Health Assessment and Physical Examination Notes

Health Assessment and Physical Examination Notes What is a physical examination - the techniques used to gather objective data about the body What are the purposes of a physical examination - 1. to obtain baseline data 2. to identify nursing diagnoses 3. to monitor the status of a previously identified problem 4. to screen for health problems What are the types of physical examinations - 1. Comprehensive physical assessment 2. focused physical assessment 3. system -specific assessment 4. ongoing assessment How do you prepare to perform a physical exam...three things - 1. prepare yourself 2. prepare the environment 3. prepare the client what are the two approaches to a physical exam - 1. head to toe approach 2. body systems approach .How do I prepare the client for a physical exam - 1. select a time when the client is relaxed and receptive 2. establish rapport with the client 3. alert the client before touching him/her 4. consider developmental and cultural differences What techniques do I need to perform a physical exam - 1. Inspection--use of sight 2. Palpation--use of touch 3. Percussion-- use of tapping 4. Auscultation--use of hearing What modifications are there for different age groups - 1. Infants--parental holding or pads on table 2. Toddlers--they're the squirmers...engage them 3. Preschoolers--demonstrate procedures on doll or parent 4. School-age children--develop rapport 5. Adolescents--self conscious 6. Young adults and middle adults--we're cool 7. Older adults--assess ability to perform activities of daily living (use SPICES) What is a general survey - your overall impression of the client what is a BMI - Body mass index--indicates the relationship between weight and height What are characteristics of the integumentary system - skin, hair, and nails What is SPICES - it is an acronym for assessment of elderly needs 1. S leep disorders 2. P roblems with eating 3. I ncontinence 4. C onfusion 5. E evidence of falls 6. S kin breakdown What are the components of a general survey - 1. Appearance and behavior 2. Body type and posture 3. Speech 4. Dress, Grooming, and Hygiene 5. Mental State 6. Vital signs 7. Height and Weight Head to toe assessments by physicians generally follow this order after assessment of the patient's general overall appearance and skin condition. - 1. Head 2. Neck 3. Eyes 4. Ears 5. Nose and sinuses 6. Mouth and throat 7. Chest and lungs 8. Heart 9. Breasts 10. Abdomen 11. Genitalia 12. Rectum 13. Musculoskeletal System 14. Neurological System........