Post on 05-Apr-2018
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Health History Physical Assessment Subjective database
Obtained through interview
ID strength, actual orpotential health problems,support system, teaching
needs, DC and referral needs
Use of effectivecommunications skills
Objective database
Obtained by observation and
physical assessmenttechniques
Completes the clients health
picture
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Complete Health History
Biographical data Reason for Seeking Care History of Present Illness Past HealthAccidents and Injuries Hospitalizations and Operations Family History Review of Systems
Functional Assessment ( Activities of Daily Living) Perception of Health
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Physical Assessment Environment Adequate lighting. Facilities for handwashing. Easy access to a restroom. A door or curtain that ensure privacy.
Adequate warmth for client comfort. A padded, adjustable table or bed. A lined receptacle for soiled articles. Sufficient room for moving to either side of the
client. A clean counter for placing examination
equipment.
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Positions Used During aPhysical Assessment
Sitting used to take vital signs Supine allows relaxation of abdominal
muscles Dorsal recumbent used for patients having
difficulty maintaining supine position Sims assessment of rectum or vagina Prone assessment of hip joint and posterior
thorax, Lithotomy assessment of female rectum and
vagina; used for brief period only Knee-chest assessment of the rectal area;
used for brief period only Standing assessment of posture, gait, and
balance
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Assessment Sequencing Head to - Toe Assessment
Body Systems Assessment
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Head-to-toe Assessment
Physical Assessment using head toe approachTest hearingCranial nervesInspect lymph nodesInspect neck veinsChest
Inspect and palpate breastInspect and auscultate lungsAuscultate heartAbdomenInspect, auscultate, palpate four
quadrants
Palpate and percuss liver, stomach,bladder
Bowel eliminationUrinary elimination
General SurveyGeneral health statusVital signs and weightNutritional statusMobility and self care
Observe postureAssess gait and balanceEvaluate mobilityActivities of daily livingHead face and neckEvaluate cognition
LOCOrientationMoodLanguage and memorySensory functionTest vision
Inspect and examine ears
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Head to Toe Assessment
ExtremitiesPalpate arterial pulsesObserve capillary refillEvaluate edemaAssess joint mobility
Measure strengthAssess sensory functionAssess circulation,movement, & sensation
Deep tendon reflexesInspect skin and nails
Skin, hair and nailsInspect scalp, hair & nailsEvaluate skin turgorObserve skin lesionAssess wounds
GenitaliaInspect female clientInspect male client
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Body System approachReview Of Systems
General presentation of symptoms: Fever, chills, malaise, pain, sleep
patterns, fatigability
Diet: Appetite, likes and dislikes, restrictions, written dairy of food intake
Skin, hair, and nails: rash or eruption, itching, color or texture change,
excessive sweating, abnormal nail or hair growth
Musculoskeletal: Joint stiffness, pain, restricted motion, swelling, redness,
heat, deformityHead and neck:
Eyes:visual acuity, blurring, diplopia, photophobia, pain, recent change in
vision
Ears:Hearing loss, pain, discharge, tinnitus, vertigo
Nose: Sense of smell, frequency of colds, obstruction, epistaxis, sinuspain, or postnasal discharge
Throat and mouth: Hoarseness or change in voice, frequent sore throat,
bleeding o swelling, of gums, recent tooth abscesses or extractions, soreness
of tongue or mucosa.
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Endocrine and genital reproductive: Thyroid enlargement or
tenderness, heat or cold intolerance, unexplained weight
change, polyuria, polydipsia, changes in distribution of facial
hair; Males: Puberty onset, difficulty with erections, testicular
pain, libido, infertility; Females: Menses {onset, regularity,
duration and amount}, Dysmenorrhea, last menstrual period,
frequency of intercourse, age at menopause, pregnancies
{number, miscarriage, abortions} type of delivery,complications, use of contraceptives; breasts {pain, tenderness,
discharge, lumps}
Chest and lungs: Pain related to respiration, dyspnea, cyanosis,
wheezing, cough, sputum {character, and quantity}, exposure to
tuberculosis (TB), last chest X-ray
Heart and blood vessels: Chest pain or distress, precipitating
causes, timing and duration, relieving factors, dyspnea,
orthopnea, edema, hypertension, exercise tolerance
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Gastrointestinal: Appetite, digestion, food intolerance, dysphagia,
heartburn, nausea or vomiting, bowel regularity, change in stool color,
or contents, constipation or diarrhea, f latulence or hemorrhoids Genitourinary: Dysuria, f lank or suprapubic pain, urgency, frequency,
nocturia, hematuria, polyuria, hesitancy, loss in force of stream,
edema, sexually transmitted disease
Neurological: Syncope, seizures, weakness or paralysis, abnormalities
of sensation or coordination, tremors, loss of memory
Psychiatric: Depression, mood changes, difficulty concentrating
nervousness, tension, suicidal thoughts, irritability.
Pediatrics: along with systemic approach in case of pediatrics,
measure anthropometric measurement and neuromuscularassessment.
