PHYSICAL ASSESSMENT-SYSTEMATIC EXAMINATION   OF BODY STRUCTURES           IDENTIFY THE CLIENT/ REVIEW CLIENT’S MEDICAL HIS...
PHYSICAL ASSESSMENT/ENVIRONMENT                    l ORGANIZE EQUIPMENT                    l Easy access to a restroom-   ...
EQUIPMENT            drjAlo   3
“PURPOSES-gather objective data fromclient”l OBTAIN BASELINE MEASUREMENTS/FOR FUTURE  COMPARISONSl COMPARE WITH NORMAL DAT...
VITAL SIGNSl BODY  TEMPERATUREl PULSE RATEl RESPIRATORY  RATEl BLOOD PRESSURE                   drjAlo   5
VITAL SIGNS-NORMAL RANGESl TEMP-98.6-100.4 (ORAL)l       100.4-100.8 (RECTAL)l       95.8-99.4 (AXILLARY)l TYMPANIC-CALIBR...
PERIPHERAL PULSE SITES             drjAlo      7
“APICAL HEART RATE (loudest sound)-TO THE LEFT OF THE STERNUM ATTHE INTERSPACE BELOW THE 5TH RIBIN MIDLINE TO CLAVICLE”   ...
APICAL-RADIAL RATE-SHOULD BETHE SAME, IF NOT CHECK PULSEDEFICIT-REPORT FINDINGS PROMPT              drjAlo             9
PULSE        drjAlo   10
NORMAL AND ABNORMALRESPIRATORY PATTERNS             drjAlo    11
BLOOD PRESSURE            drjAlo   12
HYPOTENSION COMMON IN ELDERLYl ASSIST THE CLIENT TO SIT  OR STANDl BE PREPARED TO STEADY  OR ASSIST CLIENT IF  BECOMES DIZ...
ASSESSMENT TECHNIQUESl INSPECTION-1st-scan clientl AUSCULTATION-2ndl PERCUSSIONl PALPATIONl “What do you do first? Than se...
INSPECTION-”ONCE OVER”                      l OBSERVE-WHAT YOU                        SEE(COLOR OF SKIN-                  ...
LOOK FOR CLUES OF POOR HEALTHl LEVEL OF CONSCIOUSNESSl PERSONAL HYGIENEl NUTRITIONAL STATUSl POSTURE, GAIT—AMBULATORY AIDS...
CONT’ CLUESl ASSESS WHETHER AGE IS CONGRUENT  WITH APPEARANCEl OBSERVE BODY FAT, STATURE, MOTOR  MOVEMENTS, BODY AND BREAT...
AUSCULTATION                        l LISTENING TO                          BODY SOUNDS                        l HEART, LU...
PERCUSSION                      l STRIKING OR TAPPING A                        PART OF THE BODY                      l PRO...
PALPATION                     l LIGHTLY TOUCHING OR                       APPLYING DEEP PRESSURE                       (1 ...
APPROACH FOR DATA COLLECTIONl HEAD TO TOE APPROACHl ADVANTAGES-PREVENTS OVERLOOKING  SOME ASPECT OF DATA COLLECTION, IT  R...
DATA COLLECTION                     l HEAD-SYMMETRY, LUMPS                     l ASSESS MENTAL STATUS-                    ...
EYE ASSESSMENT                     l   EYES-SIMILAR IN SIZE AND DISTANCE                         FROM CENTER OF FACE      ...
PERRLA – PUPILS EQUALLY ROUNDAND REACT TO LIGHT ANDACCOMODATION                       l PUPILS ARE MEASURED IN            ...
EYE ASSESSMENT                     l EXTRAOCULAR                       MOVEMENTS-CAN THE                       CLIENT FOCU...
PERIPHERAL VISION ASSESS                      l GROSS ASSESSMENT-                        NURSE STANDS                     ...
EYES       drjAlo   27
EARS                l   INSPECT-(child=pull ear down and back;                    ADULT=pull ear up and back), PALPATE    ...
INNER EAR            drjAlo   29
NOSEl SEPTUM SHOULD BE MIDLINE, CAUSING THE NASAL  PASSAGES TO BE EQUAL IN SIZE-PRESS TIP OF NOSE FOR  DEEPER INSPECTION. ...
MOUTH AND ORAL MUCOUSMEMBRANE                      l EXAMINE THE                        MOUTH(PINK/MOIST),                ...
drjAlo   32
NECKl INSPECT AND PALPATE THE TRACHEA. DOES IT  RUN MIDLINE?l PALPATE THE NECK/LYMPH NODES-CHECK FOR  GOITER, NODULES, ENL...
FACIAL SKIN AND SKIN INTEGRITY OFTHE BODYl WOUND=BREAK IN THE SKINl ULCER=OPEN CRATER-LIKE AREAl ABRASION=AREA THAT HAS BE...
drjAlo   35
DECUBITUS STAGES            drjAlo   36
SKIN       drjAlo   37
VASCULAR LESIONS            drjAlo   38
VASCULAR LESIONS            drjAlo   39
VASCULAR LESIONS            drjAlo   40
UPPER NEUROMUSCULAREXAMINATIONl   INSPECT AND PALPATE MUSCLES, BONES, AND JOINTS.l   SYMMETRICAL, SIZE, TONE, RANGE OF MOT...
