ayesa

• Physical and Health Assessment


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Findings from physical exam are used to diagnose or help diagnose diseases or abnormalities
• Inspection


  1. Assess normal conditions and deviations using vision, smell, and hearing

  2. Assess for color, size, location, movement, texture, symmetry, odors, and sounds
• Palpation (Light and Deep)


  1. Light palpation: Feel for surface abnormalities, depress skin 1/2 to 3/4 inch, assess texture, tenderness, temperature, moisture, elasticity, pulsations, and masses

  2. Deep palpation: Feel internal organs and masses, depress skin 1 1/2 to 2 inches, use one hand on top of other to exert firmer pressure
• Percussion (Direct and Indirect)


  1. Direct percussion: Reveals tenderness, commonly used to assess adult's sinuses

  2. Indirect percussion: Elicits sounds that give clues to the makeup of the underlying tissue
• Auscultation


  Listening for various lung, heart, and bowel sounds with a stethoscope
• Health Assessment


  Key component of nursing practice, required for planning and provision of patient and family centered care
• Health Assessment


  Conducting a comprehensive and systematic nursing assessment, planning nursing care in consultation with individuals/groups, significant others & the interdisciplinary health care team, and responding effectively to unexpected or rapidly changing situations
• Data Collection in Health Assessment


  • Physical Examination
  • Obtaining Patient's Health History
• Subjective Data


  Information from the client's point of view (symptoms), including feelings, perceptions, and concerns obtained through interviews
• Objective Data


  Observable and measurable data (signs) obtained through observation, physical examination, and laboratory and diagnostic testing
• Sources of Data


  • Primary Source (the patient)
  • Secondary Source (significant others, guardians, relatives, laboratory examination)
• Evaluation Phase


  1. Ensure information collected is complete, accurate and documented appropriately

  2. Draw on critical thinking and problem solving skills to make clinical decisions and plan care

  3. Communicate abnormal findings to medical/allied health team

  4. Continuously assess for changes in condition and document assessments regularly
• Integumentary Assessment


  • Inspection and palpation
  • Assess for pungent body odor, pallor, cyanosis, jaundice, erythema, vitiligo, edema, lesions
• Edema


  Excess fluid in the tissue, characterized by swelling, taut and shiny skin, may leave an indentation after pressure is released (pitting edema)
• Edema Grading


  • 0: none
  • +1: trace, 2mm
  • +2: moderate, 4mm
  • +3: deep, 6mm
  • +4: very deep, 8mm
• Turgor


  Fullness or elasticity of the skin, usually assessed on the sternum or under the clavicle
• Describing Skin Lesions


  • Type or Structure (primary vs secondary)
  • Size, Shape and Texture
  • Color
  • Distribution
  • Configuration

  
• Hair and Scalp Assessment


  • Inspect hair color, texture, and distribution
  • Assess for conditions like kwashiorkor, alopecia, hirsutism
• Nail Assessment


  • Inspect nail plate shape, angle between nail and nail bed, nail texture, nail bed color, intactness of tissue around nails
  • Assess for clubbing, blanch test, koilonychia, Beau's lines, paronychia
• Head Assessment


  • Inspect and palpate for size, shape, proportion, symmetry of skull and face
  • Normocephalic: normal head size according to standard size tables