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Nursing Fundamentals
HEALTH ASSESSMENT


 Dr. James M. Alo, RN, MAN, MAP, PhD
Preparing for the Health
            Assessment

 Environment
  •   Ensure privacy
  •   Quiet, warm room
  •   Special needs of the client
  •   Surface for placement of equipment




                  drjma                    27-2
Preparing for the Health
         Assessment

 Equipment
  • Maintenance
  • Isolation precautions
  • Adequate number of gloves




               drjma                27-3
Preparing for the Health
          Assessment

 Positioning
  • Ensures accessibility to the body part being
    assessed.
 Draping
  • Prevents chilling.
  • Prevents unnecessary exposure.




                drjma                              27-4
Conducting the Health and
         Physical Assessment

 Aimed at establishing a data base
  against which subsequent data can be
  compared.
  • Comprehensive Assessment (head to toe)
  • Assessment of a body part (focused)
  • Assessment of a body system (focused)




               drjma                         27-5
Conducting the Health and
         Physical Assessment

 Conducted in an aseptic, systematic, and
  efficient manner.
 Requires the fewest position changes for
  the client.




               drjma                         27-6
General Survey

 Initial Observations
  •   Client’s physical appearance
  •   Mood and behavior
  •   Speech patterns and voice intonations
  •   Signs and symptoms of distress
  •   Vital signs
  •   Height and weight


                  drjma                       27-7
General Survey

 Special Considerations
  • Elderly clients
  • Disabled clients
  • Abused clients




                drjma      27-8
Measurement of Height and
           Weight

 Height
  • Height is expressed in inches (in), feet (ft),
    centimeters (cm), or meters (m).
  • A scale for measuring height is usually
    attached to a standing weight scale.
  • Infant’s length is measured from vertex (top)
    of head to soles of feet while infant is lying
    with knees extended.



                 drjma                               27-9
Measurement of Height and
           Weight

 Weight
  • Measurement of weight is expressed in
    ounces (oz), pounds (lb), grams (g), or
    kilograms (kg).
  • 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.


                drjma                          27-10
Measurement of Height and
           Weight

 Weight
  • Types of scales available include chair,
    stretcher, bed, and platform scales.
  • Infants are weighed on platform or cradle
    scales.




                drjma                           27-11
Measurement of Height and
          Weight

 Nursing Considerations
  • Accurate recordings are necessary for drug
    dosage calculations and evaluation of
    effectiveness of drug, fluid, and nutritional
    therapy.




                 drjma                              27-12
Measurement of Height and
          Weight

 Documentation
  • Height and weight are recorded on the
    admission assessment form.
  • Daily weights are usually recorded on the
    vital signs record.
  • Measurements taken at different times or on
    different scales should be recorded.



                drjma                             27-13
Vital Signs

 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).
 Vital signs are the first step in the
  physical examination.



               drjma                         27-14
Vital Signs

 Assessment of vital signs provides
  specific data regarding the client’s
  current condition.
 Variations from baseline values may
  indicate potential problems with the
  client’s health status.




               drjma                     27-15
Vital Signs

 The sequence for recording vital sign
  measurements in the nurses’ notes is T-
  P-R and BP.
 Vital signs are plotted on graphic forms
  that facilitate data comparison at a
  glance.



               drjma                         27-16
Thermoregulation

 The body’s physiological function of heat
  regulation to maintain a constant internal
  body temperature




               drjma                           27-17
Physiologic Function

 Thermoregulation
  • The heat of the body is measured in units
    called degrees.
  • The core internal temperature of 98.6
    degrees Fahrenheit (F) does not vary more
    than 1.4 degrees F.
  • Core internal temperature is higher than the
    skin and external temperature.


                drjma                              27-18
Thermoregulation

 Heat Production
  •   Basal Metabolic Rate (BMR)
  •   Vasodilation
  •   Vasoconstriction
  •   Piloerection




                 drjma             27-19
Thermoregulation

 Heat Loss
  •   Radiation
  •   Conduction
  •   Convection
  •   Evaporation
 Insensible Heat Loss



                    drjma     27-20
Thermoregulation

 Behavioral Control of Body Temperature
  • The person makes appropriate
    environmental adjustments in response to
    the body’s signaling conditions of either
    being overheated or too cold.