UPPER NEUROMUSCULAR EXAM           drjAlo          42
CHEST AND BREAST EXAMINATION                       l INSPECT AND PALPATE                         BREAST, NIPPLE, AND      ...
CHEST SHAPE AND MOVEMENT                     l LATERAL DIMENSION                       OF THE CHEST IS                    ...
SPINE OR COLUMN OF VERTEBRAE                       l MIDLINE WITH GENTLE                         CONVEX CURVES WHEN       ...
HEART                 l   A= AORTIC AREA                 l   P= PULMONIC AREA                 l   T= TRICUSPID AREA       ...
LUNG SOUNDS                       l AIR MOVING IN OUT                         OF AIR                         PASSAGEWAYS  ...
NORMAL LUNG SOUNDSl TRACHEAL SOUNDS-LOUD AND  COARSE; EQUAL IN LENGTH  DURING INSPIRATION AND  EXPIRATION AND ARE SEPARATE...
ABNORMAL LUNG SOUNDSl CRACKLES/RALES ARE INTERMITTENT, HIGH PITCHED, POPPING SOUNDS  HEAD IN DISTANT AREA OF THE LUNGS PRI...
ABDOMEN                   l   INSPECT SIZE(MEASURE GIRTH),                       CONTOUR(DISTENDED, HARD, SOFT),          ...
ABDOMEN          drjAlo   51
ABDOMEN          drjAlo   52
GENITOURINARY SYSTEM                     l   ASK CLIENT VOIDING-ANY BURNING,                         FREQUENCY,INCONTINENC...
LOWER EXTREMITY ANDMUSCULOSKELETAL EXAMINATIONl   HAVE CLIENT WALK ACROSS ROOM WHILE OBSERVING GAIT-NORMAL, UNSTEADY,    P...
MUSCULOSKELETAL           drjAlo   55
Musculoskeletal strength                 drjAlo    56
DOCUMENTING EDEMA           drjAlo   57
LOWER EXTREMITY            drjAlo   58
PHYSICAL ASSESSMENTl COMPARE THE CLIENT’S STATUS TO AGE-APPROPRIATE  STANDARDS FOR ACTIVITIES OF DAILY LIVING (ADLs), GROS...
PSYCHIATRIC ASSESSMENTl DISTURBED AFFECTl AVERSIVE EYE CONTACTl SYMPTOMS OF DEPRESSION OR  ANXIETYl DISRUPTED OR CONFUSED ...
SEXUAL HISTORY ASSESSMENTl EXPLAIN TO CLIENT YOU WILL BE ASKING  QUESTIONS PERTAINING TO HIS OR HER SEX LIFE  TO IDENTIFY ...
SEXUAL ASSESSMENTl IF THE ANSWER IS YESl HOW FREQUENTLY DO YOU HAVE SEX? IS  THIS A SATISFYING FREQUENCY FOR YOU?  IF NOT,...
drjAlo   63
l Thank You    drjAlo    64
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Physical assessment.drjma

  1. 1. PHYSICAL ASSESSMENT-SYSTEMATIC EXAMINATION OF BODY STRUCTURES IDENTIFY THE CLIENT/ REVIEW CLIENT’S MEDICAL HISTORY DETERMINE THE CLIENT’S AGE, GENDER, AND RACE OBSERVE THE CLIENT’S STATE OF ALERTNESS AND ABILITY TO MOVE; physical appearance in relation to their clothing and hygiene ASK A CLIENT’S OPINION ABOUT HIS OR HER HEALTH STATUS AND ANY CURRENT OR RECENT SIGNS AND SYMPTOMS WASH HANDS IN FRONT OF CLIENT EXPLAIN PROCEDURE TO CLIENT ANSWER CLIENT’S QUESTIONS DR. JAMES M. ALO, RN, MAN,MAP, PHD
  2. 2. PHYSICAL ASSESSMENT/ENVIRONMENT l ORGANIZE EQUIPMENT l Easy access to a restroom- empty bladder l ASSIST CLIENT TO A SITTING POSITION, IF APPLICABLE ON A PADDED, ADJUSTABLE TABLE OR BED l SUFFICIENT ROOM FOR MOVING TO EITHER SIDE OF THE CLIENT l WELL-LIT, WARM, PRIVATE ROOM-PULL CURTAIN l FACILITIY TO WASH HANDS l CLEAN COUNTER FOR PLACING EQUIPMENT l A LINED RECEPTACLE FOR SOILED ARTICLES drjAlol EXAMINE CLIENT 2 l HEIGHT, WEIGHT
