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Chapter 27 Health Assessment
Preparing for the Health Assessment <ul><li>Environment </li></ul><ul><ul><li>Ensure privacy </li></ul></ul><ul><ul><li>Qu...
Preparing for the Health Assessment <ul><li>Equipment </li></ul><ul><ul><li>Maintenance </li></ul></ul><ul><ul><li>Isolati...
Preparing for the Health Assessment <ul><li>Positioning  </li></ul><ul><ul><li>Ensures accessibility to the body part bein...
Conducting the Health and Physical Assessment <ul><li>Aimed at establishing a data base against which subsequent data can ...
Conducting the Health and Physical Assessment <ul><li>Conducted in an aseptic, systematic, and efficient manner. </li></ul...
General Survey <ul><li>Initial Observations  </li></ul><ul><ul><li>Client’s physical appearance </li></ul></ul><ul><ul><li...
General Survey <ul><li>Special Considerations </li></ul><ul><ul><li>Elderly clients </li></ul></ul><ul><ul><li>Disabled cl...
Measurement of Height and Weight <ul><li>Height </li></ul><ul><ul><li>Height is expressed in inches (in), feet (ft), centi...
Measurement of Height and Weight <ul><li>Weight </li></ul><ul><ul><li>Measurement of weight is expressed in ounces (oz), p...
Measurement of Height and Weight <ul><li>Weight </li></ul><ul><ul><li>Types of scales available include chair, stretcher, ...
Measurement of Height and Weight <ul><li>Nursing Considerations </li></ul><ul><ul><li>Accurate recordings are necessary fo...
Measurement of Height and Weight <ul><li>Documentation </li></ul><ul><ul><li>Height and weight are recorded on the admissi...
Vital Signs <ul><li>The  taking of vital signs  refers to measurement of the client’s body temperature (T), pulse (P) rate...
Vital Signs <ul><li>Assessment of vital signs provides specific data regarding the client’s current condition. </li></ul><...
Vital Signs <ul><li>The sequence for recording vital sign measurements in the nurses’ notes is T-P-R and BP. </li></ul><ul...
Thermoregulation <ul><li>The body’s physiological function of heat regulation to maintain a constant internal body tempera...
Physiologic Function <ul><li>Thermoregulation </li></ul><ul><ul><li>The heat of the body is measured in units called degre...
Thermoregulation  <ul><li>Heat Production </li></ul><ul><ul><li>Basal Metabolic Rate (BMR) </li></ul></ul><ul><ul><li>Vaso...
Thermoregulation <ul><li>Heat Loss </li></ul><ul><ul><li>Radiation </li></ul></ul><ul><ul><li>Conduction </li></ul></ul><u...
Thermoregulation <ul><li>Behavioral Control of Body Temperature </li></ul><ul><ul><li>The person makes appropriate environ...
Respiration <ul><li>Respiration is the act of breathing.  </li></ul><ul><li>Terms related to respiratory function are: </l...
Respiration <ul><li>Major physiological pulmonary functions are: </li></ul><ul><ul><li>Ventilation </li></ul></ul><ul><ul>...
Hemodynamic Regulation <ul><li>The circulatory system transports nutrients to the tissues, removes waste products, and car...
Hemodynamic Regulation <ul><li>Systemic Circulation </li></ul><ul><ul><li>Arteries </li></ul></ul><ul><ul><li>Arterioles <...
Hemodynamic Regulation <ul><li>Cardiac Cycle </li></ul><ul><ul><li>Systole </li></ul></ul><ul><ul><li>Diastole </li></ul><...
Hemodynamic Regulation <ul><li>Pulse </li></ul><ul><ul><li>The pulse is caused by the stroke volume ejection and distensio...
Hemodynamic Regulation <ul><li>Blood Pressure  </li></ul><ul><ul><li>Measurement of pressure pulsations exerted against th...
Blood Pressure <ul><li>Systolic Pressure  </li></ul><ul><ul><li>Maximum pressure exerted against arterial walls during sys...
Hemodynamic Regulation <ul><li>Hemodynamic regulators for blood pressure control are: </li></ul><ul><ul><li>Blood volume <...
Factors Influencing Vital Signs <ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Heredity </li></ul><ul><li>Race </l...
Factors Influencing Vital Signs <ul><li>Medications </li></ul><ul><li>Pain </li></ul><ul><li>Exercise </li></ul><ul><li>An...
Assessing Body Temperature <ul><li>Temperature Scales </li></ul><ul><ul><li>Centigrade or Fahrenheit scales are used to me...
