HA

• General survey


  Involves observation of the client's general appearance, level of comfort, and mental status
• Appearance & mental status

  • The general appearance and behavior of an individual must be assessed in relationship to culture, educational level, socioeconomic status, and current circumstances
• Overall impression of the client


  Requires objective observation skills to assess the client's appearance, mobility, and body build
• Mental status exam


  Helps determine the client's emotional and cognitive functional statuses, provides information about the cerebral cortex function, and provides clues regarding the validity of the subjective information provided by the client
• Vital signs


  • Pulse (PR)
  • Respiration (RR)
  • Blood Pressure (BP)
  • Temperature (Temp)
  • Pain
• Vital signs


  • Always start with the non-invasive procedure or signs, ask the client if he or she has any pain, no subjective report of pain
• Signs of distress and pain

  Observe for posture, facial grimace, sad expression, difficulty in breathing, and skin color
• Appearance in relation to age

  Compare client's stated age with his or her apparent age and developmental stage, difference between biological age and chronological age
• Body structure


  • Observe physical development, malnourished children may be short for their age, thin or bloated, overweight & obesity-abnormal or excessive fat accumulation that presents a risk to health, observe for fat distribution (apple-shaped, pear-shaped), observe body proportion, note symmetry of body parts, length of the limbs
• Height and weight


  Measure and observe variations, is the height and weight appropriate to body structure, calculate BMI

  
• Body Mass Index (BMI)


  An inexpensive and easy screening method for weight category—underweight, healthy weight, overweight, and obesity

  
• Posture and gait


  • Observe posture and gait, posture is erect and comfortable for age, gait is rhythmic and coordinated with arms swinging at side, spastic gait, scissor gait, propulsive gait, slipping gait, waddling gait, observe for any curvatures of spine (lordosis, kyphosis, scoliosis, forward head)
• Physical deformities


  Congenital malformation, birthmarks, webbed digits or extra digits (polydactyly), two or more digits fused together (syndactyly)
• Hygiene and grooming


  • Observe overall hygiene and grooming, client is clean and groomed appropriately for occasion, clothes appropriate to age group, weather, culture, and occasion, signs of self-care deficit in relation to personal hygiene and clothing
• Body odor and breath

  Note for client's body odor and breath odor, halitosis (bad breath), keto breath (fruity scent as nail polish remover, sign of abnormally high ketones)
• Facial features and expression

  • Facial drooping loss of facial movement due to damage to the nerve (Bell's palsy or stroke), ptosis (drooping of the upper eyelid result from damage to the nerve that controls the muscles of the eyelid)
• Affect and mood


  Observe behavioral, body movements and affect, affect (what others sees in you), mood (what you're feeling), client is cooperative and purposeful in his or her interactions with others, mild to moderate anxiety maybe normal for clients on physical assessment, observe the client's level of consciousness
• Speech


  • Listen to speech, note tone, clarity, style and pattern, speech is in moderate tone, clear, moderately paced, and culturally appropriate, remember older adult's responses may be slowed but speech is clear and moderately paced, slurred speech (a symptom characterized by poor pronunciation of words, mumbling, or a change in speed or rhythm during talking, caused by damage to the glossopharyngeal (9th) & vagus (10th) cranial nerves)
• Post implementation


  Validate data gathered for accuracy, reliability, and completeness, discard PPE appropriately and perform hand hygiene, report significant findings and needs that requires immediate intervention to nurse supervisor or the physician, document and record data and findings gathered in the client's chart in a factual manner using appropriate terminologies
• Integumentary system


  Organ system consisting of the skin, nails and exocrine glands

  
• Skin


  • Largest organ of the body, physical barrier that protects the underlying tissues and organs, thicker on the palms and soles, plays vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis
• Layers of the skin

  • Epidermis (stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale)
  • Dermis (eccrine glands, apocrine glands)
  • Subcutaneous tissue (hypodermis)
• Hair


  Consists of layers of keratinized cells, found over much of the body except for the lips, nipples, soles of the feet, palms of the hands, provides thermoregulation by wicking sweat away from the body, protects scalp, provides insulation, and allows self-expression, nasal hair, auditory canal hair, eyelashes and eyebrows filter dust and other airborne debris
• Parts of the hair

  • Hair shaft
  • Hair follicle
  • Arrector pili muscles
  • Hair bulb
  • Hair papilla
• Nails


  Located on distal phalanges of fingers and toes, hard, transparent plates of keratinized epidermal cells that grow from the cuticle, protects the distal ends of the fingers and toes, enhance precise movements of digits, lunula, eponychium, cuticle, hyponychium

  
• Physical assessment process for integumentary system

  • Collect subjective data (ask questions about current skin problems, what aggravates/relieves the problem, cultural considerations), examine the skin for suspected lesions using the ABCDE mnemonic (asymmetry, border, color, diameter, evolution)
• Skin cancer is the abnormal growth of skin cells, most often develops on skin exposed to the sun, but can also occur on areas of skin not ordinarily exposed to sunlight, Asians are less susceptible, the fairer you are, the higher your risk
• Three major types of skin cancer

  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Melanoma (most dangerous)
• Skin cancer prevention


  Ensure diet is adequate in vitamin B3 (niacin), examine the skin for suspected lesions using the ABCDE mnemonic to assess suspicious lesions
• Skin cancer


  The abnormal growth of skin cells, most often develops on skin exposed to the sun
• Skin cancer can also occur on areas of your skin not ordinarily exposed to sunlight
• Asians are less susceptible to skin cancer, it is common in the US
• The fairer you are, the higher your risk of skin cancer
• Three major types of skin cancer

  • Basal Cell Carcinoma
  • Squamous Cell Carcinoma
  • Melanoma (most dangerous)
• Basal Cell Carcinoma


  • Occurs in sun-exposed areas such as neck and face, appear as pearly or waxy bump, sore that heals and returns
• Squamous Cell Carcinoma


  • Occurs in sun-exposed areas, appear firm, red nodule, flat lesion
• Melanoma


  • Can affect any skin tone, large brownish spot with darker speckles like a mole that changes in color, size, texture, or that bleeds and irregular border
• Prevention of skin cancer

  • Ensure that diet is adequate in vitamin B3 (niacin)
  • Examine the skin for suspected lesions using the ABCDE mnemonic to assess suspicious lesions: Asymmetry, Border, Color, Diameter, Evolution
• Client's preparation for physical examination

  • Remove all clothing, jewelry to put the examination gown
  • Remove all nail accessories (bare nails)
  • Comfortable and private
• Materials/equipment for physical examination

  • Gloves
  • Penlight
  • Mirrors for client's self-examination of skin
  • Magnifying glass
  • Centimeter ruler
  • Wood light
  • Examination gown and drapes
  • Assessment Tool- BRADEN SCALE FOR PREDICTING SORE RISK