                drjma                           27-21
Respiration

 Respiration is the act of breathing.
 Terms related to respiratory function are:
  •   External respiration
  •   Internal respiration
  •   Inspiration
  •   Expiration
  •   Vital capacity


                   drjma                       27-22
Respiration

 Major physiological pulmonary functions
  are:
  •   Ventilation
  •   Circulation
  •   Diffusion
  •   Transport
  •   Regulation


                    drjma                   27-23
Hemodynamic Regulation

 The circulatory system transports
  nutrients to the tissues, removes waste
  products, and carries hormones from one
  part of the body to another.




              drjma                         27-24
Hemodynamic Regulation

 Systemic Circulation
  •   Arteries
  •   Arterioles
  •   Capillaries
  •   Veins
  •   Venules




                    drjma            27-25
Hemodynamic Regulation

 Cardiac Cycle
  • Systole
  • Diastole
 Stroke Volume
 Cardiac Output
 Compensatory Mechanisms



               drjma               27-26
Hemodynamic Regulation

 Pulse
  • The pulse is caused by the stroke volume
    ejection and distension of the walls of the
    aorta.
  • The bounding of blood flow in an artery is
    palpable at various points in the body (pulse
    points).



                 drjma                              27-27
Hemodynamic Regulation

 Blood Pressure
  • Measurement of pressure pulsations exerted
    against the blood vessel walls during systole
    and diastole




                drjma                               27-28
Blood Pressure

 Systolic Pressure
  • Maximum pressure exerted against arterial
    walls during systole
 Diastolic Pressure
  • Pressure remaining in the arterial system
    during diastole




                drjma                           27-29
Hemodynamic Regulation

 Hemodynamic regulators for blood
  pressure control are:
  •   Blood volume
  •   Cardiac output
  •   Peripheral vascular resistance
  •   Viscosity




                  drjma                27-30
Factors Influencing Vital Signs

   Age
   Gender
   Heredity
   Race
   Lifestyle
   Environment


                  drjma                 27-31
Factors Influencing Vital Signs

   Medications
   Pain
   Exercise
   Anxiety and Stress
   Postural Changes
   Diurnal (daily) Variations



                  drjma                   27-32
Assessing Body Temperature

 Temperature Scales
  • Centigrade or Fahrenheit scales are used to
    measure temperature.
  • Glass or electronic thermometers are used.
 Temperature Sites
  • Oral
  • Rectal
  • Axillary


                 drjma                            27-33
Assessing Body Temperature

 Alterations in Body Temperature
  •   Pyrexia
  •   Hyperthermia
  •   Heat Exhaustion
  •   Heat Stroke
  •   Hypothermia
  •   Frostbite


                 drjma                  27-34
Assessing Pulse

 Sites
  • The most accessible peripheral sites are the
    radial and carotid sites.
  • The carotid site should always be used to
    assess the pulse in a cardiac emergency.




                drjma                              27-35
Assessing Pulse

 A peripheral pulse is palpated by placing
  the first two fingers on the pulse point
  with moderate pressure.
 A Doppler ultrasound stethoscope is
  used on superficial pulse points.
 A stethoscope is used to auscultate the
  heart’s rate and rhythm.


               drjma                          27-36
Assessing Pulse




    drjma         27-37
Assessing Pulse

 A pulse deficit occurs when the apical
  pulse rate is greater than the radial pulse
  rate.
 Pulse Characteristics
  •   Pulse quality
  •   Pulse rate (bradycardia, tachycardia)
  •   Pulse rhythm (dysrhythmias)
  •   Pulse volume

                  drjma                         27-38
Assessing Pulse

 Nursing Considerations
  • An irregular pulse rate, if not previously
    documented, should be reported
    immediately.
  • Clients on certain cardiac medications may
    need to monitor their pulse rate.
  • Routine exercise lowers resting and activity
    pulses.


                drjma                              27-39
Assessing Respirations

 Sites
  • Observation of chest wall expansion and
    bilateral symmetrical movement of the
    thorax
  • Placement of back of hand next to client’s
    nose and mouth to feel expired air




                drjma                            27-40
Assessing Respirations

 Rate is counted by number of breaths
  taken per minute.
 Observation of thoracic and abdominal
  movements includes:
  • Depth, rhythm, and symmetry
  • Costal (thoracic) breathing
  • Diaphragmatic breathing


               drjma                      27-41
Assessing Respirations

 A stethoscope is used to auscultate
  breath sounds throughout the respiratory
  system.