Assessing Body Temperature <ul><li>Alterations in Body Temperature </li></ul><ul><ul><li>Pyrexia </li></ul></ul><ul><ul><l...
Assessing Pulse <ul><li>Sites </li></ul><ul><ul><li>The most accessible peripheral sites are the radial and carotid sites....
Assessing Pulse  <ul><li>A peripheral pulse is palpated by placing the first two fingers on the pulse point with moderate ...
Assessing Pulse
Assessing Pulse  <ul><li>A  pulse deficit   occurs when the apical pulse rate is greater than the radial pulse rate. </li>...
Assessing Pulse  <ul><li>Nursing Considerations </li></ul><ul><ul><li>An irregular pulse rate, if not previously documente...
Assessing Respirations <ul><li>Sites </li></ul><ul><ul><li>Observation of chest wall expansion and bilateral symmetrical m...
Assessing Respirations <ul><li>Rate is counted by number of breaths taken per minute. </li></ul><ul><li>Observation of tho...
Assessing Respirations <ul><li>A stethoscope is used to auscultate breath sounds throughout the respiratory system. </li><...
Assessing Respirations <ul><li>Dyspnea, </li></ul><ul><li>Bradypnea, tachypnea, apnea </li></ul><ul><li>Hypoventilation </...
Assessing Respiratory Function <ul><li>Cyanosis </li></ul><ul><ul><li>Bluish appearance in the nail beds, lips, and skin <...
Assessing Respiratory Function <ul><li>Clients with respiratory alterations require additional nursing assessment. </li></...
Assessing Respiratory Function
Assessing Blood Pressure <ul><li>The direct method of measuring blood pressure requires an invasive procedure. </li></ul><...
Assessing Blood Pressure <ul><li>The most common site for indirect measurement is the client’s arm over the brachial arter...
Assessing Blood Pressure <ul><li>Korotkoff sounds  are five distinct phases of sound heard with a stethoscope during auscu...
Assessing Blood Pressure <ul><li>Hypotension   refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg be...
Assessing Blood Pressure <ul><li>Orthostatic Hypotension (postural hypotension) </li></ul><ul><ul><li>Sudden drop in systo...
Assessing Blood Pressure <ul><li>False Readings </li></ul><ul><ul><li>Clients who have recently eaten, ambulated, or exper...
The Physical Examination <ul><li>Techniques </li></ul><ul><ul><li>Inspection </li></ul></ul><ul><ul><li>Palpation </li></u...
Integumentary System <ul><li>Skin </li></ul><ul><li>Hair and Scalp </li></ul><ul><li>Nails </li></ul>
Skin Assessment <ul><li>Skin assessment provides a noninvasive window to observe the body’s physiological functions. </li>...
Skin Assessment <ul><li>Color </li></ul><ul><li>Lesions </li></ul><ul><li>Moisture </li></ul><ul><li>Temperature </li></ul...
Integumentary System <ul><li>Hair </li></ul><ul><ul><li>The amount and texture of hair vary with age, sex, race and body p...
Integumentary System <ul><li>Nails </li></ul><ul><ul><li>Clubbing </li></ul></ul><ul><ul><li>Koilonychia (spoon nail) </li...
Physical Examination <ul><li>Head </li></ul><ul><ul><li>Skull and   face assessment involves inspection and palpation.  </...
Physical Assessment <ul><li>Eyes </li></ul><ul><ul><li>Conjunctive and sclera are assessed for color, redness, swelling, e...
Physical Assessment <ul><li>Ears </li></ul><ul><ul><li>Auditory screening </li></ul></ul><ul><ul><li>Inspection and palpat...
Physical Examination <ul><li>Mouth and Pharynx </li></ul><ul><ul><li>Breath </li></ul></ul><ul><ul><li>Lips </li></ul></ul...
Physical Examination <ul><li>Neck </li></ul><ul><ul><li>Neck muscles </li></ul></ul><ul><ul><li>Lymph nodes of head and ne...
Physical Examination <ul><li>Thorax and Lungs </li></ul><ul><ul><li>Landmarks for inspection, auscultation, and percussion...
Thorax and Lungs <ul><li>Auscultation of Normal Breath Sounds </li></ul><ul><ul><li>Vesicular sounds </li></ul></ul><ul><u...
Thorax and Lungs. <ul><li>Auscultation of Adventitious Breath Sounds </li></ul><ul><ul><li>Crackles </li></ul></ul><ul><ul...
Heart and Vascular System <ul><li>Heart </li></ul><ul><ul><li>Landmarks for inspection, palpation, auscultation </li></ul>...
