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Physical Assessmentassessment Dr.Dr PhysicalPhysical AssessmentAssessment Dr.Dr. KarimaKarima ElshamyElshamy FacultyFaculty ofof NursingNursing MansouraMansoura UniversityUniversity EgyptEgypt PhysicalPhysical HealthHealth AssessmentAssessment NursingNursing historyhistory andand physicalphysical examinationexamination NursesNurses useuse physicalphysical assessmentassessment skillsskills to:to: – Develop (obtain baseline data) and expand the data base from which subsequent phases of the nursing process can evolve – To identify and manage a variety of patient problems (actual and potential) – Evaluate the effectiveness of nursing care – Enhance the nurse -patient relationship – Make clinical judgments ExceptExcept forfor thosethose occasionsoccasions whenwhen youyou seesee aa patientpatient specificallyspecifically toto conductconduct aa nursingnursing assessment,assessment, thethe assessmentassessment mustmust bebe integratedintegrated intointo routineroutine nursingnursing carecare –– Example:Example: thethe bathbath isis aa perfectperfect timetime toto incorporateincorporate assessmentassessment skillsskills frameworkframework thatthat isis usedused forfor assessmentassessment SubjectiveSubjective datadata -- SSaidaid byby thethe clientclient –– (S)(S) ObjectiveObjective datadata -- OObservedbserved byby thethe nursenurse –– (O)(O) NursingNursing ProcessProcess –– SOAPIERSOAPIER PreparingPreparing forfor thethe assessmentassessment ExplainExplain when,when, wherewhere andand whywhy thethe assessmentassessment willwill taketake placeplace HelpHelp thethe clientclient prepareprepare (empty(empty bladder,bladder, changechange clothes)clothes) PreparePrepare thethe environmentenvironment (lighting,(lighting, temperature,temperature, equipment,equipment, drapes,drapes, privacyprivacy –– SeeSee TableTable 2828 --22 forfor equipmentequipment usedused duringduring assessmentassessment PositioningPositioning PositionsPositions usedused duringduring nursingnursing assessment,assessment, medicalmedical examinations,examinations, andand duringduring diagnosticdiagnostic procedures:procedures: – Dorsal recumbent – Supine – Sims – Prone – Lithotomy – Genupectoral SeeSee TableTable 2828 --22 forfor clientclient positionspositions AssessmentAssessment TechniquesTechniques InspectionInspection -- criticalcritical observationobservation –– TakeTake timetime toto ““observeobserve ”” withwith eyes,eyes, ears,ears, nosenose –– UseUse goodgood lightinglighting –– LookLook atat color,color, shape,shape, symmetry,symmetry, positionposition –– OdorsOdors fromfrom skin,skin, breath,breath, woundwound –– DevelopDevelop andand useuse nursingnursing instinctsinstincts InspectionInspection isis donedone alonealone andand inin combinationcombination withwith otherother assessmentassessment techniquestechniques AssessmentAssessment TechniquesTechniques PalpationPalpation -- lightlight andand deepdeep touchtouch –– BackBack ofof handhand toto assessassess skinskin temperaturetemperature –– FingersFingers toto assessassess texture,texture, moisture,moisture, areasareas ofof tendernesstenderness –– AssessAssess size,size, shape,shape, andand consistencyconsistency ofof lesionslesions –– SeeSee BoxBox 2828 --4,4, p.p. 529529 toto describedescribe characteristicscharacteristics ofof massesmasses AssessmentAssessment TechniquesTechniques PercussionPercussion -- soundssounds producedproduced byby strikingstriking bodybody surfacesurface –– ProducesProduces differentdifferent notesnotes dependingdepending onon underlyingunderlying massmass (dull,(dull, resonant,resonant, flat,flat, tympani)tympani) –– UsedUsed toto determinedetermine sizesize andand shapeshape ofof underlyingunderlying structuresstructures byby establishingestablishing theirtheir bordersborders andand indicatesindicates ifif tissuetissue isis airair --filled,filled, fluidfluid --filled,filled, oror solidsolid –– SeeSee tabletable 2828 --4,4, pagepage 530530 forfor percussionpercussion notesnotes AssessmentAssessment TechniquesTechniques AuscultationAuscultation -- listeninglistening toto soundssounds producedproduced byby thethe bodybody Direct auscultation – sounds are audible without stethoscope Indirect auscultation – uses stethoscope – Know how to use stethoscope properly (practice) – Fine -tune your ears to pick up subtle changes (practice) – Describe sound characteristics (frequency, pitch intensity, duration, quality) (practice) Flat diaphragm picks up high -pitched respiratory sounds best Bell picks up low pitched sounds such as heart murmurs Practice using BOTH diaphragms PRACTICEPRACTICE CompleteComplete HistoryHistory andand PhysicalPhysical NursingNursing historyhistory isis subjectivesubjective -- includesincludes thingsthings likelike biographicbiographic data,data, thethe chiefchief