Basics of Nursing Ch 20,21,22

• Cultural assesment includes:

  • asking about preferences for food, bathing, personal care, and treatment.
• Physical assesments can be performed in:

  • hospitals
  • health centers
  • clinics
  • schools
  • long-term care
  • PCP offices
• Data collection/assessment is performed on an almost continual basis
• Assess for cultural preferences and health beliefs
• Physical data:

  • head and neck
  • chest, heart and lungs
  • abdomen
  • genutourinary system
  • extremities and musculoskeletal system
  • endocrine system
• Physical assessment provides a complete picture of physiologic functioning
• Comprehensive/in-depth

  -all systems of the body
• Brief, scanning examination

  -confined to a specific body part or system
• Visual observation:

  • General appearance
  • contours of the body
  • skin tone, rashes, scars, lesions
  • deformities or extremity weakness
• Palpation uses the hands and fingertips to touch and feel parts of the body
• Physical examination techniques:

  • palpation
  • percussion
  • auscultation
• percussion: light quick tapping on the body to produce sounds
• Percussion helps to determine:

  • size of organs
  • location of organs
  • density of organs
  • presence of air or fluids in tissue in a body cavity
• Auscultation: listening to presence or absence of body sounds with a stethoscope
• Auscultation is primarily used for:

  • lung sounds
  • heart sounds
  • abdomen sounds
• “Lubb“ = S1 sound is the closing of the mitral and tricuspid valves

  • start of systole
• “Dubb” sound= S2

  -closing of pulmonic and aortic valves

  -end of systole
• maximum Impulse can be found in between the 6th and 7th intercostal
• 5 areas of auscultation for the heart:

  • aortic
  • pulmonic
  • erbs point
  • tricuspid
  • mitral

  
• Olfaction is smelling
• Basic physical exam:

  • height and weight
  • infant without a diaper
  • vital signs
  • review of body systems
• Head & neck

  • appearance of the eyes
  • condition of hair
  • difficulty hearing or seeing
  • pupils equal in size
  • corneas clear
• Chest, Heart & Lungs

  • are shoulders equal height?
  • lordosis, kyphosis, scoliosis
  • signs of dyspnea
  • heart sounds normal?
  • apical pulse rate normal?
• PMI may be:

  • Tapping-normal
  • Sustained- suggests hypertrophy from hypertension
  • Diffuse- suggests dilated ventricle from congestive heart failure
• Inspect the spine from the rear and side
• Lordosis- exaggerated lumbar curve
• Kyphosis- increased forward curve of the thoracic area

  
• Scoliosis- pronounced lateral curvature of the spine
• Lung sounds:

  • vesicular- heard over the periphery of the lung fields
  • bronchovesicular- heard over the chest or back
  • Adventitious- abnormal lung sounds
• Wheeze- whistling, musical, high-pitched sound from air being forced through a narrow airway
• Rhonchi- coarse, low-pitched rattling sounds caused by secretions in the air passages
• Crackles- fine or coarse nonmusical sounds (rubbing hair between fingers)

  fine=high pitched

  coarse=low pitched
• Stertor- snoring sound produced by inability to cough up secretions from the trachea or bronchi
• Stridor- croaking or crowing sound heard when there is partial obstruction of the upper airway
• Pleural friction rub- grating or scratchy sound similar to opening a squeaky door. When irritated pleural membranes rub over each other
• Normal refill time of color to the nail bed when releasing pressure is less than 3 seconds
• Inspect skin:

  • rashes
  • flaking or dryness
  • signs of dehydration
  • turgor
  • capillary refill (checking nail bed)
• Reviewing abdomen:

  • bowel sounds in all four quadrants
  • silent, hyperactive, hyperactive, normal (5-30 sounds/min)
• Auscultation of bowel sounds

  
• abdominal assesment points

  1. epigastric
  2. umbilical
  3. hypogastric/suprapubic