  3. 3. EQUIPMENT drjAlo 3
  4. 4. “PURPOSES-gather objective data fromclient”l OBTAIN BASELINE MEASUREMENTS/FOR FUTURE COMPARISONSl COMPARE WITH NORMAL DATA (VARY WITH AGE- NORMAL TEMPERATURE DO NOT RULE OUT ILLNESS, ESP. YOUNG OR ELDERLYl EVALUATE CLIENT’S CURRENT PHYSICAL CONDITIONl DETECT EARLY SIGNS OF DEVELOPING HEALTH PROBLEMSl TO EVALUATE THE CLIENT’S RESPONSES TO MEDICAL AND NURSING INTERVENTIONS drjAlo 4
  5. 5. VITAL SIGNSl BODY TEMPERATUREl PULSE RATEl RESPIRATORY RATEl BLOOD PRESSURE drjAlo 5
  6. 6. VITAL SIGNS-NORMAL RANGESl TEMP-98.6-100.4 (ORAL)l 100.4-100.8 (RECTAL)l 95.8-99.4 (AXILLARY)l TYMPANIC-CALIBRATED TO ORAL OR RECTAL SCOREl PULSE-60-100 BEATS/MIN(NORMAL,WEAK, REGULAR, IRREGULAR, C/O OF PALPITATIONS)l RESPIRATIONS-MEN=14-18/MINl WOMEN=16-20/MINl ASSESS CHEST WALL RISING EQUAL BILATERAL, IF THE MOVEMENT IS LABORED OR IF THE CLIENT IS USING ACCESSORY MUSCLES TO BREATHE drjAlo 6
  7. 7. PERIPHERAL PULSE SITES drjAlo 7
  8. 8. “APICAL HEART RATE (loudest sound)-TO THE LEFT OF THE STERNUM ATTHE INTERSPACE BELOW THE 5TH RIBIN MIDLINE TO CLAVICLE” drjAlo 8
  9. 9. APICAL-RADIAL RATE-SHOULD BETHE SAME, IF NOT CHECK PULSEDEFICIT-REPORT FINDINGS PROMPT drjAlo 9
  10. 10. PULSE drjAlo 10
  11. 11. NORMAL AND ABNORMALRESPIRATORY PATTERNS drjAlo 11
  12. 12. BLOOD PRESSURE drjAlo 12
  13. 13. HYPOTENSION COMMON IN ELDERLYl ASSIST THE CLIENT TO SIT OR STANDl BE PREPARED TO STEADY OR ASSIST CLIENT IF BECOMES DIZZYl WAIT 30 SECONDS-TAKE B/Pl DETERMINE IF THE SYSTOLIC B/P FALLS 20MM Hg OR MORE, THE DIASTOLIC FALLS 10MM Hg OR MORE, PULSE RISE 20 BEATS OR MOREl CHECK HX SYNCOPE, CHEST PAIN, CHF, PACEMAKER drjAlo 13
  14. 14. ASSESSMENT TECHNIQUESl INSPECTION-1st-scan clientl AUSCULTATION-2ndl PERCUSSIONl PALPATIONl “What do you do first? Than second? drjAlo 14
  15. 15. INSPECTION-”ONCE OVER” l OBSERVE-WHAT YOU SEE(COLOR OF SKIN- PINK, DUSTY, MOTTLED, SKIN DISCOLORED), SMELL l STARTS DURING HEALTH HISTORY UNTIL END OF EXAM(BEFORE YOU TOUCH OR LISTEN) l FIRST NOTE GENERAL OBSERVATIONS drjAlo 15
  16. 16. LOOK FOR CLUES OF POOR HEALTHl LEVEL OF CONSCIOUSNESSl PERSONAL HYGIENEl NUTRITIONAL STATUSl POSTURE, GAIT—AMBULATORY AIDSl SYMMETRYl APPEARANCE AND APPROPRIATENESS OF CLOTHINGl LISTEN TO QUALITY AND APPROPRIATENESS OF SPEECHl OBSERVE FACIAL EXPRESSIONS-ANY EYE CONTACTl HOW COMFORTABLE IS CLIENT WITH INTERPERSONAL INTERACTION drjAlo 16
  17. 17. CONT’ CLUESl ASSESS WHETHER AGE IS CONGRUENT WITH APPEARANCEl OBSERVE BODY FAT, STATURE, MOTOR MOVEMENTS, BODY AND BREATH ODORSl GENERAL MANNERISMS-MOOD AND AFFECTl LOOK FOR SIGNS OF DISTRESS-AS EVIDENT BY BREATHING PATTERNS, SPEECH, FACIAL EXPRESSIONS, PERSPIRATION, TENSION, GUARDING, BRACING AND ANXIETY drjAlo 17
  18. 18. AUSCULTATION l LISTENING TO BODY SOUNDS l HEART, LUNGS, ABDOMEN l ELIMINATE OR REDUCE ENVIRONMENTAL NOISE drjAlo 18