complaint,complaint, sourcesource ofof thethe data,data, historyhistory ofof presentpresent illness,illness, pastpast medicalmedical history,history, immunizationimmunization history,history, allergies,allergies, habitshabits ,, stressors,stressors, familyfamily historyhistory includingincluding genogram,genogram, patternspatterns ofof healthhealth care,care, andand aa reviewreview ofof thethe bodybody ’’ss systemssystems HistoryHistory ofof PresentPresent IllnessIllness HPIHPI isis aa chronologicalchronological storystory ofof whatwhat hashas beenbeen happeninghappening – Must get details of the problem, therefore must be systematic – OLFQQAAT (one system – there are others): onset, location, frequency, quality, quantity, aggravating factors, alleviating factors, associated symptoms, treatments tried (include all treatments - Rx, OTC, herbal, folk) – Lots of systems – find one that works, and use it UseUse whateverwhatever systemsystem worksworks forfor you,you, butbut useuse aa systemsystem painpain intensityintensity scales,scales, etcetc –– Pain,Pain, quality/quantity,quality/quantity, radiation,radiation, setting,setting, timingtiming –– RateRate painpain fromfrom 11 toto 1010 –– UseUse ageage appropriateappropriate toolstools (faces)(faces) CulturallyCulturally appropriateappropriate carecare ExamExam OrderOrder andand DocumentationDocumentation DateDate andand identifyingidentifying datadata -- name,name, age,age, sex,sex, race,race, placeplace ofof birthbirth (if(if pertinent),pertinent), maritalmarital status,status, occupation,occupation, religionreligion SourceSource andand reliabilityreliability ofof historyhistory ChiefChief complaintcomplaint == reasonreason forfor visitvisit OrderOrder && DocumentationDocumentation FHFH -- ageage andand healthhealth ofof parentsparents andand siblingssiblings oror causecause ofof deathdeath (genogram);(genogram); HTN,HTN, DM,DM, CVD,CVD, Ca,Ca, HA,HA, arthritis,arthritis, addictionsaddictions ROSROS (subjective(subjective headhead --toto --toetoe review)review) – General - recent wt. change, fatigue, fever – Skin - rashes, lesions, changes, dryness, itching, color change, hair loss, change in hair or nails – Eyes - change in vision, floaters, glasses, HA, pain OrderOrder && DocumentationDocumentation ROSROS – Ears - pain, loss of hearing, vertigo, ringing, discharge, infections – Nose and sinuses - frequent colds, congestion, HA, nosebleed – Mouth and throat - condition of teeth and gums, last dental visit, hoarseness, frequent sore throats – Neck - lumps, stiffness, goiter – Breasts - lumps, pain, discharge, BSE OrderOrder && DocumentationDocumentation ROSROS – Respiratory - cough, sputum, wheezing, asthma, COPD, last PPD, last CXR, smoking history (can do here, or with “habits ”) – Cardiac - heart trouble, chest pain, SOB, murmur, h/o rheumatic fever, past EKG, FH of heart disease <50 yrs of age – GI - problems swallowing, heartburn, vomiting, bowel habits, pain, jaundice – Urinary - frequency, incontinence, pain, burning, hesitancy, nocturia, polyuria OrderOrder && DocumentationDocumentation ROSROS –– GenitaliaGenitalia -- lesions,lesions, discharge,discharge, sexualsexual orientation,orientation, sexualsexual function,function, menstrualmenstrual history,history, contraception,contraception, pregnancypregnancy history,history, TSETSE –– PeripheralPeripheral vascularvascular -- intermittentintermittent claudication,claudication, varicosevaricose veins,veins, bloodblood clotsclots –– MSMS -- musclemuscle oror jointjoint pain,pain, redness,redness, stiffness,stiffness, warmth,warmth, swelling,swelling, familyfamily historyhistory –– NeuroNeuro -- fainting,fainting, blackouts,blackouts, seizures,seizures, weaknessweakness OrderOrder && DocumentationDocumentation ROSROS –– EndocrineEndocrine -- sweats,sweats, skinskin change,change, heatheat oror coldcold intolerance,intolerance, excessiveexcessive thirstthirst (polydipsia),(polydipsia), excessiveexcessive urinationurination (polyuria),(polyuria), weightweight change,change, menstrualmenstrual changeschanges –– PsychiatricPsychiatric -- mentalmental illness,illness, thoughtsthoughts ofof harmingharming selfself oror othersothers AllAll ofof ROSROS isis subjectivesubjective;; PEPE isis objectiveobjective CompleteComplete H&PH&P -- ObjectiveObjective HistoryHistory isis subjective;subjective; PhysicalPhysical assessmentassessment isis objectiveobjective – Objective portion of exam begins with the general survey ; Each body system reviewed in text has nursing history at the beginning of the procedure for the objective exam – In actual practice, you get most of the history before ever touching the client, but there are usually additional history questions to ask during the exam OrderOrder ofof examexam -- headhead toto toetoe inin systematicsystematic
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