Professional Documents
Culture Documents
Preparing
Client and environment require special consideration Keep the client informed Be organized demonstrate respect for the clients apprehension Appear calm, organized and competent at the bedside Adjust environment according to the clients need (special accommodations), quiet, warm and well lit Gather equipment Positioning and draping
HEALTH HISTORY
Purpose of the Health History Health history is a review of the clients functional health patterns prior to the current contact with a health care agency,
Purpose of physical health examination is to evaluate the physiologic outcomes of health care and thus the progress of a clients health problem
Allergies
Current medications Psychosocial history Value and belief system
2.
3. 4.
Elimination
Rest/sleep Activity/exercise Review of systems(ROS)-pain assessment
Objective data
Physical assessment
Height , weight, v/s, (general survey) Physical exam can be head to toe exam, focused exam of a body part, or body system Conducted in an aseptic, systematic and efficient manner
Physical assessment
General survey; clients physical appearance, mood and
behavior, signs and symptoms of distress Document data in an organized format, use proper terminology and agency-approved abbreviations
Techniques
1. 2. 3. 4.
Systems
1. Integumentary system (hair, scalp, skin and nails) 2. Head and Neck (skull, face, eyes, ears, nose, mouth, pharynx, and neck) 3. Thorax and Lungs 4. Heart and Vascular system 5. Lymphatic system 6. Abdomen
7. Genitalia
8. Musculoskeletal system 9. Neurologic system
Integumentary system
Skin Hair and Scalp Nails Skin assessment provides a noninvasive window to observe the bodys physiological functions.
SKIN
2. Bronchovesicular sounds
3. Bronchial sounds
Rhonchi
Wheezes
Heart
Landmarks for inspection, palpation, auscultation Heart sounds Palpation for thrills and heaves Abnormal auscultatory findings
Murmurs Bruits
Vascular System
Blood perfusion of peripheral vessels
Peripheral pulses compared bilaterally Skin temperature, color
Measurements
Capillary Refill: Push on the tip of the great toe or the nail bed until blanching occurs. Then release and note how long it takes for the red color to return, a reflection of blood inflow to the distal aspect of the lower extremity. Longer then 2-3 seconds is considered abnormal and consistent with arterial insufficiency.
Edema: There is a very subjective scale for rating edema which ranges from "trace at the ankles" to "4+ to the level of the knees." After examining many patients, you'll develop a sense of what is a lot and what is not.
Pulses: These are rated on a scale ranging from 0 (not palpable) to 2+ (normal). As with edema, this is very subjective and it will take you a while to develop a sense of relative values. In the event that the pulse is not palpable, the doppler signal generated is also rated, ranging again from 0 to 2+.
Abdomen
Inspection
Contour Symmetry Umbilicus Surface motion Scars
Auscultation
All four quadrants in a systematic fashion Beginning with the RLQ
Tympany Dullness Bruits Hyperactive or hypoactive bowel sounds
Abdomen
Musculoskeletal system
Mental Status
Appearance Level of alertness Speech Behavior Awareness of environment, also referred to as orientation Mood Affect: flat ,excitable, appropriate. Thought Process Thought Content Memory Judgment Higher cortical functioning and reasoning
Wakefulness
Unresponsive, Sleepy, Drowsy, Awake, Alert (Eye Opening None to spontaneous in Glascow Coma Scale)
Confusion
Memory defects of all kinds, intermittent or constant (Delirium b/c illness or medication OR depression, or dementia)
Orientation
Identifies person, place, time typically, but circumstances may prevent those steps if medicated or unfamiliar with environment
Wounds