  19. 19. PERCUSSION l STRIKING OR TAPPING A PART OF THE BODY l PRODUCE VIBRATORY SOUNDS l “AIDS IN DETERMINING LOCATION, SIZE, AND DENSITY OF UNDERLYING STRUCTURES” l CLIENT SHOULD NOT HAVE DISCOMFORT. PAIN COULD INDICATE DISEASE PROCESS OR TISSUE INJURY l “Descriptive terms/location-EX: normal lung = resonant” drjAlo 19
  20. 20. PALPATION l LIGHTLY TOUCHING OR APPLYING DEEP PRESSURE (1 INCH) l USE OF FINGER TIPS, BACK OF THE HAND, OR PALM OF HAND l SIZE, SHAPE, CONSISTENCY, MOBILITY OF NORMAL AND UNUSUAL MASSES, SYMMETRY l SKIN TEMPERATURE AND MOISTURE l ANY TENDERNESS l UNUSUAL VIBRATIONS drjAlo 20
  21. 21. APPROACH FOR DATA COLLECTIONl HEAD TO TOE APPROACHl ADVANTAGES-PREVENTS OVERLOOKING SOME ASPECT OF DATA COLLECTION, IT REDUCES THE NUMBER OF POSITION CHANGES REQUIRED OF THE CLIENT; GENERALLY TAKES LESS TIME BECAUSE THE NURSE IS NOT CONSTANTLY MOVING AROUND THE CLIENT IN HAPHAZARD MANNERl BODY SYSTEM APPROACH - TO FUNCTIONAL SYSTEM OF THE BODY-EX. SKIN, HEART, LUNG, ETC. drjAlo 21
  22. 22. DATA COLLECTION l HEAD-SYMMETRY, LUMPS l ASSESS MENTAL STATUS- COGNITIVE STATUS, ABLE TO THINK ABSTRACTLY, BEHAVIOR, MOOD, LOC-ALERT, DROWSY, STUPOROUS, COMATOSE l RESPONSIVENESS-AWAKE, SLEEPY, PAIN RESPONSE l ORIENTATION-TIME, PLACE, PERSON, YEAR, PRESIDENT l EMOTIONAL STATE-HAPPY, SAD, WITHDRAWN l HX OF HEAD INJURY, SEIZURES l HAIR- COLOR,TEXTURE,DISTRIBUTION EYEBROWS, EYELAHES,SCALP(SMOOTH, INTACT, FREE OF LESIONS, NITS; PALPATE SKULL FOR ANY UNUSUAL CONTOUR drjAlo 22
  23. 23. EYE ASSESSMENT l EYES-SIMILAR IN SIZE AND DISTANCE FROM CENTER OF FACE l IRIS SAME COLOR l SCLERAE-WHITE l CORNEAS-CLEAR l EYELASHES PRESENT l ADVANCE EXAM-USE A OPHTHALMOSCOPE l VISUAL ACUITY-ABLE TO SEE BOTH FAR AND NEAR; WEAR GLASSES OR CONTACT LENS; FALSE EYE; BLIND l FAR (central)VISION-ASK CLIENT TO STATE(SNELLEN CHART-READ LETTERS) HOW MANY FINGERS ARE UP FROM 20 FEET AWAY. “ex: 20/40-ONE THAT PEOPLE WITH NORMAL VISION CAN SEE FROM 40 FT AWAY” l CLOSE VISION- “(Jaeger Chart)HAVE THEM READ NEWSPAPER FROM APPROXIMATELY 14 INCHES away” drjAlo 23
  24. 24. PERRLA – PUPILS EQUALLY ROUNDAND REACT TO LIGHT ANDACCOMODATION l PUPILS ARE MEASURED IN MILLIMETER l DIM LIGHTS-MOVE LIGHT FROM TEMPLE TOWARD EYE; OBSERVE PUPIL AS WELL AS UNSTIMULATED PUPIL; REPEAT IN OTHER EYE; ASK CLIENT TO LOOK AT FINGER OR OBJECT 4 INCHES FROM FACE- LOOK NEAR AND FAR l CONSENSUAL RESPONSE(BRISK, EQUAL, SIMULTANEIOUS CONSTRICTION WITH LIGHT) “Notices the other pupil reacts simultaneously” l ACCOMMODATION(ABILITY TO CONSTRICT WHEN LOOKING AT A NEAR OBJECT AND DILATE WHEN LOOKING AT AN OBJECT IN THE DISTANCE l “Head injury-the nurse assesses client’s pupillary response.” drjAlo 24
  25. 25. EYE ASSESSMENT l EXTRAOCULAR MOVEMENTS-CAN THE CLIENT FOCUS AND TRACK MOVING OBJECT-EYES SHOULD MOVE IN COORDINATED MANNER. NO MOVE IN ONE EYE MAY INDICATE CRANIAL NERVE DAMAGE; IRREGULAR OR UNCOORDINATED MOVEMENT MAY SUGGEST OTHER NEUROLOGIC PATHOLOGY drjAlo 25