Heart and Vascular System <ul><li>Vascular System </li></ul><ul><ul><li>Blood perfusion of peripheral vessels </li></ul></...
Physical Examination <ul><li>Lymphatic System </li></ul><ul><ul><li>Lymphatic drainage </li></ul></ul><ul><ul><li>Lymph no...
Breasts and Axillae <ul><li>Palpation of four quadrants of breasts </li></ul><ul><li>Palpation of supraclavicular, infracl...
Breasts and Axillae <ul><li>Drainage patterns of the left breast. </li></ul>
Abdomen <ul><li>Inspection  </li></ul><ul><ul><li>Contour  </li></ul></ul><ul><ul><li>Symmetry </li></ul></ul><ul><ul><li>...
Abdomen <ul><li>Auscultation  </li></ul><ul><ul><li>All four quadrants in a systematic fashion </li></ul></ul><ul><ul><li>...
Abdominal Quadrants
Abdomen <ul><li>Light palpation in all four quadrants beginning with the RLQ </li></ul><ul><ul><li>Resistance </li></ul></...
Female Genitalia and Anus <ul><li>Cultural Considerations  </li></ul><ul><li>Inspection and Palpation  </li></ul><ul><ul><...
Male Genitalia, Anus, and Rectum <ul><li>Testes and male gonads </li></ul><ul><li>Seminal vesicles and bulbourethral gland...
Musculoskeletal System <ul><li>Inspection </li></ul><ul><li>Palpation </li></ul><ul><li>Range of Motion (ROM) </li></ul><u...
Musculoskeletal System <ul><li>Muscle </li></ul><ul><ul><li>Hypertrophy </li></ul></ul><ul><ul><li>Atrophy </li></ul></ul>...
Musculoskeletal System <ul><li>Joints </li></ul><ul><ul><li>Arthritis </li></ul></ul><ul><ul><li>Osteoarthritis </li></ul>...
Neurologic System <ul><li>Mental Status  </li></ul><ul><ul><li>Physical appearance and behavior </li></ul></ul><ul><ul><li...
Mental Status <ul><li>Cognitive Abilities and Mentation </li></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Memory ...
Neurological Assessment <ul><li>Sensory Assessment </li></ul><ul><ul><li>Exteroceptive sensations </li></ul></ul><ul><ul><...
Neurological Assessment <ul><li>Cranial Nerves Assessment </li></ul><ul><li>Motor Assessment </li></ul><ul><li>Cerebellar ...
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NURSING FUNDAMENTALS: HEALTH ASSESSMENT

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NURSING FUNDAMENTALS: HEALTH ASSESSMENT

  1. 1. Chapter 27 Health Assessment
  2. 2. Preparing for the Health Assessment <ul><li>Environment </li></ul><ul><ul><li>Ensure privacy </li></ul></ul><ul><ul><li>Quiet, warm room </li></ul></ul><ul><ul><li>Special needs of the client </li></ul></ul><ul><ul><li>Surface for placement of equipment </li></ul></ul>
  3. 3. Preparing for the Health Assessment <ul><li>Equipment </li></ul><ul><ul><li>Maintenance </li></ul></ul><ul><ul><li>Isolation precautions </li></ul></ul><ul><ul><li>Adequate number of gloves </li></ul></ul>
  4. 4. Preparing for the Health Assessment <ul><li>Positioning </li></ul><ul><ul><li>Ensures accessibility to the body part being assessed. </li></ul></ul><ul><li>Draping </li></ul><ul><ul><li>Prevents chilling. </li></ul></ul><ul><ul><li>Prevents unnecessary exposure. </li></ul></ul>
  5. 5. Conducting the Health and Physical Assessment <ul><li>Aimed at establishing a data base against which subsequent data can be compared. </li></ul><ul><ul><li>Comprehensive Assessment (head to toe) </li></ul></ul><ul><ul><li>Assessment of a body part (focused) </li></ul></ul><ul><ul><li>Assessment of a body system (focused) </li></ul></ul>
  6. 6. Conducting the Health and Physical Assessment <ul><li>Conducted in an aseptic, systematic, and efficient manner. </li></ul><ul><li>Requires the fewest position changes for the client. </li></ul>
  7. 7. General Survey <ul><li>Initial Observations </li></ul><ul><ul><li>Client’s physical appearance </li></ul></ul><ul><ul><li>Mood and behavior </li></ul></ul><ul><ul><li>Speech patterns and voice intonations </li></ul></ul><ul><ul><li>Signs and symptoms of distress </li></ul></ul><ul><ul><li>Vital signs </li></ul></ul><ul><ul><li>Height and weight </li></ul></ul>
