HTT

• ROMANS 12:1-2: '"I appeal to you therefore, brothers, by the mercies of God, to present your bodies as a living sacrifice, holy and acceptable to God, which is your spiritual worship. Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect."'
• Nursing assessment


  • An important step of the whole nursing process
  • The base or foundation of the nursing process
  • If weak or incorrect, can create incorrect nursing diagnosis and plans, therefore creating wrong interventions and evaluations
• Physical examination


  Health care provider studies the body to determine physical health status
• Assessment


  The base or foundation of the nursing process
• Methods of physical examination

  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Inspection


  • Visual and olfactory to observe (color, odor, size, shape, symmetry, movement)
• Palpation


  • Using sense of touch (softness, temperature, position, texture)
• Percussion


  • Striking body surfaces, producing sounds (direct- tapping, indirect-using nail beds to transfer vibration)
• Percussion sounds

  • Flat
  • Dull
  • Resonant
  • Hyper resonant
  • Tympanic
• Auscultation


  • Listening to sound using stethoscope
• Preparation for physical examination

  • Environment
  • Equipment
  • Physical prep for patient
  • Psychological prep for patient
• Patient positions

  • Sitting
  • Supine
  • Dorsal recumbent
  • Sims
  • Prone
  • Lithotomy
  • Knee-chest or genu-pectoral
• Schiotz tonometer


  Measures intraocular pressure (IOP)
• Goniometer


  Measures joint ranges
• Skinfold caliper

  Assess the skinfold thickness
• Observations in general survey

  • Race
  • Sex
  • Nutrition state
  • Mental state
  • Evidence of pain
  • Posture
  • Gait
  • Clothes
  • Age
  • Grooming
  • Emotional status
• Scales to assess level of consciousness

  • Reaction Level Scale
  • Glasgow Coma Scale
• Vital signs

  • Temperature
  • Pulse
  • Respiration
  • Blood pressure
• Temperature


  Measures the degree of heat of the body (plus integumentary, vaginal, groin and otic)
• Factors that may alter temperature: environment, human activity, consumption
• Formula to convert Celsius to Fahrenheit

  °C= 5/9 (°F-32, °F= (9/5 x °C)+32
• Temperature measurement sites


  • Oral
  • Rectal
  • Axillary
• Pulse


  Regular beating caused by the arteries in each ventricular
• Factors that can alter pulse

  • Medication
  • Diet
  • Medical condition
  • Cardiac function
  • Peripheral vascular disease
  • Varicose vein
  • Thrombosis
  • Embolism
• Normal pulse rates per minute

  • Newborn: 130-140
  • 1yo: 115-130
  • 2yo: 100-115
  • 7yo: 85-90
  • Adult male: 70-80
  • Adult female: 80-90
• Respiration


  Continual process of drawing in and spelling out air from lungs (inspiration and expiration)
• Normal respiration rates (cpm)


  • Infants: 30-40
  • Children: 20-25
  • Adults: 16-20
• Blood pressure


  Force exerted by the blood against the wall of the vessels during ventricular contraction
• Normal blood pressure ranges

  • Adults: 110-149/60-90 mmHg
  • Children: 60-90/40-60 mmHg
  • Infants: 50-80/40-58 mmHg
• Skin observations

  • Color (cyanosis, pallor, jaundice, flushing, pigmentation)
  • Lesions (macule, papule, vesicle)
  • Vascularity (bruising, bleeding, edema, vascular and purpuric lesions)
  • Moisture (dryness, sweating, oiliness)
  • Texture (rough, scaly, smooth)
  • Temperature (warm, hot, cold)
  • Mobility and turgor (firm and loose)
• Normocephalic


  Occipitofrontal head circumference between the 3rd and 97th percentile for sex and age
• Hydrocephalic


  Cerebrospinal fluid builds up in the brain, causing increased pressure inside the skull
• Hair and scalp observations


  • Quantity and distribution
  • Dry, brittle
  • Alopecia (hair loss)
• Conjunctivitis


  Inflammation of the white part of the eye and the inside of the eyelid that causes it to appear pink or red
• Sclera


  White part of the eyeball
• Icteric sclerae


  Yellow color of sclera
• Puncta


  Small openings in the eyelids that drain tears from the eyes
• PERRLA

  Pupils are equally round and reactive to light and accommodation
• Normal pupil size

  3mm to 7mm
• Tunnel syndrome


  Can only see straight, loss of peripheral vision