  26. 26. PERIPHERAL VISION ASSESS l GROSS ASSESSMENT- NURSE STANDS DIRECTLY IN FRONT OF THE CLIENT. NURSE INSTRUCTS CLIENT TO LOOK STRAIGHT AHEAD AND INDICATE WHEN HE OR SHE SEES A LIGHT OR THE NURSE’S FINGER AS THE NURSE BRINGS IT FROM SEVERAL SECTORS OF THE PERIPHERY TOWARD THE CENTER drjAlo 26
  27. 27. EYES drjAlo 27
  28. 28. EARS l INSPECT-(child=pull ear down and back; ADULT=pull ear up and back), PALPATE THE EXTERNAL EAR, INCLUDING ALIGNMENT(TOP OF EAR CROSSES AN IMAGINARY LINE FROM EYE TO OCCIPUT), l “Normal to have some cerumen” l CHECK FOR TAGS, EXCESS WAX, DRAINAGE, DEFORMITIES, NODULES, INFLAMMATION, PAIN, TENDER OR “BOGGY” MASTOID l OBSERVE THE SHAPE, COLOR, SIZE OF THE EAR l OTOSCOPIC-START AT EAR CANAL, TYMPANIC MEMBRANE AND ITS MOVEMENT-CHECK FOR INFECTIONS l HEARING ACUITY-NOTE RESPONSES TO SOUND-VOICE/WHISPER OR WATCH TICK 1-2 FEET. CONDUCT WEBER AND RHINNE TEST(TUNING FORK) “If the client does not continue to hear sound when the tuning fork is beside the ear, it indicates a problem with the ear structure that collect and transmit sound through the ear.” l DOES CLIENT USE ANY AIDS? drjAlo 28
  29. 29. INNER EAR drjAlo 29
  30. 30. NOSEl SEPTUM SHOULD BE MIDLINE, CAUSING THE NASAL PASSAGES TO BE EQUAL IN SIZE-PRESS TIP OF NOSE FOR DEEPER INSPECTION. HAVE CLIENT INHALE AND EXHALE THROUGH EACH NOSTRILl AIR SHOULD MOVE FAIRLY QUIETLYl MUCOUS MEMBRANE-PINK, MOIST, FREE OF OBVIOUS DRAINAGEl ABNORMAL-DEVIATED SEPTUM, LESIONS, GROWTHS, FLARING OF THE NOSTRILS, UNUSUAL DRAINAGEl SMELLING ASSESS-IDENTIFY ODORS-HAVE CLIENT CLOSE EYES-OCCLUDE ONE NOSTRIL AT A TIME-PLACE SUBSTANCES-VANILLA, COFFEE, ETC HAVE THEM IDENTIFY THE SMELL AFTER INHALING (TEST CN-I=OLFACTORY NERVE) drjAlo 30
  31. 31. MOUTH AND ORAL MUCOUSMEMBRANE l EXAMINE THE MOUTH(PINK/MOIST), TEETH(COUNT), TONGUE(MIDLINE), AND THROAT l INSPECT AND PALPATE LIPS(SYMMETRICAL), GUMS, TONGUE PROTRUSION, HARD AND SOFT PALATE, TONSILS, UVULA POSITION AND MOVEMENT- IDENTIFY LESIONS, COLOR OF MEMBRANES, CAVITIES, ODORS,SWELLING, INFLAMMATION, SWALLOWING DIFFICULITIES, CLEAR VOICE l CONDUCT GAG REFLEX RESPONSE, TASTE TEST FOR SWEET, SOUR, BITTER, AND SALT. l DENTURES(FIT PROPERLY), PARTIAL, BRIDGE drjAlo 31
  32. 32. drjAlo 32
  33. 33. NECKl INSPECT AND PALPATE THE TRACHEA. DOES IT RUN MIDLINE?l PALPATE THE NECK/LYMPH NODES-CHECK FOR GOITER, NODULES, ENLARGEMENTS OR TENDERNESS IN THE NECK AND THYROID.l PALPATE THE TEMPORAL AND CAROTID PULSES. ASSESS THE QUALITY, CHARACTER, RHYTHM, AND STRENGTH OF THE PULSEl BEND HEAD FORWARD, BACKWARD, TO EITHER SIDE AS WELL AS ROTATE 180 DEGREEl THERE SHOULD BE NO UNUSUAL BULGES OR FULLNESS IN THE NECK drjAlo 33
  34. 34. FACIAL SKIN AND SKIN INTEGRITY OFTHE BODYl WOUND=BREAK IN THE SKINl ULCER=OPEN CRATER-LIKE AREAl ABRASION=AREA THAT HAS BEEN RUBBED AWAY BY FRICTIONl LACERATION=TORN, JAGGED WOUNDl FISSURE=CRACK IN THE SKIN ESP. IN OR NEAR A MUCOUS MEMBRANESl SCAR=MARK LEFT BY THE HEALING OF A WOUND OR LESION drjAlo 34
