Chapter 30 Health Assessment and Physical Examination/ Potter and Perry Rated 100% Correct!!

Five nursing purposes for performing a physical assessment: - 1) Gather baseline data about the patient's health status. 2) Support and refute subjective data obtained in nursing history. 3) Confirm and identify nurse's diagnoses. 4) Make clinical judgments about patient's changing health status and management. Principles related to the nurse performing daily physical examinations: - 1) A head-to-toe physical assessment is required daily. 2) Reassessment is performed when the patient's condition changes as it improves or worsens. 3) The environment equipment and the patient are properly prepared. 4) Safety for confused patients should be a priority. Proper examination includes: - a) Infection control (wash hands before & after visit, wear gloves) b) A private environment c) Equipment needed should be ready at bedside d) Physical preparation of the patient. e) Psychological preparation of the patient. (Let the patient know what you are going to do) purposes for performing a physical assessment - Seven variation in the nurse's individual style that are appropriate when examining children: - 1) Gather all the parts and histories and children from parents. 2) Perform the examination in a nonthreatening area and provide time for play. 3) Offer support to the parents during the examination and do not pass judgment. 4) Call children by their first names and address their parents as Mr. and Mrs. 5) Use open-end questions to allow parents to share more information.6) Treat adolescents as adults. 7) Provide confidentiality for adolescents; speak to them alone. Seven variations in the nurse's individual style that are appropriate when examining and older adult. - 1) Do not stereotype the aging patients' level of cognition. 2) Be sensitive to sensory or physical limitations, (more time). 3) Adequate space is needed. 4) Use patience, allow for pauses, and observe for details. 5) Certain types of information may be stressful to give. 6) Perform examination near bathroom facilities. 7) Be alert for signs of increasing fatigue. Principles to follow to keep an examination well organized: - 1) Compare both sides for symmetry 2) If the patient is ill, first assess the systems of the body part that is most at risk. 3) Offer rest periods if the patient becomes fatigued. 4) Record assessments in specific terms in the record. 5) Use common and accepted medical terms and abbreviations. 6) Record quick notes during examination to avoid delays. Inspection: - Is looking, listening and smelling to distinguish normal form abnormal findings. Guidelines to achieve the best results during inspection: - a) Adequate lighting is available. b) Use a direct light source. c) Inspect each area for size, shape, and color. d) Position and expose body parts as needed, maintaining privacy. e) Validate findings with the patient. Palpation: - Involves using hands to touch body palpation - involves pressing inward 1 cm (superficial) Deep palpation - involves depressing the area 4 cm to assess the condition of organs.