Nursing 100Tonights Plan

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Nursing 100-Tonights Plan

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

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Health Assessment Physical Assessment

• Chapter 32

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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

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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

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Skills of Physical Assessment
Head to Toe
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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

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

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

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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

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

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

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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

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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

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

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

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• 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

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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

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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

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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)
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Head Neck Includes head, eyes, ears, nose,
throat, mouth and neck (HEENT). (Inspection,
palpation, auscultation used)
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Head Neck contd
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Thorax Lungs Nursing History p. 718, Table
32-20
Landmarks

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

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Thorax Lungs (Inspection, Palpation,
Percussion, Auscultation)
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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

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Heart(Inspection, Palpation, Auscultation)

• Client teaching - p. 726, Box 32-20

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

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

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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

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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?

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

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

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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

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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

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MusculoskeletalNHx-p. 756, Table 32-33
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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

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CRANIAL NERVES

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

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After Examination

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

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

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