  8. 8. General Survey <ul><li>Special Considerations </li></ul><ul><ul><li>Elderly clients </li></ul></ul><ul><ul><li>Disabled clients </li></ul></ul><ul><ul><li>Abused clients </li></ul></ul>
  9. 9. Measurement of Height and Weight <ul><li>Height </li></ul><ul><ul><li>Height is expressed in inches (in), feet (ft), centimeters (cm), or meters (m). </li></ul></ul><ul><ul><li>A scale for measuring height is usually attached to a standing weight scale. </li></ul></ul><ul><ul><li>Infant’s length is measured from vertex (top) of head to soles of feet while infant is lying with knees extended. </li></ul></ul>
  10. 10. Measurement of Height and Weight <ul><li>Weight </li></ul><ul><ul><li>Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg). </li></ul></ul><ul><ul><li>Daily weights should be obtained at the same time of the day, on the same scale, with the client wearing the same type of clothing. </li></ul></ul>
  11. 11. Measurement of Height and Weight <ul><li>Weight </li></ul><ul><ul><li>Types of scales available include chair, stretcher, bed, and platform scales. </li></ul></ul><ul><ul><li>Infants are weighed on platform or cradle scales. </li></ul></ul>
  12. 12. Measurement of Height and Weight <ul><li>Nursing Considerations </li></ul><ul><ul><li>Accurate recordings are necessary for drug dosage calculations and evaluation of effectiveness of drug, fluid, and nutritional therapy. </li></ul></ul>
  13. 13. Measurement of Height and Weight <ul><li>Documentation </li></ul><ul><ul><li>Height and weight are recorded on the admission assessment form. </li></ul></ul><ul><ul><li>Daily weights are usually recorded on the vital signs record. </li></ul></ul><ul><ul><li>Measurements taken at different times or on different scales should be recorded. </li></ul></ul>
  14. 14. Vital Signs <ul><li>The taking of vital signs refers to measurement of the client’s body temperature (T), pulse (P) rate, respiratory (R) rate, and blood pressure (BP). </li></ul><ul><li>Vital signs are the first step in the physical examination. </li></ul>
  15. 15. Vital Signs <ul><li>Assessment of vital signs provides specific data regarding the client’s current condition. </li></ul><ul><li>Variations from baseline values may indicate potential problems with the client’s health status. </li></ul>
  16. 16. Vital Signs <ul><li>The sequence for recording vital sign measurements in the nurses’ notes is T-P-R and BP. </li></ul><ul><li>Vital signs are plotted on graphic forms that facilitate data comparison at a glance. </li></ul>
  17. 17. Thermoregulation <ul><li>The body’s physiological function of heat regulation to maintain a constant internal body temperature </li></ul>
  18. 18. Physiologic Function <ul><li>Thermoregulation </li></ul><ul><ul><li>The heat of the body is measured in units called degrees. </li></ul></ul><ul><ul><li>The core internal temperature of 98.6 degrees Fahrenheit (F) does not vary more than 1.4 degrees F. </li></ul></ul><ul><ul><li>Core internal temperature is higher than the skin and external temperature. </li></ul></ul>
  19. 19. Thermoregulation <ul><li>Heat Production </li></ul><ul><ul><li>Basal Metabolic Rate (BMR) </li></ul></ul><ul><ul><li>Vasodilation </li></ul></ul><ul><ul><li>Vasoconstriction </li></ul></ul><ul><ul><li>Piloerection </li></ul></ul>
  20. 20. Thermoregulation <ul><li>Heat Loss </li></ul><ul><ul><li>Radiation </li></ul></ul><ul><ul><li>Conduction </li></ul></ul><ul><ul><li>Convection </li></ul></ul><ul><ul><li>Evaporation </li></ul></ul><ul><li>Insensible Heat Loss </li></ul>
  21. 21. Thermoregulation <ul><li>Behavioral Control of Body Temperature </li></ul><ul><ul><li>The person makes appropriate environmental adjustments in response to the body’s signaling conditions of either being overheated or too cold. </li></ul></ul>
