NURS 190 Physical Assessment Practicum

NURS 190 Physical Assessment Practicum Physical Assessment Practicum For Every System: 1. 2. 3. 4. 5. 6. 7. Introduction Provide privacy Hand washing Instruct patient Position patient General appearance VS “If at any point you feel uncomfortable, please let me know” VERBALIZE, EXPLAIN, & DEMONSTRATE System I: SKIN AND NAILS, HEENT RELATED LYMPHATICS • • • • • • • • • • • • • • • • • • • • • Subjective data: Have you noticed any changes in the color of your skin? Do you have any sores or ulcers on your body that are healing slow? Have you noticed any lumps or swellings on your neck? Do you have headaches? Have you had any injuries to your head? Inspect & palpate skin for color, temp, elasticity (skin turgor), lesions, scars Head and hair – texture, lesions, cleanliness Eyes Visual acuity – rosenbaum, snellen (Make a chart?) Confrontation – sit facing patient 2-3 ft apart at eye level, explain that you are testing peripheral vision, cover opposite eyes and look directly into open eye, hold penlight on side of COVERED eye and advance it to midline until the patient sees it 6 cardinal fields of gaze (H or snowflake) + accommodation Corneal light reflex – shine light on pupils, should see “twinkle” Cover/Uncover test – cover one card with a card and observe uncovered eye, should remain focused on designated point; quickly remove card and observe newly uncovered eye, should focus straight ahead Pupillary response – constriction Ears External ear – look for discharge, redness, swelling Palpate auricle, push on tragus – should not cause pain Palpate mastoid process Whisper test Rinne – explain that this test compares air and bone conduction Place base on mastoid process, have pt tell you when sound is no longer heard – note # seconds Immediately move tines of fork to front of external auditory meatus, have pt tell you when sound is no longer heard – note # secs NORMAL = AC > BC • 1 Weber – explain that this test evaluates hearing better in one ear Place base against patients skull on midline of frontal bone or midline of• • • • • • • • • • • • • • • • forehead Sound lateralizes to impaired ear