neo 111 melanie jorgenson, rn, bsn. inspection: performing deliberate, purposeful observations in a...
TRANSCRIPT
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Health Assessment: Part 1
NEO 111Melanie Jorgenson, RN, BSN
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Examination Techniques
Inspection: performing deliberate, purposeful observations in a systematic manner
Palpation: using the sense of touch
Percussion: striking one object against another to produce sound
Auscultation: listening with a stethoscope to sounds produced in the body
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Health History
Biographical data
Reason for seeking care
History of present health concern
Past medical history
Family history
Lifestyle
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Positions for Physical Examination
Sitting (to examine head, back, lungs, breast, heart, extremities)
Supine (to examine head, neck, lungs, breast, abdomen, heart, extremities)
Sims (to examine rectum and vagina)
Knee-chest (to examine rectum)
Dorsal recumbent (to examine head, neck, lungs, breast, heart)
Prone (to examine posterior thorax, lungs, hip)
Lithotomy (to examine female genitalia, rectum, genital tract)
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Assessments Made Using Palpation
Temperature
Turgor
Texture
Moisture
Pulsations
Vibrations
Shape and masses
Organs
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Assessments Made Using Percussion
Location
Shape
Size of organs
Density of other underlying structures or tissues
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Assessments and Characteristics of Sounds Determined by Auscultation
Assessments Blood pressure Heart sounds Lung sounds Bowel sounds
Characteristics of sounds Pitch Loudness Quality
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Initial Assessment Data
General survey
Height and weight
Vital signs
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Elements of a Head-to-Toe Physical Assessment
The Head & Neck The Eyes & Ears The Nose & Sinuses The Mouth & Throat
Chest and back The Posterior and Lateral Thorax The Anterior Thorax The Heart
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Height and Weight Measurements
As important as assessing the client’s vital signs.
Routinely taken on admission to acute care facilities and on visits to physicians’ offices, clinics, and other health care settings.
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Neck and Head Assessments
Facial structures Eyes, ears, nose, mouth, and throat
Anterior neck structures Trachea, esophagus, thyroid glad,
arteries, veins, and lymph nodes Posterior neck areas
Upper portion of the spine
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Thoracic Assessment
Focuses on:
Cardiovascular status.
Respiratory status.
Wounds, scars, drains, tubes, dressings.
Breasts.
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Types of Normal Breath Sounds
Bronchial (loud and high-pitched with a hollow quality)
Bronchovesicular (medium-pitched and blowing)
Vesicular (soft, breezy, and low-pitched)
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Terms Pertaining to Breath Sounds
Adventitious breath sounds (abnormal)
Sibilant wheezes (high-pitched, whistling)
Sonorous wheezes (low-pitched snoring)
Crackles (popping sounds heard on inhalation or exhalation
Pleural friction rub (low-pitched grating sound heard on inhalation or exhalation)
Stridor (high-pitched, harsh sound heard on inspiration while trachea or larynx is obstructed)
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Thorax and Lung Assessments
Respiratory system Recognizing and identifying normal and
abnormal breath sounds Components of the thorax
Lungs, rib cage, cartilage, and intercostal muscles
Assessment techniques Inspection, palpation, percussion, and
auscultation
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Palpating the Posterior Thorax (Sequence)
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Cardiovascular System Assessments
Functions of the system Transports oxygen, nutrients, and other
substances to the body tissues Removes metabolic waste products to
the kidneys and lungs Assessment techniques
Careful auscultation is important to identify heart sounds
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Documentation of Cardiac Assessment Findings
Any symptoms patient is experiencing Vital signs Color and temperature of skin; capillary refill
of nails Inspection findings related to carotid
arteries, jugular veins, and anterior chest wall
Palpation findings related to sternoclavicular area and anterior chest wall
Auscultation findings, including rate, rhythm, pitch, and location of sounds
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Palpating the Apical Impulse
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Questions?
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Health Assessment: Part 2
NEO 111Melanie Jorgenson, RN, BSN
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Elements of a Head-to-Toe Physical Assessment – Part 2
Neurological
Skin
Musculoskeletal
Upper and lower extremities
Abdomen
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Neurologic & Musculoskeletal Assessment
Neurologic system Assesses cognitive function Evaluates sensation in the body, cranial
nerves, and DTR Musculoskeletal examination
Provides information on muscles and joints
Peripheral vascular system Identifies condition of arteries and veins
in the extremities
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Neurological Assessment
Focuses on:
Level of consciousness
Pupil response
Hand grasps
Foot pushes
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Integumentary Assessments
Components of the integumentary system Skin, hair, nails, sweat glands, and
sebaceous glands Findings
Nutrition and hydration Overall health status Information associated with certain
systemic diseases, infection, immobility, sun exposure, and allergies
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Inspecting Overall Skin Coloration
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Musculoskeletal and Extremity Assessment
Through observation of client gait and overall range of movement, the nurse is able to obtain some knowledge of the symmetry and strength of muscles
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Abdominal Assessment
Focuses on gastrointestinal and genitourinary status
Includes use of inspection, auscultation, percussion, and palpation within the four quadrants of the abdomen to establish bowel function and status
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Abdomen Assessments
Components of the abdominal cavity Men and women: stomach, small and large
intestines, liver, gallbladder, pancreas, spleen, kidneys, urinary bladder, adrenal gland, and major blood vessels
Women: uterus, fallopian tubes, and ovaries Assessment techniques
Order: inspection, auscultation, percussion, and palpation
Not all organs can be assessed
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Assessment of Wounds, Drains, Tubes, and Dressings
The nurse must maintain accurate documentation of the amount of drainage, color, or other changes
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Questions?