               drjma                         27-42
Assessing Respirations

   Dyspnea,
   Bradypnea, tachypnea, apnea
   Hypoventilation
   Hyperventilation




                drjma               27-43
Assessing Respiratory Function

 Cyanosis
  • Bluish appearance in the nail beds, lips, and
    skin
  • Reduced oxygen levels in the arterial blood




                 drjma                              27-44
Assessing Respiratory Function

 Clients with respiratory alterations require
  additional nursing assessment.
  • Pulse oximetry
  • Apnea monitor




                drjma                            27-45
Assessing Respiratory Function




    drjma                   27-46
Assessing Blood Pressure

 The direct method of measuring blood
  pressure requires an invasive procedure.
 The indirect method requires use of the
  sphygmomanometer and stethoscope for
  auscultation and palpation as needed.




               drjma                         27-47
Assessing Blood Pressure

 The most common site for indirect
  measurement is the client’s arm over the
  brachial artery.
 Accurate measurement requires the
  correct width of the blood pressure cuff
  as determined by the circumference of
  the client’s extremity.


               drjma                         27-48
Assessing Blood Pressure

 Korotkoff sounds are five distinct phases
  of sound heard with a stethoscope during
  auscultation.
 The forearm or leg sites can be palpated
  to obtain a systolic reading when the
  brachial artery is inaccessible.




               drjma                          27-49
Assessing Blood Pressure

 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.
 Hypertension refers to a persistent
  systolic pressure greater than 135 to 140
  mm Hg and a diastolic pressure greater
  than 90 mm Hg.

               drjma                          27-50
Assessing Blood Pressure

 Orthostatic Hypotension (postural
  hypotension)
  • Sudden drop in systolic pressure when client
    moves from a lying to a sitting to a standing
    position




                drjma                               27-51
Assessing Blood Pressure

 False Readings
  • Clients who have recently eaten, ambulated,
    or experienced an emotional upset
  • Improper cuff width
  • Improper technique in deflating cuff
  • Improper positioning of extremity
  • Failure to recognize an auscultatory gap



                drjma                             27-52
The Physical Examination

 Techniques
  •   Inspection
  •   Palpation
  •   Percussion
  •   Auscultation




                     drjma             27-53
Integumentary System

 Skin
 Hair and Scalp
 Nails




              drjma             27-54
Skin Assessment

 Skin assessment provides a noninvasive
  window to observe the body’s
  physiological functions.




              drjma                        27-55
Skin Assessment

   Color
   Lesions
   Moisture
   Temperature
   Texture
   Mobility and Turgor
   Edema

                 drjma       27-56
Integumentary System

 Hair
  • The amount and texture of hair vary with
    age, sex, race and body part.
  • Vellus
  • Terminal hair
 The scalp should be smooth, clean,
  intact, and free of lumps or tender areas.


                drjma                          27-57
Integumentary System

 Nails
  •   Clubbing
  •   Koilonychia (spoon nail)
  •   Beau’s line
  •   Paronchia




                  drjma            27-58
Physical Examination

 Head
  • Skull and face assessment involves
    inspection and palpation.
  • The client’s face has its own unique
    characteristics related to race, state of
    health, emotions, environment.




                 drjma                          27-59
Physical Assessment

 Eyes
  • Conjunctive and sclera are assessed for
    color, redness, swelling, exudate, foreign
    bodies
  • Visual acuity
  • Fundoscopy




                 drjma                           27-60
Physical Assessment

 Ears
  •   Auditory screening
  •   Inspection and palpation of external ear
  •   Placement, symmetry
  •   Otoscopic assessment
 Nose and Sinuses
  • Inspection and palpation
  • Use of a penlight

                   drjma                         27-61
Physical Examination

 Mouth and Pharynx
  •   Breath
  •   Lips
  •   Tongue
  •   Buccal mucosa
  •   Gums and teeth
  •   Hard and soft palate
  •   Pharynx

                  drjma            27-62
Physical Examination

 Neck
  •   Neck muscles
  •   Lymph nodes of head and neck
  •   Thyroid gland
  •   Trachea




                 drjma               27-63
Physical Examination

 Thorax and Lungs
  • Landmarks for inspection, auscultation, and
    percussion
  • Anterior and posterior examination
  • Shape and symmetry
  • Thoracic expansion
  • Tactile fremitus



                drjma                             27-64
Thorax and Lungs

 Auscultation of Normal Breath Sounds
  • Vesicular sounds
  • Bronchovesicular sounds
  • Bronchial sounds




               drjma                     27-65
Thorax and Lungs.