  22. 22. Respiration <ul><li>Respiration is the act of breathing. </li></ul><ul><li>Terms related to respiratory function are: </li></ul><ul><ul><li>External respiration </li></ul></ul><ul><ul><li>Internal respiration </li></ul></ul><ul><ul><li>Inspiration </li></ul></ul><ul><ul><li>Expiration </li></ul></ul><ul><ul><li>Vital capacity </li></ul></ul>
  23. 23. Respiration <ul><li>Major physiological pulmonary functions are: </li></ul><ul><ul><li>Ventilation </li></ul></ul><ul><ul><li>Circulation </li></ul></ul><ul><ul><li>Diffusion </li></ul></ul><ul><ul><li>Transport </li></ul></ul><ul><ul><li>Regulation </li></ul></ul>
  24. 24. Hemodynamic Regulation <ul><li>The circulatory system transports nutrients to the tissues, removes waste products, and carries hormones from one part of the body to another. </li></ul>
  25. 25. Hemodynamic Regulation <ul><li>Systemic Circulation </li></ul><ul><ul><li>Arteries </li></ul></ul><ul><ul><li>Arterioles </li></ul></ul><ul><ul><li>Capillaries </li></ul></ul><ul><ul><li>Veins </li></ul></ul><ul><ul><li>Venules </li></ul></ul>
  26. 26. Hemodynamic Regulation <ul><li>Cardiac Cycle </li></ul><ul><ul><li>Systole </li></ul></ul><ul><ul><li>Diastole </li></ul></ul><ul><li>Stroke Volume </li></ul><ul><li>Cardiac Output </li></ul><ul><li>Compensatory Mechanisms </li></ul>
  27. 27. Hemodynamic Regulation <ul><li>Pulse </li></ul><ul><ul><li>The pulse is caused by the stroke volume ejection and distension of the walls of the aorta. </li></ul></ul><ul><ul><li>The bounding of blood flow in an artery is palpable at various points in the body (pulse points). </li></ul></ul>
  28. 28. Hemodynamic Regulation <ul><li>Blood Pressure </li></ul><ul><ul><li>Measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole </li></ul></ul>
  29. 29. Blood Pressure <ul><li>Systolic Pressure </li></ul><ul><ul><li>Maximum pressure exerted against arterial walls during systole </li></ul></ul><ul><li>Diastolic Pressure </li></ul><ul><ul><li>Pressure remaining in the arterial system during diastole </li></ul></ul>
  30. 30. Hemodynamic Regulation <ul><li>Hemodynamic regulators for blood pressure control are: </li></ul><ul><ul><li>Blood volume </li></ul></ul><ul><ul><li>Cardiac output </li></ul></ul><ul><ul><li>Peripheral vascular resistance </li></ul></ul><ul><ul><li>Viscosity </li></ul></ul>
  31. 31. Factors Influencing Vital Signs <ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Heredity </li></ul><ul><li>Race </li></ul><ul><li>Lifestyle </li></ul><ul><li>Environment </li></ul>
  32. 32. Factors Influencing Vital Signs <ul><li>Medications </li></ul><ul><li>Pain </li></ul><ul><li>Exercise </li></ul><ul><li>Anxiety and Stress </li></ul><ul><li>Postural Changes </li></ul><ul><li>Diurnal (daily) Variations </li></ul>
  33. 33. Assessing Body Temperature <ul><li>Temperature Scales </li></ul><ul><ul><li>Centigrade or Fahrenheit scales are used to measure temperature. </li></ul></ul><ul><ul><li>Glass or electronic thermometers are used. </li></ul></ul><ul><li>Temperature Sites </li></ul><ul><ul><li>Oral </li></ul></ul><ul><ul><li>Rectal </li></ul></ul><ul><ul><li>Axillary </li></ul></ul>
  34. 34. Assessing Body Temperature <ul><li>Alterations in Body Temperature </li></ul><ul><ul><li>Pyrexia </li></ul></ul><ul><ul><li>Hyperthermia </li></ul></ul><ul><ul><li>Heat Exhaustion </li></ul></ul><ul><ul><li>Heat Stroke </li></ul></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><ul><li>Frostbite </li></ul></ul>
  35. 35. Assessing Pulse <ul><li>Sites </li></ul><ul><ul><li>The most accessible peripheral sites are the radial and carotid sites. </li></ul></ul><ul><ul><li>The carotid site should always be used to assess the pulse in a cardiac emergency. </li></ul></ul>
  36. 36. Assessing Pulse <ul><li>A peripheral pulse is palpated by placing the first two fingers on the pulse point with moderate pressure. </li></ul><ul><li>A Doppler ultrasound stethoscope is used on superficial pulse points. </li></ul><ul><li>A stethoscope is used to auscultate the heart’s rate and rhythm. </li></ul>