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Assessment techniques
Setting Environment &Equipment Technique
General survey
Head to toe or systems approach
Minimize exposure
Areas to assess first unaffectedareas, external before internal
parts
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Physical Health Exam-General Survey
Appearance
Age, skin color, facial features
Body Structure - Stature, nutrition, posture, position, symmetry
Mobility - Gait, ROM
Behavior
Facial expression, mood/affect, speech, dress, hygiene
Cognition
Level of Consciousness and Orientation (x4)
Include any signs of distress- facial grimacing, breathing problems
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Assessment techniques
Inspection Close and careful visualization of the person as a whole
and of each body system
Ensure good lighting Perform at every encounter with your client
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Assessment techniques
Palpation
Temperature, Texture,Moisture
Organ size and location
Rigidity or spasticity
Crepitation & Vibration
Position & Size
Presence of lumps or masses
Tenderness, or pain
Palpation Techniques
Light
Deep
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Assessment techniques
Percussion assess underlying structures forlocation, size, density ofunderlying tissue.
Direct
Indirect
Blunt percussion
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Percussion Sounds
Resonance: A hollow sound. Hyper resonance: A booming sound.
Tympany: A musical sound or drum sound like thatproduced by the stomach.
Dullness: Thud sound produced by dense structures suchas the liver, and enlarged spleen, or a full bladder.
Flatness: An extremely dull sound like that produced byvery dense structures such as muscle or bone.
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Percussion sounds
Example oforigin
QualityLengthPitchIntensitySound
Normal lungHollowLongLowLoudResonance(heard over partair and part solid
Lung withemphysema
BoomingLongLowVery loudHyper-resonance(heard over
mostly air
Puffed-outcheek,gastricbubble
Drum likeModerateHighLoudTympany (heardover air)
Diaphragm,pleuraleffusion
Thud likeModerateMedium
MediumDullness (heardover more solidtissue
Muscle,Bone, Thigh
FlatshortHighSoftFlatness (heardover very dense
tissue
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Assessment techniques
Auscultation Listening to soundsproduced by the body
Instrument: stethoscope(to skin)
Diaphragmhighpitched sounds
Heart
LungsAbdomen
Bell low pitchedsounds
Blood vessels
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Normal Breath SoundsVesicular sounds
Soft rustling sounds heard over most lung tissue
Bronchovesicular sounds Has characteristics of above two
Heard only over major airways
Tracheal sounds
Hollow tubular sounds
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Abnormal (Adventitious)
Breath Sounds Crackles (rales)
discontinuous pop-like sounds
generally heard on inspiration but can be heard on exhalationalso
Wheezes
high-pitched continuous musical sounds
can be heard on both inspiration or exhalation
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Abnormal Breath Sounds Continued Rhonchi
low-pitched snoring sound that is continuous
can be heard on inspiration or exhalation
Bronchial Breath Sounds
same as Tracheal Sounds except heard over lungparenchyma
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Abnormal Breath Sounds Continued Stridor - high pitched raspy sound
is heard at its loudest over the trachea
indicates upper airway narrowing
heard in such conditions as;
post extubation stenosis
croup in young children
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Abnormal Breath Sounds Continued Pleural Friction Rub
Egophony - e to a changes
first section heard is the normal e sound second sound heard is the example of egophony: letter
e heard as a
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Crackles can indicateAtelectasis
Bronchitis
Pneumonia Pulmonary edema
Pulmonary fibrosis (dry crackles)
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Ronchi indicates Secretions in larger airways
frequently clear with a cough
seen in any condition that creates lung mucus
in COPD ronchi may occur because of airf lowobstruction unrelated to secretions
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Other Less Common Sounds Pleural friction rub
occurs when pleural surfaces rub together
seen in some pneumonias effecting pleural surfaces
Stridor
High pitched rasping sound heard mainly on inspiration
Indicative of upper airway obstruction
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Breathing Patterns Cheyne-Stokes Breathing
Irregular patterns of deep breathing followed by periodsof shallow breathing; usually ending with a period ofapnea
Biots Breathing
Irregular patterns of breathing; usually very
disorganzied. May be periods of apnea Kussmauls Breathing
Rapid & deep breathing
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More Breathing Patterns
Apneustic Pattern
Prolonged inspirations; serial inspirations w/oexhalation after each followed by summative
exhalationAsthmatic Pattern
Excessively long expiratory periods
Paradoxical Breathing Is present when a portion of chest wall moves in the
opposite direction as it should during the breathingcycle
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Voice Sounds Egophony
1. Place stethoscope over lung area
2. Ask patient to say the letter e3. If you actually hear the hard a sound;
4. The area has a fluid or consolidation
Bronchophony
An increase in intensity and clarity of vocal sounds.
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Cardiac Sounds Lub - Dub
S1, S2
PMI (Point of Maximal Impulse) Fifth intercostal, mid clavicular, left side
PVCs are common
Heaves, gallops, murmurs, bruits