 Auscultation of Adventitious Breath
  Sounds
  •   Crackles
  •   Rhonchi
  •   Wheezes
  •   Pleural friction rub
  •   Stridor



                    drjma               27-66
Heart and Vascular System

 Heart
  • Landmarks for inspection, palpation,
    auscultation
  • Heart sounds
  • Palpation for thrills and heaves
  • Abnormal auscultatory findings
    - Murmurs
    - Bruits


                drjma                      27-67
Heart and Vascular System

 Vascular System
  • Blood perfusion of peripheral vessels
    - Peripheral pulses compared bilaterally
    - Skin temperature, color




                 drjma                         27-68
Physical Examination

 Lymphatic System
  • Lymphatic drainage
  • Lymph nodes




               drjma            27-69
Breasts and Axillae

 Palpation of four quadrants of breasts
 Palpation of supraclavicular,
  infraclavicular, and axillary nodes
 Education and encouragement of
  questions about breast self-examination
  (BSE)
 Breast cancer can also occur in males.

               drjma                        27-70
Breasts and Axillae

 Drainage patterns of
  the left breast.




                 drjma          27-71
Abdomen

 Inspection
  •   Contour
  •   Symmetry
  •   Umbilicus
  •   Surface motion
  •   Scars




                 drjma   27-72
Abdomen

 Auscultation
  • All four quadrants in a systematic fashion
  • Beginning with the RLQ
     -   Tympany
     -   Dullness
     -   Bruits
     -   Hyperactive or hypoactive bowel sounds




                    drjma                         27-73
Abdominal Quadrants




    drjma             27-74
Abdomen

 Light palpation in all four quadrants
  beginning with the RLQ
  •   Resistance
  •   Tenderness
  •   Rebound tenderness
  •   Organ enlargement




                 drjma                    27-75
Female Genitalia and Anus

 Cultural Considerations
 Inspection and Palpation
  •   Mons pubis and vulva
  •   Labia majora, labia minora
  •   Clitoris
  •   Urethral meatus and vaginal introitus
  •   Perineum and anus


                  drjma                       27-76
Male Genitalia, Anus, and
         Rectum

 Testes and male gonads
 Seminal vesicles and bulbourethral
  glands
 Epididymis, vas deferens, ejaculatory
  ducts
 Scrotum, penis, spermatic cord
 Anorectral exam including the prostate
 Monthly testicular self-examination (TSE)

               drjma                          27-77
Musculoskeletal System

   Inspection
   Palpation
   Range of Motion (ROM)
   Bilateral Comparison




               drjma               27-78
Musculoskeletal System

 Muscle
  •   Hypertrophy
  •   Atrophy
  •   Hypertonicity
  •   Hypotonicity




                  drjma              27-79
Musculoskeletal System

 Joints
  • Arthritis
  • Osteoarthritis
  • Crepitus




                 drjma              27-80
Neurologic System

 Mental Status
  • Physical appearance and behavior
  • Communication
  • Level of consciousness




               drjma                   27-81
Mental Status

 Cognitive Abilities and Mentation
  •   Attention
  •   Memory
  •   Judgment, insight
  •   Spatial perception
  •   Calculation
  •   Abstraction
  •   Thought process and content

                 drjma                27-82
Neurological Assessment

 Sensory Assessment
  •   Exteroceptive sensations
  •   Proprioceptive sensations
  •   Cortical sensations
  •   Dermatome map




                  drjma               27-83
Neurological Assessment

   Cranial Nerves Assessment
   Motor Assessment
   Cerebellar Assessment
   Reflex Assessment




