NSG 101 techniques assessment

• HEALTH ASSESSMENT

  • It is a comprehensive assessment of the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community.
• • A complete health assessment includes both a nursing history and physical examination.
• PREPARATION GUIDELINES FOR PHYSICAL EXAMINATION

  1. SETTING
  2. THE PATIENT
• SETTING

  ➢ The examination room should be adequately ventilated, comfortable, quiet, private, with adequate lighting.

  ➢ Position the examination table so that both sides of the patient are easily accessible.
• Setting

  ➢ The examination table should be at a height that prevents the examiner from stooping and should be equipped to raise the head up to 45 degrees.

  ➢ A bedside stand or table should be available to lay out all equipment needed.
• THE PATIENT ➢ Prepare the patient physically and psychologically to allay anxiety. ➢ Provide privacy to prevent feelings of embarrassment. Curtain the unit as necessary.
• THE PATIENT

  ➢ Prepare the patient physically and psychologically to allay anxiety.

  ➢ Provide privacy to prevent feelings of embarrassment. Curtain the unit as necessary.
• THE PATIENT

  ➢ Provide adequate information about the procedure, what to expect during the procedure, and what is expected of the client, to gain his cooperation.

  ➢ Provide a new, clean gown.
• PHYSICAL EXAMINATION GUIDELINES

  ➢ Wash hands before the procedure.

  ➢ The general sequence of performing the techniques of physical examination is as follows: Inspection, Palpation, Percussion and Auscultation (IPPA),

  ➢ Begin physical examination procedure by measuring the person's height, weight, blood pressure, temperature, pulse and respirations.
• PHYSICAL EXAMINATION GUIDELINES

  ➢ Explain each step in the examination and how the patient can cooperate. Encourage the patient to ask questions.

  ➢ Touch the patient’s hands, check the skin color, nail beds, metacarpophalangeal joints. This is less threatening manner to ease a patient into being touched
• PHYSICAL EXAMINATION GUIDELINES

  ➢ Organize the steps of physical examination so the patient does not change position too often and to avoid omissions.

  ➢ Write out the examination sequence and refer to it as needed, or use a printed form of the procedure, initially. Explain to the patient that making brief notations will ensure accuracy of findings. As the nurse gains experience, he/she will find that he/she will glance at the form less and less.
• PHYSICAL EXAMINATION GUIDELINES

  ➢ Perform the procedure using head-to-toe sequence.

  ➢ The sequence of techniques for examination of the abdomen is as follows: Inspection, Auscultation, Percussion, and Palpation (IAPP). Palpation is done as the last technique on the abdomen because if the examiner happens to palpate a tender area, the patient may not be able to relax anymore. And the patient may not want to finish the procedure. Palpation of the abdomen may also disturb the bowel sounds at the start of the procedure. This may make results of the examination inaccurate.
• PHYSICAL EXAMINATION GUIDELINES

  ➢ During examination of the abdomen, it is important to flex the patient's knees to relax the abdominal muscles. This facilitates the examination of abdominal organs.

  ➢ The sequence of examining the quadrants of the abdomen is as follows: right lower quadrant, right upper quadrant, left upper quadrant, left lower quadrant (RLQ RUQ LUQ LLQ).
• PHYSICAL EXAMINATION GUIDELINES

  ➢ Avoid abdominal palpation among patients with tumor of the liver and tumor of the kidneys.

  ➢ Do auscultation of the abdomen for 5 minutes before concluding absence of bowel sounds.
• Assessment Techniques

  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
• Inspection (Look)

  More specific, precise, and close visual examination of the body.
• Inspection (Look)

  • The process of observation.

  • To use inspection effectively, the nurse observes the following principles:
• Inspection (look)

  The process of observation.
• Inspection (Look)

  To use inspection effectively, the nurse observes the following principles: a. Make sure good lighting is available.

  b. Position and expose body parts so that all surfaces can be viewed.

  c. Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations

  d. Assess for color, size, shape, location, movement, texture, symmetry; odor and abnormalities.

  e. If possible, compare each area inspected with the same area on the opposite side of the body. f. Use additional light (e.g penlight) to inspect body cavities.
• Essential Elements of Inspection

  1. Color
  2. Odor
  3. Size
  4. Shape
  5. Symmetry
  6. Movement
  7. Location
• Palpation

  Tactile examination, it involves the sense of touch and in most cases is used simultaneously with inspection.
• Palpation

  ➢ Palpation requires touching the patient with different parts of your hands, using varying degrees of pressure just observed and noting what the various structures feel like.

  ➢ Keep your fingernails short and your hands warm.

  ➢ Wear gloves when palpating mucous membranes or areas in contact with body fluids.

  ➢ Palpate tender areas last
• Palpation

  ➢ With experience comes the ability to distinguish variations of normal from abnormal.

  ➢ Is performed in an organized manner from region to region.
• Types of Palpation

  ➢ Light Palpation

  ➢Deep palpation
• ➢ Light Palpation

  ➢ Use this technique to feel for surface abnormalities.

  ➢ Depress the skin ½ to ¾ inches (about 1 to 2 cm) with your finger pads, using the lightest touch possible.

  ➢ Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.
• Deep palpation

  ➢Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.

  ➢Depress the skin 1½ to 2 inches (about 4 to 5 cm) with firm, deep pressure. Use one hand on top of the other to exert firmer pressure, if needed.
• Essential Elements of Palpation

  1. Softness/Rigidity
  2. Masses
  3. Temperature
  4. Position
  5. Size
• Percussion

  Striking Body surface to elicit sounds or vibration.
• Percussion involves tapping your fingers or hands quickly and sharply against parts of the patient's body to help you locate organ borders, identifies organ shape and position, and determines if an organ is solid or filled with fluid or gas.
• Types of Percussion

  ➢ Direct percussion

  ➢ Indirect Percussion
• Direct percussion

  ➢ This technique reveals tenderness; it's commonly used to assess an adult's sinuses.

  ➢ Using one or two fingers, tap directly on the body part.

  ➢ Ask the patient to tell you which areas are painful, and watch his face for signs of discomfort
• ➢ Indirect Percussion

  ➢ This technique elicits sounds that give clues to the makeup of the underlying tissue.

  ➢ Press the distal part of the middle finger of your non dominant hand firmly on the body part.

  ➢ Keep the rest of your hands off the body surface.
• Indirect Percussion

  ➢ Flex the wrist of your non dominant hand.

  ➢ Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient's skin.

  ➢ Listen to the sounds produced
• Auscultation

  An assessment technique in which the examiner listens to and assesses the sound produced by various body organs and tissues such as heart, lung, or bowel with the use of stethoscope.
• Auscultation

  ➢ Preparation for auscultation:

  ➢ Provide a quiet environment.

  ➢ Make sure the area to be auscultate is exposed (a gown or bed linens can interfere with sounds.)

  ➢ Warm the stethoscope head in your hand.

  ➢ Close your eyes to help focus your attention.
• Auscultation

  This method uses the stethoscope to augment the sense of hearing.
• Auscultation

  2. The stethoscope must be constructed well and must fit the user. Earpieces should be comfortable, the length of the tubing should be 10-15 inches, and the head should have a diaphragm or bell.
• Auscultation

  1. the bell is used for low-pitched sounds - heart murmurs.
  2. the diaphragm is good for high frequency sounds – breath sounds