  35. 35. drjAlo 35
  36. 36. DECUBITUS STAGES drjAlo 36
  37. 37. SKIN drjAlo 37
  38. 38. VASCULAR LESIONS drjAlo 38
  39. 39. VASCULAR LESIONS drjAlo 39
  40. 40. VASCULAR LESIONS drjAlo 40
  41. 41. UPPER NEUROMUSCULAREXAMINATIONl INSPECT AND PALPATE MUSCLES, BONES, AND JOINTS.l SYMMETRICAL, SIZE, TONE, RANGE OF MOTION.l ASSESS STRENGTH USING RESISTIVE ROM.l EXAMINE THE CERVICAL SPINE-FLEX, EXTENDl EXAMINE THE SHOULDERS-FLEX, HYPEREXTEND, ABDUCT, ADDUCT, TURN ININTERNAL AND EXTERNAL ROTATION, SHRUG AND PUSH/PULL AGAINST THE SHOULDERl EXAMINE WRISTS, ELBOWS-FLEX, EXTEND, ROTATEl HAND GRIPSl FINGERS-ABDUCT/ADDUCT. PERFORM FINGER THUMB OPPOSITION COUNTINGl CHECK FOR TENDERNESS/MOBILITY drjAlo 41
  42. 42. UPPER NEUROMUSCULAR EXAM drjAlo 42
  43. 43. CHEST AND BREAST EXAMINATION l INSPECT AND PALPATE BREAST, NIPPLE, AND AREOLA. PALPATE THE AXILLARY LYMPH NODES- DETECT LUMPS, NODULES, TENDERNES,DISCHARGE l Breast exam-massage small circles or a spokes of a wheel “outer margins of the breast tp the nipple.” l OBSERVE THE SHAPE OF THE CHEST AND HOW IT MOVES DURING BREATHING l TURGOR- elastic quality(RESILIENCY OF SKIN) INDICATES HYDRATION. (>3SEC ABNORMAL-prolonged tenting sign of dehydration) drjAlo 43
  44. 44. CHEST SHAPE AND MOVEMENT l LATERAL DIMENSION OF THE CHEST IS APPROX. TWICE THE ANTERIOR-POSTERIOR DIMENSIONS l ABNORMALITIES OF HEART AND LUNG CAN CAUSE CHEST TO CHANGE SHAPE l NORMAL BREATHING, CHEST EXPANDS EQUALLY ON BOTH SIDES drjAlo 44
  45. 45. SPINE OR COLUMN OF VERTEBRAE l MIDLINE WITH GENTLE CONVEX CURVES WHEN VIEWED FROM THE SIDE l SHOULDERS EQUAL IN HEIGHT l “SCOLIOSIS-LATERAL CURVATURE” l LORDOSIS-NATURAL LUMBAR CURVE OF THE SPINE IS EXAGGERATED l KYPHOSIS-INCREASED CURVE IN THE THORACIC AREA drjAlo 45
  46. 46. HEART l A= AORTIC AREA l P= PULMONIC AREA l T= TRICUSPID AREA l M=MITRAL AREA(APICAL)(PMI- loudest sound) l “S1”=LUB l S2=DUB l S3 NOT NORMAL IN ADULTS BUT NORMAL IN CHILDREN. SOUNDS LIKE LUB-DUB-DUB (KEN-TUCK-Y) l S4 LUB-LUB-DUB(BEFORE S1) TEN-NES-SEE (ABNORMAL) l LISTEN FOR ABNORMAL MURMURS, CLICKS, RUBS drjAlo 46
  47. 47. LUNG SOUNDS l AIR MOVING IN OUT OF AIR PASSAGEWAYS l SOUNDS VARY IN PITCH AND DURATION IN RELATION TO THE SIZE AND LOCATION OF THE AIR PASSAGES drjAlo 47
  48. 48. NORMAL LUNG SOUNDSl TRACHEAL SOUNDS-LOUD AND COARSE; EQUAL IN LENGTH DURING INSPIRATION AND EXPIRATION AND ARE SEPARATED BY A BRIEF PAUSEl BRONCHIAL SOUNDS-HEARD UPPER PART OF STERNUM AND BETWEEN SCAPULAE, ARE HARSH AND LOUD.l BRONCHOVESICULAR SOUNDS- HEARD EITHER SIDE OF CHEST- MEDIUM RANGE SOUNDS OF EQUAL LENGTH DURING INSPIRATION AND EXPIRATION WITH NO NOTICEABLE PAUSEl “VESICULAR SOUNDS LOCATED IN THE PERIPHERY OF ALL LUNG FIELDS”. THEY ARE SOFT, RUSTLING QUALITY IS LONGER ON INSPIRATION THAN EXPIRATION, WITH NO PAUSE BETWEEN. drjAlo 48
