HA lec 4

• Physical Examination


  A systematic and efficient manner of evaluating the body and its function
• Purpose of Physical Assessment

  • To obtain baseline data about the client's functional abilities
  • To supplement, confirm, or refute data obtained in nursing history
  • To obtain data that would help the nurse establish nursing diagnoses and establish a plan for the client's care
  • To evaluate the progress of the client's health problem
  • To identify areas of health promotion and disease prevention
• Physical Examination Techniques


  1. Inspection

  2. Palpation

  3. Percussion

  4. Auscultation
• Inspection


  Use of one's senses to consciously observe the patient; which involves sense of vision, smell, and hearing
• Palpation

  Touching the patient in a diagnostic manner to elicit specific information
• Percussion

  Striking one's object against another to cause vibration to produce sound
• Auscultation


  Process of active listening to sounds within the body to gather information on a patient's health status (with the use of stethoscope)
• Physical Examination Positions


  • Sitting
  • Supine
  • Dorsal Recumbent
  • Lithotomy
  • Genupectoral/Knee-Chest
  • Standing
  • Sims' Position
  • Prone Position

  
• Sitting Position

  • Used to examine the skin, head, eyes, ears, nose and sinuses, mouth and pharynx, neck and reflexes, posterior and anterior thorax
  • Allows full expansion of the lungs and assessment of symmetry of upper body parts
• Supine Position

  • Used to examine the head, neck, axillae, anterior thorax, lungs, breasts, heart extremities, abdomen, peripheral pulses
  • Allows the abdominal muscles to relax and provides easy access to peripheral pulse sites
• Dorsal Recumbent Position

  • Used to examine the head and neck, axillae, anterior thorax, breasts, heart, extremities, vagina
  • May be more comfortable than supine position for clients with pain in the back or abdomen
  • Abdomen should not be assessed as the abdominal muscles are contracted
• Lithotomy Position


  • Used to examine the female genitals/reproductive tract, rectum
  • An exposed position, clients may feel embarrassed
  • Elderly clients may not be able to assume this position for very long or at all
• Genupectoral/Knee-Chest Position

  • Used to examine the rectum
  • May be embarrassing and uncomfortable for the client, should be kept in the position for as limited a time as possible
  • Elderly clients and clients with respiratory and cardiac problems may be unable to tolerate this position
• Standing Position

  • Used to assess posture, balance, and gait
  • Also used for examining the male genitalia

  
• Sims' Position

  • Used to examine the rectum and vagina
  • Clients with joint problems and elderly clients may have some difficulty assuming and maintaining this position
• Prone Position

  • Used to assess the hip joint and the back
  • Clients with cardiac and respiratory problems cannot tolerate this position
• Emotional Preparation


  • Ensure privacy
  • Explain the process and steps of the procedures and instrumentation
  • Keep the patient informed
  • Observe the client's reaction (verbal and non-verbal cues)
• Equipment/Materials Preparation


  • Flashlight/Penlight
  • Laryngeal/Dental Mirror
  • Nasal Speculum
  • Vaginal Speculum
  • Percussion Hammer
  • Tuning Fork
  • Otoscope
  • Tongue Depressor
  • Snellen's Chart
• Materials to be used should be clean before use to prevent transmitting microorganisms to both the client and the examiner
• Equipment and instruments to be used must be functional and ready for use to prevent needless disruption of the physical examination
• In addition, materials required for the examination should be placed well within the reach of the nurse to prevent waste of time and effort
• Materials required for examination

  • FLASHLIGHT / PENLIGHT
  • LARYNGEAL / DENTAL MIRROR
  • NASAL SPECULUM
  • VAGINAL SPECULUM
  • PERCUSSION HAMMER
  • TUNING FORK
  • OTOSCOPE
  • TONGUE DEPRESSOR
  • SNELLEN'S CHART
• Materials required for ALL examination

  • GLOVES
  • GOWNS
• Gloves


  Clean disposable gloves, always dispose of after each examination, universal protection to a nurse and patient
• Gowns


  You could use a blanket, this is used to drape or cover the patient
• Materials required for VITAL SIGNS examination

  • SPHYGMOMANOMETER
  • STETHOSCOPE
  • THERMOMETER (oral, rectal tympanic)
  • WATCH WITH SECOND HAND
  • PAIN RATING SCALE
• Sphygmomanometer


  To measure diastolic and systolic blood pressure
• Stethoscope


  To auscultate blood sounds when measuring blood pressure
• Thermometer


  To measure body temperature
• Watch with second hand


  To time heart rate and pulse rate
• Pain rating scale


  Determine perceived pain level
• Materials required for NUTRITIONAL STATUS examination

  • SKINFOLD CALIPERS
  • FLEXIBLE TAPE MEASURE
  • SKIN MARKING PEN
  • PLATFORM SCALE WITH HEIGHT ATTACHMENT
• Skinfold calipers

  To measure skinfold thickness of subcutaneous tissue, specifically for the abdomen and triceps
• Flexible tape measure

  To measure mid-arm circumference
• Skin marking pen

  Mark measurements
• Platform scale with height attachment

  To measure height and weight
• Materials required for SKIN, HAIR, AND NAILS examination


  • EXAMINATION LIGHT
  • PENLIGHT
  • MIRROR
  • METRIC RULER
  • MAGNIFYING GLASS
  • WOOD'S LIGHT
  • BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK
  • PRESSURE ULCER SCALE FOR HEALING (PUSH)
• Examination light


  For client's self-examination of skin
• Penlight


  To test for fungus
• Metric ruler


  To measure size of skin lesions