HA

• Check patient’s vital signs: blood pressure, temperature, pulse, respiration.
• Mental status: observe client’s level of consciousness-ask client his name, address and phone number.
• Crying or depressive behavior is also considered abnormal.
• Note style and pattern of speech, which can be disorganized, consistent, nonstop, or with a long period of silence, indicating possible mental illness or neurologic disorder.
• Listen to speech.
• Abnormal behavior includes uncooperative, bizarre behavior such as being angry, fidgety and restless.
• Purposeless movement, aggressiveness, and withdrawal are signs of a neurologic deficit.
• Observe facial expression.
• Observe body build as well as muscle mass and fat distribution.
• Anxious or apathetic behavior is also considered abnormal.
• Types of palpation include light palpation, moderate palpation, deep palpation, and bimanual palpation.
• Palpation uses parts of the hand (fingerpads, ulnar/palmar surface, dorsal surface) to touch and feel for the following characteristics: texture (rough/smooth), temperature (warm/cold), moisture (dry/wet), mobility (fixed/movable/still/vibrating), consistency (soft/hard/fluid-filled), strength of pulses (strong/weak/thread/bounding), size (small/medium/large), shape (well defined/irregular), degree of tenderness.
• Lithotomy is a position where the client lies on their back with their hips at the edge of the examination table and their feet supported by the stirrups, used to examine the female genitalia, reproductive tracts, and the restum.
• Parts of the hands used in palpation include the fingerpads, ulnar/palmar surface, dorsal surface.
• Types of percussion include direct percussion and blunt percussion.
• Few body systems require the use of special equipment such as an opthalmoscope for eye inspection and an otoscope for ear inspection.
• Guidelines in inspection include a comfortable temperature of the room, good lighting, preferably sunlight, looking and observing before touching, completely exposing the body part being inspected while draping the rest of the client as appropriate, noting the following: color, pattern, size, location, consistency, symmetry, movement, behavior, odor, sounds, and comparing the appearance of symmetric body parts or both sides of any individual part.
• Inspection involves using the senses (vision, smell, hearing) to observe and detect any normal or abnormal findings, and precedes the PPA because the latter techniques can potentially alter the appearance of what is being inspected.
• Percussion involves tapping body parts to produce sound waves/vibrations, which enable the examiner (nurse) to assess underlying structures.
• Assessment uses of percussion include eliciting pain, determining location, size and shape, determining density, detecting abnormal masses, and eliciting reflexes.
• Techniques of indirect percussion include placing the middle finger of your non-dominant hand on the body part you are going to percuss, keeping your other finger off the body part being percussed, and using the pad of your middle finger of the other hand to strike the middle finger of your non-dominant hand that is placed on the body part.
• Abnormal physical and sexual development includes delayed puberty, male client with female characteristics, appearing older than actual chronologic age, extreme pallor, flushed or yellow skin, loss of red tones and ashen gray cyanosis, unkempt appearance with foul body odor, and abnormal posture and gait.
• Percussion notes, referred to as tones, are classified according to origin, quality, intensity, and pitch.
• Techniques of auscultation include eliminating distracting or competing sounds from the environment, exposing the body part you are going to auscultate, using the diaphragm of the stethoscope for high pitch sounds such as the normal heart sounds, breath sounds and bowel sounds, and using the bell of the stethoscope to listen to low pitched sounds such as abnormal heart sounds, and bruits.
• Sounds elicited by percussion include sound intensity, pitch, length, quality, and origin.
• Do’s and don’ts in the use of a stethoscope include warming the diaphragm or bell of the stethoscope before placing it on the client’s skin, explaining what you are listening for and answering any question the client is asking, not applying too much pressure when using the bell, and avoiding listening through clothing.
• Auscultation requires the use of a stethoscope to listen for heart sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract.
• Solid tissues produce a softer sound in percussion.
• As density increases, the sound produced by indirect percussion becomes quieter.
• Indirect or mediate percussion is the most commonly used method of percussion, producing a sound or tone that varies with the density of the underlying structure.
• General impression in physical and sexual development includes observing physical and sexual development, comparing the client’s age with her apparent age and developmental stage, observing skin condition and color, observing dress, observing hygiene, and observing posture and gait.
• Sounds heard during auscultation are classified according to intensity, pitch, duration, and quality.
• Throughout the procedure, continue to explain what procedure you are performing and why you are performing it.
• Leave the room while the client changes into the gown and knock before entering the room to ensure client’s privacy.
• Begin the examination with the less intrusive procedures such as measuring vital signs, height and weight.
• If a pin or other sharp object is used to assess sensory perception, discard the pin and use a new one for the next client.
• Some positions may be very difficult or impossible for the older client to assume or maintain because of decreased joint mobility and flexibility.
• Dorsal recumbent position is used when the client lies down on the examining table with the knees bent, legs apart/separated, feet flat on the table or bed.
• Some older clients may process information at a slower rate- explain procedure and integrate teaching in a clear and slow manner.
• Allow client to put on her underwear until just before the genital examination to promote comfort.