  49. 49. ABNORMAL LUNG SOUNDSl CRACKLES/RALES ARE INTERMITTENT, HIGH PITCHED, POPPING SOUNDS HEAD IN DISTANT AREA OF THE LUNGS PRIMARILY DURING INSPIRATION. RESEMBLE RICE KRISPIES WITH MILK ADDED. SOUNDS ATTRIBUTED TO THE OPENING OF PARTIALLY COLLAPSED ALVEOLIl GURGLES /RHONCHI LOW PITCHED, CONTINUOUS, BUBBLING SOUNDS HEAD IN LARGER AIRWAY. PROMINENT ON EXPIRATION. WET SNORING SOUND. MAY CLEAR AFTER YOU GET CLIENT TO COUGHl WHEEZES WHISTLING OR SQUEAKING SOUNDS BY AIR MOVING THROUGH A NARROWED PASSAGE. HEARD ANY WHERE THROUGHTOUT THE CHEST DURING INSPIRATION AND EXPIRATION. SOME ARE AUDIBLE WITHOUT STETOSCOPE. COUGHING AND DEEP BREATHING DO NOT ALTER A WHEEZE. IN FACT IF WHEEZING SUDDENLY STOPS, IT MAY MEAN THAT THE AIR PASSAGES IS TOTALLY OCCLUDED.l RUBS GRATING OR LEATHERY SOUNDS CAUSED BY TWO DRY PLEURAL SURFACES MOVING OVER EACH OTHER.l DIMINISEDl Watch for cyanosis, pursed lips,l ALWAYS INSPECT SPUTUM (esp. if client has a cough)-COLOR, AMOUNT, ODOR, CONSISTENCY REQUIRING SUCTION, OXYGEN, PULSE OXIMETRY, TRACHEOSTOMY drjAlo 49
  50. 50. ABDOMEN l INSPECT SIZE(MEASURE GIRTH), CONTOUR(DISTENDED, HARD, SOFT), SYMMETRY l NOTE PIGMENTATION, SCARS, STRIAE, MASSES, NODULES, CONDITION OF UMBILICUS, ANY RESPIRATORY OR PERISTALTIC MOVEMENT(LAST BM) l LISTEN FOR BOWEL SOUNDS IN EACH 4 QUADRANTS-CLICKS AND GURGLES OCCURS 5-34/MIN; HYPER^; HYPO-LONG INTERVAL OF SILENCE AND ABSENT IF NO SOUND HEARD FOR 2-5 MINUTES l PERCUSS RLQ, RUQ, GASTRIC BUBBLES, SPLEEN, BLADDER, LLQ, LUQ, LIVER SPAN l PALPATE FIRST SUPERFICIALLY THEN DEEP AND REBOUND PALPATIONS TO IDENTIFY ANY DISCOMFORT TENDERNESS, OR ABNORMALITIES. EVALUATE FOR GUARDING ON EXPIRATION l NAUSEA, VOMITING, FLATULENCE l PRESENCE OF HERNIA, COLOSTOMY, ILEOSTOMY, GASTROSTOMY l NUTRITIONAL APPROACH-ORAL, FEEDING, IV l CHECK FEMORAL PULSES(SYMMETRICAL AND EVEN) AND SUPERFICIAL AND DEEP INGUINAL NODES(NORMAL,1CM, MOVABLE AND NONTENDER) drjAlo 50
  51. 51. ABDOMEN drjAlo 51
  52. 52. ABDOMEN drjAlo 52
  53. 53. GENITOURINARY SYSTEM l ASK CLIENT VOIDING-ANY BURNING, FREQUENCY,INCONTINENCE, NOCTURIA(HOW MANY TIMES), RETENTION, CATHETER l NOTE URINE-COLOR(YELLOW, CLOUDY, FOAMY), ODOR l MENOPAUSE SYMPTOMS l LMP l OBSERVE PUBIC HAIR DISTRIBUTION, COLOR, TEXTURE l CHECK FOR SKIN ABNORMALITIES-IN WOMAN- EXAMINE MONS PUBIS, LABIA MAJORA, LABIA MINORA, CLITORIS, URETHRAL MEATUS, VAGINAL INTROITUS, AND PERINEUM l IN MEN-CHECK URETHRAL MEATUS, PENIS(GLANS, FORESKIN, SHAFT), SCROTOM RUGAE, TESTICLES l CHECK FOR ABNORMAL LESIONS, ODOR, SWELLING, INFLAMMATION, NODULES, CONDYLOMA, VESICLES, PUSTULES, SCALING, EDEMA l EXAMINE ANUS-FREE OF LESIONS, SWELLING,INFLAMMATION, TENDERNESS, ITCHING, FISSURES, RASHES, MASSES, HEMORRHOIDS, OR SKIN TAGS drjAlo 53
