered, Readings, Questions
• Plan for Todays Lecture
• Unit VI- Chapter 32- Health Assessment Physical
  Examination
• Summarize

2
Health Assessment Physical Assessment

• Chapter 32

3
Purposes of the Physical Exam

• Gather baseline data
• Supplement, confirm, or refute data obtained in
  the history
• Confirm and identify nursing diagnoses
• Make clinical judgments about the clients health
  status
• Evaluate the physiological outcomes of care

4
Cultural Sensitivity

• Clients health beliefs
• Use of alternative therapies
• Nutritional habits
• Relationships with family
• Comfort with the nurses physical closeness and
  contact during the exam
• Now a days important to know country of origin,
  religious and/or moral beliefs

5
Skills of Physical Assessment
Head to Toe
6
Inspection-process of observation-Refer to p. 674

• General appearance
• Ht. Wt.
• Signs of distress
• Skin lesions color
• Level of consciousness
• Gait
• Eye contact
• Clear or cloudy color

7
Palpation- sense of touchRefer to p.675, Table
32-2 Figure 32-1 p. 676, Figure 32-2

• Temp.
• Moisture
• Turgor
• Hard / soft
• Swelling

8
Percussion- tapping the body with fingertips to
evaluate size of borders consistency of body
organ. Refer to p. 677, Figure 32-3 Table 32-3

• Tympany
• Resonance
• Hyper-resonance
• Dullness
• Flatness

9
Auscultation - listening to sounds the body
produces. Refer to p. 678, Box 32-1

• Loud or soft
• Quality
• Duration
• Wheezing
• Gurgling
• Crackles

10
Olfaction - using the sense of smell.Refer to p.
678, Table 32-4

• Foul smelling
• Stale smelling
• Sweet smelling
• Clean smelling
• Dirty smelling
• Musty odor

11
Preparing for the Exam

• Infection control
• Wash hands/gloves
• Environment
• Well lit, privacy
• Equipment
• Readily available
• Physical preparation and positioning of the
  client
• Psychological preparation of the client
• Age-related factors

12
Physical Preparation PositioningRefer to p.
681, Table 32-5

• Dressed Draped,
• Sitting
• Supine
• Lithotomy
• Sims
• Prone
• Lateral
• Knee-chest

13

• Psychological Prep of Client
• As an RN you are a professional
• Use simple terms-avoid medical jargon
• Practice SOLER talk to client
• Have 3rd person if examining opposite gender
• Observe non-verbal of client

14
Organization of the Exam

• Compare both sides of the body
• Assess areas of symptoms or greatest risk first
• Offer rest periods as necessary
• Perform painful procedures last
• Record results in a systematic way, using
  appropriate and specific terminology

15
General Survey

• General appearance behavior
• Gender/race
• Age
• Signs of distress
• Body type
• Posture Gait
• Body movements
• Hygiene grooming dress
• Body Odor
• Affect mood
• Speech
• Abuse-Refer to p. 684, Box 32-3
• Substance abuse-Refer to p. 685, Box 32-4

• Vital Signs
• Reviewed from Chap. 31
• Height Weight
• Look for changes
• Weight varies daily related to fluid loss or
  gain, always weigh client on same day, same scale
  and same clothing
• Refer to p. 686, Box 32-5, Table 32-7, Table 32-8
• Circumferences
• Infants head chest

16
Skin, Hair, Nails-RN may inspect all skin
surfaces or may assess the skin gradually while
other body systems are examined. (Inspection,
Palpation, Olfaction used)
17
Head Neck Includes head, eyes, ears, nose,
throat, mouth and neck (HEENT). (Inspection,
palpation, auscultation used)
18
Head Neck contd
19
Thorax Lungs Nursing History p. 718, Table
32-20
Landmarks

• Client Teaching Refer to p. 722, Box 32-19

20
Thorax Lungs (Inspection, Palpation,
Percussion, Auscultation)
21
HeartNursing History - p. 723, Table 32-23

• Landmarks refer to
• p. 723, Figure 32-43
• p. 725, Figure 32-45
• p. 725, Figure 32-46
• p. 726, Figure 32-47

22
Heart(Inspection, Palpation, Auscultation)

• Client teaching - p. 726, Box 32-20

23
Vascular SystemNursing History-p. 727, Table
32-24
24
Vascular System contd

• Vascular Client Teaching refer to p. 730, Box
  32-21

25
BREASTS, AXILLAE NODES Nursing History-p.737,
Table 32-27

• Inspect-Refer to p. 738, Fig. 32-66
• Symmetry
• Discharge
• Palpation-Refer to p. 740, Fig. 32-68 to 70
• Nodes
• If found note
• size
• shape
• tenderness Males are not excluded
  
• mobility from cancer of the breast

26
BREASTS, AXILLAE NODES contd

• Refer to
• Breast self examination-p.736, Box 32-22
• THINK/LINK-What do you think would be a health
  promotion client education activity?

27
AbdomenNursing History-p. 741, Table
32-28IMPORTANT SEQUENCE Inspect, Auscultate,
Percuss, Palpate
28
Abdomen contd

• Abdominal Client Teaching refer to p. 730, Box
  32-21

29
Genitalia Reproductive System

• Female
• NHx p. 747, Table 32-29
• Inspect
• Sexual maturity
• Hair growth
• Inflammation, lesions, irritation, bulging,
  prolapse
• Palpate
• Soft, no tenderness
• Cl. Teaching
• p. 748, Box 32-26
• Examination
• PAP smear

• Male
• NHx p. 751, Table 32-31
• Inspect
• Sexual maturity
• Hair growth
• Penis
• Scrotum
• Inguinal ring canal
• Palpate
• Scrotum ing ring canal
• Cl. Teaching
• p. 751, Box 32-27
• Examination
• p. 752, Box 32-28

30
Rectum AnusNursing History-p. 754, Table 32-32

• Inspect
• Note-lumps, hemprroids, inflammation, rashes,
  irritation, excoriation, scars, pain.
• Palpation
• Performed digitally-refer to p. 755, Fig. 32-81
• Client Education
• Refer to p. 754, Box 32-29

31
MusculoskeletalNHx-p. 756, Table 32-33
32
NEUROLOGICAL SYSTEMNHx-p. 761, Table 32-37

• Mental Emotional Status
• LOCLevel of consciousness-p. 762, Table 32-38
  (Glasgow)
• Behavior/moods
• Lanquage / speech
• Intellectual Function
• Memory, knowledge, abstract thinking,
  association, judgement
• Cranial Nerve Function- refer to p. 764, Table
  32-39
• Sensory System
• Motor Function refer to p. 765, Fig 32-87
• Coordination balance
• Reflexes refer to p. 768, Table 32-89

33
CRANIAL NERVES

• On
• Old
• Olympus
• Toweling
• Tops
• A
• Finn
• And
• German
• Viewed
• Some
• Hops

34
After Examination

• Assist client with dressing.
• Assure privacy and dignity.
• Document, sign and date your findings

35
You are now ready to go practicephysical exams
36
Summary of Tonights Class

• Covered
• Unit V- Chapter 32
• Health Assess Physical Exam
• Questions?