  37. 37. Assessing Pulse
  38. 38. Assessing Pulse <ul><li>A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate. </li></ul><ul><li>Pulse Characteristics </li></ul><ul><ul><li>Pulse quality </li></ul></ul><ul><ul><li>Pulse rate (bradycardia, tachycardia) </li></ul></ul><ul><ul><li>Pulse rhythm (dysrhythmias) </li></ul></ul><ul><ul><li>Pulse volume </li></ul></ul>
  39. 39. Assessing Pulse <ul><li>Nursing Considerations </li></ul><ul><ul><li>An irregular pulse rate, if not previously documented, should be reported immediately. </li></ul></ul><ul><ul><li>Clients on certain cardiac medications may need to monitor their pulse rate. </li></ul></ul><ul><ul><li>Routine exercise lowers resting and activity pulses. </li></ul></ul>
  40. 40. Assessing Respirations <ul><li>Sites </li></ul><ul><ul><li>Observation of chest wall expansion and bilateral symmetrical movement of the thorax </li></ul></ul><ul><ul><li>Placement of back of hand next to client’s nose and mouth to feel expired air </li></ul></ul>
  41. 41. Assessing Respirations <ul><li>Rate is counted by number of breaths taken per minute. </li></ul><ul><li>Observation of thoracic and abdominal movements includes: </li></ul><ul><ul><li>Depth, rhythm, and symmetry </li></ul></ul><ul><ul><li>Costal (thoracic) breathing </li></ul></ul><ul><ul><li>Diaphragmatic breathing </li></ul></ul>
  42. 42. Assessing Respirations <ul><li>A stethoscope is used to auscultate breath sounds throughout the respiratory system. </li></ul>
  43. 43. Assessing Respirations <ul><li>Dyspnea, </li></ul><ul><li>Bradypnea, tachypnea, apnea </li></ul><ul><li>Hypoventilation </li></ul><ul><li>Hyperventilation </li></ul>
  44. 44. Assessing Respiratory Function <ul><li>Cyanosis </li></ul><ul><ul><li>Bluish appearance in the nail beds, lips, and skin </li></ul></ul><ul><ul><li>Reduced oxygen levels in the arterial blood </li></ul></ul>
  45. 45. Assessing Respiratory Function <ul><li>Clients with respiratory alterations require additional nursing assessment. </li></ul><ul><ul><li>Pulse oximetry </li></ul></ul><ul><ul><li>Apnea monitor </li></ul></ul>
  46. 46. Assessing Respiratory Function
  47. 47. Assessing Blood Pressure <ul><li>The direct method of measuring blood pressure requires an invasive procedure. </li></ul><ul><li>The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed. </li></ul>
  48. 48. Assessing Blood Pressure <ul><li>The most common site for indirect measurement is the client’s arm over the brachial artery. </li></ul><ul><li>Accurate measurement requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity. </li></ul>
  49. 49. Assessing Blood Pressure <ul><li>Korotkoff sounds are five distinct phases of sound heard with a stethoscope during auscultation. </li></ul><ul><li>The forearm or leg sites can be palpated to obtain a systolic reading when the brachial artery is inaccessible. </li></ul>
  50. 50. Assessing Blood Pressure <ul><li>Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure. </li></ul><ul><li>Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. </li></ul>
  51. 51. Assessing Blood Pressure <ul><li>Orthostatic Hypotension (postural hypotension) </li></ul><ul><ul><li>Sudden drop in systolic pressure when client moves from a lying to a sitting to a standing position </li></ul></ul>
  52. 52. Assessing Blood Pressure <ul><li>False Readings </li></ul><ul><ul><li>Clients who have recently eaten, ambulated, or experienced an emotional upset </li></ul></ul><ul><ul><li>Improper cuff width </li></ul></ul><ul><ul><li>Improper technique in deflating cuff </li></ul></ul><ul><ul><li>Improper positioning of extremity </li></ul></ul><ul><ul><li>Failure to recognize an auscultatory gap </li></ul></ul>
  53. 53. The Physical Examination <ul><li>Techniques </li></ul><ul><ul><li>Inspection </li></ul></ul><ul><ul><li>Palpation </li></ul></ul><ul><ul><li>Percussion </li></ul></ul><ul><ul><li>Auscultation </li></ul></ul>