  54. 54. LOWER EXTREMITY ANDMUSCULOSKELETAL EXAMINATIONl HAVE CLIENT WALK ACROSS ROOM WHILE OBSERVING GAIT-NORMAL, UNSTEADY, POOR SITTING/STANDING BALANCE, DIZZINESS (FALL ASSESSMENT) ANY AMPUTATIONS, WT BEARING LIMITATIONS, PROSTHESIS, AMB. AIDSl INSPECT AND PALPATE THE SKIN. CHECK CAPILLARY REFILL- toenails (3 SEC); OBSERVE FOR HAIR DISTRIBUTION, VEINS, TEMPERATURE AND TEXTURE OF SKIN, toenails for fungal infection, inflammationl DETECTS SKIN ATROPHY, BREAKDOWN, EDEMA, ULCERATIONS, OR VARICOSE VEINS.l OBSERVE THE SIZE, SHAPE, ISOMETRIC MUSCLE CONTRACTION, TONE, STRENGTH(USING RESISTIVE ROM) OF MUSCLESl DETERMINES THAT MUSCLE SHAPE IS SYMMETRIC, WITH GOOD TONE. DETECTS ATROPHY, HYPERTROPHY, FLACCIDITY, SPASTICITY, SPASM, MASSES,OR INVOLUNTARY MOVEMENTS.l INSPECT THE JOINTS-CONFIRMS JOINTS ARTICULATE IN PROPER ALIGNMENT AND FREE FROM SWELLING, NODULES, PAIN, WARMTH, DEFORMITIES, MASSES, CRACKLING SOUND(CREPITUS), GRATING OR POPPING. EVALUATES FOR CONTRACTURES.l PALPATE ACHILLES TENDON-DORSIFLEX AND PLANTAR FLEX-EVALUATES CLONUS, DEEP VEIN THROMBOSl CHECK POPLITEAL, POSTERIOR TIBIAL, AND DORSALIS PEDIS PULSES drjAlo 54
  55. 55. MUSCULOSKELETAL drjAlo 55
  56. 56. Musculoskeletal strength drjAlo 56
  57. 57. DOCUMENTING EDEMA drjAlo 57
  58. 58. LOWER EXTREMITY drjAlo 58
  59. 59. PHYSICAL ASSESSMENTl COMPARE THE CLIENT’S STATUS TO AGE-APPROPRIATE STANDARDS FOR ACTIVITIES OF DAILY LIVING (ADLs), GROSS AND FINE MOTOR FUNCTION, SPEECH AND LANGUAGE, AND PERSONAL- SOCIAL INTERACTIONl PAIN-”DO YOU HAVE PAIN NOW?” LAST 7 DAYS? WHEN DO YOU HURT MOST? PAIN AFFECTS? DESCRIBE PAIN? WHAT RELIEVES? PAIN SCALE 0-5l SLEEP PATTERNl MEDICATIONS-ANTIPSYCHOTIC, ANTIANXIETY, ANTIDEPRESSANT, HYPNOTIC, DIURETICl SPECIAL TREATMENTS-CHEMOTHERAPY, DIALYSIS, TRANSFUSIONS, IV MED, RADIATION,l IF CLIENT UNABLE TO ANSWER QUESTIONS-NOTE FACIAL EXPRESSIONS, BREATHING, BEHAVIOR, VOCAL BEHAVIOR, BODY MOVEMENTS, CHANGES IN ADL’S, INDICATORS OF PAINl CONFIRMS HEALTH AND IDENTIFIES SIGNS AND SYMPTOMS OF ILLNESS OR DISEASE drjAlo 59
  60. 60. PSYCHIATRIC ASSESSMENTl DISTURBED AFFECTl AVERSIVE EYE CONTACTl SYMPTOMS OF DEPRESSION OR ANXIETYl DISRUPTED OR CONFUSED THOUGHT PROCESSESl INDICATIONS OF DELUSIONAL THOUGHTSl INDICATIONS OF SUICIDAL THOUGHYS drjAlo 60
  61. 61. SEXUAL HISTORY ASSESSMENTl EXPLAIN TO CLIENT YOU WILL BE ASKING QUESTIONS PERTAINING TO HIS OR HER SEX LIFE TO IDENTIFY PROBLEMS THAT COULD BE IMPROVED AND TO LEARN ABOUT POSSIBLE EXISTING CONDITIONS THAT COULD BE REVEALED THROUGH SEXUAL PROBLEMS. ASK ELDER FOR PERMISSION TO CONTINUE;l ARE YOU SEXUALLY ACTIVE?l IF NO, ASK FOR REASON(NO PARTNER, NO ENERGY, ERECTILE DYSFUNCTION)l BASED ON THE REASON, INQUIRE ABOUT THE ELDER’S INTEREST IN CHANGING THE SITUATION TO BECOME SEXUALLY ACTIVE AND RECOMMEND PLANS ACCORDINGLY drjAlo 61
  62. 62. SEXUAL ASSESSMENTl IF THE ANSWER IS YESl HOW FREQUENTLY DO YOU HAVE SEX? IS THIS A SATISFYING FREQUENCY FOR YOU? IF NOT, HOW WOULD YOU CHANGE THE FREQUENCY OF SEX/l DO YOU HAVE SEX WITH A SINGLE OR MULTIPLE PARTNERS? MALE OR FEMALE PARTNER?l IF YOU HAVE SEX WITH NEW PARTNERS, DO YOU USE A CONDOM?l DO YOU OBTAIN PLEASURE FROM SEX? IF NOT, WHY NOT? drjAlo 62
  63. 63. drjAlo 63
  64. 64. l Thank You drjAlo 64

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