                drjma                27-84
drjma   27-85

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  • 1. Nursing Fundamentals HEALTH ASSESSMENT Dr. James M. Alo, RN, MAN, MAP, PhD
  • 2. Preparing for the Health Assessment  Environment • Ensure privacy • Quiet, warm room • Special needs of the client • Surface for placement of equipment drjma 27-2
  • 3. Preparing for the Health Assessment  Equipment • Maintenance • Isolation precautions • Adequate number of gloves drjma 27-3
  • 4. Preparing for the Health Assessment  Positioning • Ensures accessibility to the body part being assessed.  Draping • Prevents chilling. • Prevents unnecessary exposure. drjma 27-4
  • 5. Conducting the Health and Physical Assessment  Aimed at establishing a data base against which subsequent data can be compared. • Comprehensive Assessment (head to toe) • Assessment of a body part (focused) • Assessment of a body system (focused) drjma 27-5
  • 6. Conducting the Health and Physical Assessment  Conducted in an aseptic, systematic, and efficient manner.  Requires the fewest position changes for the client. drjma 27-6
  • 7. General Survey  Initial Observations • Client’s physical appearance • Mood and behavior • Speech patterns and voice intonations • Signs and symptoms of distress • Vital signs • Height and weight drjma 27-7
  • 8. General Survey  Special Considerations • Elderly clients • Disabled clients • Abused clients drjma 27-8
  • 9. Measurement of Height and Weight  Height • Height is expressed in inches (in), feet (ft), centimeters (cm), or meters (m). • A scale for measuring height is usually attached to a standing weight scale. • Infant’s length is measured from vertex (top) of head to soles of feet while infant is lying with knees extended. drjma 27-9
  • 10. Measurement of Height and Weight  Weight • Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg). • 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. drjma 27-10
  • 11. Measurement of Height and Weight  Weight • Types of scales available include chair, stretcher, bed, and platform scales. • Infants are weighed on platform or cradle scales. drjma 27-11
  • 12. Measurement of Height and Weight  Nursing Considerations • Accurate recordings are necessary for drug dosage calculations and evaluation of effectiveness of drug, fluid, and nutritional therapy. drjma 27-12
  • 13. Measurement of Height and Weight  Documentation • Height and weight are recorded on the admission assessment form. • Daily weights are usually recorded on the vital signs record. • Measurements taken at different times or on different scales should be recorded. drjma 27-13
  • 14. Vital Signs  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).  Vital signs are the first step in the physical examination. drjma 27-14
  • 15. Vital Signs  Assessment of vital signs provides specific data regarding the client’s current condition.  Variations from baseline values may indicate potential problems with the client’s health status. drjma 27-15
  • 16. Vital Signs  The sequence for recording vital sign measurements in the nurses’ notes is T- P-R and BP.  Vital signs are plotted on graphic forms that facilitate data comparison at a glance. drjma 27-16
  • 17. Thermoregulation  The body’s physiological function of heat regulation to maintain a constant internal body temperature drjma 27-17
  • 18. Physiologic Function  Thermoregulation • The heat of the body is measured in units called degrees. • The core internal temperature of 98.6 degrees Fahrenheit (F) does not vary more than 1.4 degrees F. • Core internal temperature is higher than the skin and external temperature. drjma 27-18
  • 19. Thermoregulation  Heat Production • Basal Metabolic Rate (BMR) • Vasodilation • Vasoconstriction • Piloerection drjma 27-19
  • 20. Thermoregulation  Heat Loss • Radiation • Conduction • Convection • Evaporation  Insensible Heat Loss drjma 27-20
  • 21. Thermoregulation  Behavioral Control of Body Temperature • The person makes appropriate environmental adjustments in response to the body’s signaling conditions of either being overheated or too cold. drjma 27-21
  • 22. Respiration  Respiration is the act of breathing.  Terms related to respiratory function are: • External respiration • Internal respiration • Inspiration • Expiration • Vital capacity drjma 27-22
  • 23. Respiration  Major physiological pulmonary functions are: • Ventilation • Circulation • Diffusion • Transport • Regulation drjma 27-23