  54. 54. Integumentary System <ul><li>Skin </li></ul><ul><li>Hair and Scalp </li></ul><ul><li>Nails </li></ul>
  55. 55. Skin Assessment <ul><li>Skin assessment provides a noninvasive window to observe the body’s physiological functions. </li></ul>
  56. 56. Skin Assessment <ul><li>Color </li></ul><ul><li>Lesions </li></ul><ul><li>Moisture </li></ul><ul><li>Temperature </li></ul><ul><li>Texture </li></ul><ul><li>Mobility and Turgor </li></ul><ul><li>Edema </li></ul>
  57. 57. Integumentary System <ul><li>Hair </li></ul><ul><ul><li>The amount and texture of hair vary with age, sex, race and body part. </li></ul></ul><ul><ul><li>Vellus </li></ul></ul><ul><ul><li>Terminal hair </li></ul></ul><ul><li>The scalp should be smooth, clean, intact, and free of lumps or tender areas. </li></ul>
  58. 58. Integumentary System <ul><li>Nails </li></ul><ul><ul><li>Clubbing </li></ul></ul><ul><ul><li>Koilonychia (spoon nail) </li></ul></ul><ul><ul><li>Beau’s line </li></ul></ul><ul><ul><li>Paronchia </li></ul></ul>
  59. 59. Physical Examination <ul><li>Head </li></ul><ul><ul><li>Skull and face assessment involves inspection and palpation. </li></ul></ul><ul><ul><li>The client’s face has its own unique characteristics related to race, state of health, emotions, environment. </li></ul></ul>
  60. 60. Physical Assessment <ul><li>Eyes </li></ul><ul><ul><li>Conjunctive and sclera are assessed for color, redness, swelling, exudate, foreign bodies </li></ul></ul><ul><ul><li>Visual acuity </li></ul></ul><ul><ul><li>Fundoscopy </li></ul></ul>
  61. 61. Physical Assessment <ul><li>Ears </li></ul><ul><ul><li>Auditory screening </li></ul></ul><ul><ul><li>Inspection and palpation of external ear </li></ul></ul><ul><ul><li>Placement, symmetry </li></ul></ul><ul><ul><li>Otoscopic assessment </li></ul></ul><ul><li>Nose and Sinuses </li></ul><ul><ul><li>Inspection and palpation </li></ul></ul><ul><ul><li>Use of a penlight </li></ul></ul>
  62. 62. Physical Examination <ul><li>Mouth and Pharynx </li></ul><ul><ul><li>Breath </li></ul></ul><ul><ul><li>Lips </li></ul></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><li>Buccal mucosa </li></ul></ul><ul><ul><li>Gums and teeth </li></ul></ul><ul><ul><li>Hard and soft palate </li></ul></ul><ul><ul><li>Pharynx </li></ul></ul>
  63. 63. Physical Examination <ul><li>Neck </li></ul><ul><ul><li>Neck muscles </li></ul></ul><ul><ul><li>Lymph nodes of head and neck </li></ul></ul><ul><ul><li>Thyroid gland </li></ul></ul><ul><ul><li>Trachea </li></ul></ul>
  64. 64. Physical Examination <ul><li>Thorax and Lungs </li></ul><ul><ul><li>Landmarks for inspection, auscultation, and percussion </li></ul></ul><ul><ul><li>Anterior and posterior examination </li></ul></ul><ul><ul><li>Shape and symmetry </li></ul></ul><ul><ul><li>Thoracic expansion </li></ul></ul><ul><ul><li>Tactile fremitus </li></ul></ul>
  65. 65. Thorax and Lungs <ul><li>Auscultation of Normal Breath Sounds </li></ul><ul><ul><li>Vesicular sounds </li></ul></ul><ul><ul><li>Bronchovesicular sounds </li></ul></ul><ul><ul><li>Bronchial sounds </li></ul></ul>
  66. 66. Thorax and Lungs. <ul><li>Auscultation of Adventitious Breath Sounds </li></ul><ul><ul><li>Crackles </li></ul></ul><ul><ul><li>Rhonchi </li></ul></ul><ul><ul><li>Wheezes </li></ul></ul><ul><ul><li>Pleural friction rub </li></ul></ul><ul><ul><li>Stridor </li></ul></ul>
  67. 67. Heart and Vascular System <ul><li>Heart </li></ul><ul><ul><li>Landmarks for inspection, palpation, auscultation </li></ul></ul><ul><ul><li>Heart sounds </li></ul></ul><ul><ul><li>Palpation for thrills and heaves </li></ul></ul><ul><ul><li>Abnormal auscultatory findings </li></ul></ul><ul><ul><ul><li>Murmurs </li></ul></ul></ul><ul><ul><ul><li>Bruits </li></ul></ul></ul>
  68. 68. Heart and Vascular System <ul><li>Vascular System </li></ul><ul><ul><li>Blood perfusion of peripheral vessels </li></ul></ul><ul><ul><ul><li>Peripheral pulses compared bilaterally </li></ul></ul></ul><ul><ul><ul><li>Skin temperature, color </li></ul></ul></ul>
