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Physical Assessment
to obtain baseline data about the clients functional abilities to supplement, confirm, or refute data obtained in the nursing health history to obtain data that will help the nurse establish nursing diagnoses and plan the clients care to evaluate the physiologic outcomes of health care and thus the progress of a clients health problem To screen the presence of cancer.
2. Physical preparation
emptying the bowel and bladder changing into a gown draping to prevent unnecessary exposure, provide privacy, and to keep the client warm assuming a special position dorsal recumbent the client lies on the back with the legs separated, knees bent, and soles of the feet flat on the bed
areas examined:
head and neck, anterior thorax and lungs, breasts, heart, extremities, peripheral pulses
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Supine
the client lies flat on the back with the legs together but extended and slightly bent at the knees
areas examined:
head and neck, anterior thorax and lungs, breasts, heart, abdomen, extremities, peripheral pulses
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Sitting
the client sits upright in a chair or on the side of an examining table or bed or, if physically unable to maintain an upright position, may be supine in bed with the head elevated
areas examined:
head and neck, posterior and anterior thorax, lungs, breasts, heart, upper extremities, and to take vital signs
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Lithotomy
the client is in the dorsal recumbent position with the buttocks at the edge of the examining table and the feet supported in stirrups
areas examined:
Genupectoral (knee-chest)
the client kneels, using the knees and chest to bear weight of the body
areas examined:
rectum
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SimS
the client lies on either the right or left side with the lower arm behind the body, the upper arm bent at the shoulder and elbow, both knees bent, and the uppermost leg more acutely bent than the lowermost leg
areas examined:
rectum, vagina
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Prone
the client lies on the abdomen, fat on the bed, with the head turned to the side
areas examined:
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Physical assessment
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Physically Provide privacy Expose only the part to inspect. Cover body parts. Provide clean gown.
Psychologically
Skinfold caliper
Sphygmomanometer
stetoscope
Thermometer
Flashlight/penlight
Otoscope
opthalmoscope
Tuning fork
Nasal speculum
Tongue depressor
Skin-marking pen
Tape measure
Cotton balls
Clean gloves
3. Clean field.
Assessment Sequencing
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Assessment techniques
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Inspection
Close and careful visualization of the person as a whole and of each body system Ensure good lighting Perform at every encounter with your client
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Uses of Inspection
to determine the presence of normal and/or abnormal size, shape, color, symmetry, and/or position of an area of the body need to take into consideration normal variations as a result of developmental age need to take into consideration normal variations as a result of race
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Palpation
an assessment technique in which the examiner feels an area of the body with the palmar surface of the pads of
Uses of Palpation:
to determine texture (e.g., hair) to determine temperature (e.g., of a skin area) to determine vibration (e.g., of a joint) to determine the position, size, consistency, and mobility of organs or masses to determine distention (e.g., the urinary bladder) to determine the presence and rate of peripheral pulses to determine tenderness or pain.
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Light palpation
Use this technique to feel for surface abnormalities. Depress the skin to or 1.5 to 2 cm with your finger pads, using the lightest touch possible
Deep palpation
Use this technique to feel internal organs
and masses for size, shape, tenderness, symmetry and mobility.
Depress the skin 1 to 2 inches (4 to 5 cm) with firm, deep pressure. Use one hand on top of the other to exert firmer pressure if needed.
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Percussion
an assessment technique in which the examiner strikes an area of the body with the fingers Uses of percussion: to determine the borders of an underlying structure of the body by establishing the difference between tissue that is fluid-filled, air-filled, or solid to determine the absence or presence of normal and/or adventitious sounds elicited while percussing over an area of the body
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Types of Percussion :
direct percussion the examiner strikes an area of the body to be percussed directly with the pads of two, three, or four fingers or with the pad of the middle finger indirect percussion first, the examiner places the middle finger of the nondominant hand, referred to as the pleximeter, firmly on the clients skin over the area of the body to be percussed. second, the examiner strikes the distal interphalangeal joint of the pleximeter with the tip of the flexed middle finger of the dominant hand, referred to as the plexor
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Indirect percussion
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Direct Percussion
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flatness a soft, high-pitched, "dead stop of sound, absolute dullness" sound of short duration where found: typically over muscle, bone dullness a medium, medium-pitched, "thudlike" sound of moderate duration where found: typically over the liver, heart
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resonance a loud, low-pitched, "hollow" sound of long duration where found: typically over the lung hyperresonance a very loud, very low-pitched, "booming" sound of very long duration where found : typically over the emphysematous lung
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tympany a loud, high-pitched, "musical" sound of moderate duration where found : typically over the stomach filled with gas.
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Auscultation
an assessment technique in which an examiner listens to sounds produced from within an area of the body
Diaphragm high pitched sounds Heart Lungs Abdomen Bell low pitched sounds Blood vessels
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Uses of auscultation
to
determine the absence or presence of normal and/or adventitious sounds produced from within an area of the body
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Types of Auscultation :
direct auscultation
indirect auscultation
the examiner listens to sounds produced within the body by use of the unaided ear.
the examiner listens to sounds produced from within the body by use of a stetoscope.
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