  69. 69. Physical Examination <ul><li>Lymphatic System </li></ul><ul><ul><li>Lymphatic drainage </li></ul></ul><ul><ul><li>Lymph nodes </li></ul></ul>
  70. 70. Breasts and Axillae <ul><li>Palpation of four quadrants of breasts </li></ul><ul><li>Palpation of supraclavicular, infraclavicular, and axillary nodes </li></ul><ul><li>Education and encouragement of questions about breast self-examination (BSE) </li></ul><ul><li>Breast cancer can also occur in males. </li></ul>
  71. 71. Breasts and Axillae <ul><li>Drainage patterns of the left breast. </li></ul>
  72. 72. Abdomen <ul><li>Inspection </li></ul><ul><ul><li>Contour </li></ul></ul><ul><ul><li>Symmetry </li></ul></ul><ul><ul><li>Umbilicus </li></ul></ul><ul><ul><li>Surface motion </li></ul></ul><ul><ul><li>Scars </li></ul></ul>
  73. 73. Abdomen <ul><li>Auscultation </li></ul><ul><ul><li>All four quadrants in a systematic fashion </li></ul></ul><ul><ul><li>Beginning with the RLQ </li></ul></ul><ul><ul><ul><li>Tympany </li></ul></ul></ul><ul><ul><ul><li>Dullness </li></ul></ul></ul><ul><ul><ul><li>Bruits </li></ul></ul></ul><ul><ul><ul><li>Hyperactive or hypoactive bowel sounds </li></ul></ul></ul>
  74. 74. Abdominal Quadrants
  75. 75. Abdomen <ul><li>Light palpation in all four quadrants beginning with the RLQ </li></ul><ul><ul><li>Resistance </li></ul></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><li>Rebound tenderness </li></ul></ul><ul><ul><li>Organ enlargement </li></ul></ul>
  76. 76. Female Genitalia and Anus <ul><li>Cultural Considerations </li></ul><ul><li>Inspection and Palpation </li></ul><ul><ul><li>Mons pubis and vulva </li></ul></ul><ul><ul><li>Labia majora, labia minora </li></ul></ul><ul><ul><li>Clitoris </li></ul></ul><ul><ul><li>Urethral meatus and vaginal introitus </li></ul></ul><ul><ul><li>Perineum and anus </li></ul></ul>
  77. 77. Male Genitalia, Anus, and Rectum <ul><li>Testes and male gonads </li></ul><ul><li>Seminal vesicles and bulbourethral glands </li></ul><ul><li>Epididymis, vas deferens, ejaculatory ducts </li></ul><ul><li>Scrotum, penis, spermatic cord </li></ul><ul><li>Anorectral exam including the prostate </li></ul><ul><li>Monthly testicular self-examination (TSE) </li></ul>
  78. 78. Musculoskeletal System <ul><li>Inspection </li></ul><ul><li>Palpation </li></ul><ul><li>Range of Motion (ROM) </li></ul><ul><li>Bilateral Comparison </li></ul>
  79. 79. Musculoskeletal System <ul><li>Muscle </li></ul><ul><ul><li>Hypertrophy </li></ul></ul><ul><ul><li>Atrophy </li></ul></ul><ul><ul><li>Hypertonicity </li></ul></ul><ul><ul><li>Hypotonicity </li></ul></ul>
  80. 80. Musculoskeletal System <ul><li>Joints </li></ul><ul><ul><li>Arthritis </li></ul></ul><ul><ul><li>Osteoarthritis </li></ul></ul><ul><ul><li>Crepitus </li></ul></ul>
  81. 81. Neurologic System <ul><li>Mental Status </li></ul><ul><ul><li>Physical appearance and behavior </li></ul></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Level of consciousness </li></ul></ul>
  82. 82. Mental Status <ul><li>Cognitive Abilities and Mentation </li></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Memory </li></ul></ul><ul><ul><li>Judgment, insight </li></ul></ul><ul><ul><li>Spatial perception </li></ul></ul><ul><ul><li>Calculation </li></ul></ul><ul><ul><li>Abstraction </li></ul></ul><ul><ul><li>Thought process and content </li></ul></ul>
  83. 83. Neurological Assessment <ul><li>Sensory Assessment </li></ul><ul><ul><li>Exteroceptive sensations </li></ul></ul><ul><ul><li>Proprioceptive sensations </li></ul></ul><ul><ul><li>Cortical sensations </li></ul></ul><ul><ul><li>Dermatome map </li></ul></ul>
  84. 84. Neurological Assessment <ul><li>Cranial Nerves Assessment </li></ul><ul><li>Motor Assessment </li></ul><ul><li>Cerebellar Assessment </li></ul><ul><li>Reflex Assessment </li></ul>

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