  • 24. Hemodynamic Regulation  The circulatory system transports nutrients to the tissues, removes waste products, and carries hormones from one part of the body to another. drjma 27-24
  • 25. Hemodynamic Regulation  Systemic Circulation • Arteries • Arterioles • Capillaries • Veins • Venules drjma 27-25
  • 26. Hemodynamic Regulation  Cardiac Cycle • Systole • Diastole  Stroke Volume  Cardiac Output  Compensatory Mechanisms drjma 27-26
  • 27. Hemodynamic Regulation  Pulse • The pulse is caused by the stroke volume ejection and distension of the walls of the aorta. • The bounding of blood flow in an artery is palpable at various points in the body (pulse points). drjma 27-27
  • 28. Hemodynamic Regulation  Blood Pressure • Measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole drjma 27-28
  • 29. Blood Pressure  Systolic Pressure • Maximum pressure exerted against arterial walls during systole  Diastolic Pressure • Pressure remaining in the arterial system during diastole drjma 27-29
  • 30. Hemodynamic Regulation  Hemodynamic regulators for blood pressure control are: • Blood volume • Cardiac output • Peripheral vascular resistance • Viscosity drjma 27-30
  • 31. Factors Influencing Vital Signs  Age  Gender  Heredity  Race  Lifestyle  Environment drjma 27-31
  • 32. Factors Influencing Vital Signs  Medications  Pain  Exercise  Anxiety and Stress  Postural Changes  Diurnal (daily) Variations drjma 27-32
  • 33. Assessing Body Temperature  Temperature Scales • Centigrade or Fahrenheit scales are used to measure temperature. • Glass or electronic thermometers are used.  Temperature Sites • Oral • Rectal • Axillary drjma 27-33
  • 34. Assessing Body Temperature  Alterations in Body Temperature • Pyrexia • Hyperthermia • Heat Exhaustion • Heat Stroke • Hypothermia • Frostbite drjma 27-34
  • 35. Assessing Pulse  Sites • The most accessible peripheral sites are the radial and carotid sites. • The carotid site should always be used to assess the pulse in a cardiac emergency. drjma 27-35
  • 36. Assessing Pulse  A peripheral pulse is palpated by placing the first two fingers on the pulse point with moderate pressure.  A Doppler ultrasound stethoscope is used on superficial pulse points.  A stethoscope is used to auscultate the heart’s rate and rhythm. drjma 27-36
  • 37. Assessing Pulse drjma 27-37
  • 38. Assessing Pulse  A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate.  Pulse Characteristics • Pulse quality • Pulse rate (bradycardia, tachycardia) • Pulse rhythm (dysrhythmias) • Pulse volume drjma 27-38
  • 39. Assessing Pulse  Nursing Considerations • An irregular pulse rate, if not previously documented, should be reported immediately. • Clients on certain cardiac medications may need to monitor their pulse rate. • Routine exercise lowers resting and activity pulses. drjma 27-39
  • 40. Assessing Respirations  Sites • Observation of chest wall expansion and bilateral symmetrical movement of the thorax • Placement of back of hand next to client’s nose and mouth to feel expired air drjma 27-40
  • 41. Assessing Respirations  Rate is counted by number of breaths taken per minute.  Observation of thoracic and abdominal movements includes: • Depth, rhythm, and symmetry • Costal (thoracic) breathing • Diaphragmatic breathing drjma 27-41
  • 42. Assessing Respirations  A stethoscope is used to auscultate breath sounds throughout the respiratory system. drjma 27-42
  • 43. Assessing Respirations  Dyspnea,  Bradypnea, tachypnea, apnea  Hypoventilation  Hyperventilation drjma 27-43
  • 44. Assessing Respiratory Function  Cyanosis • Bluish appearance in the nail beds, lips, and skin • Reduced oxygen levels in the arterial blood drjma 27-44
  • 45. Assessing Respiratory Function  Clients with respiratory alterations require additional nursing assessment. • Pulse oximetry • Apnea monitor drjma 27-45
  • 47. Assessing Blood Pressure  The direct method of measuring blood pressure requires an invasive procedure.  The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed. drjma 27-47
  • 48. Assessing Blood Pressure  The most common site for indirect measurement is the client’s arm over the brachial artery.  Accurate measurement requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity. drjma 27-48
  • 49. Assessing Blood Pressure  Korotkoff sounds are five distinct phases of sound heard with a stethoscope during auscultation.  The forearm or leg sites can be palpated to obtain a systolic reading when the brachial artery is inaccessible. drjma 27-49
  • 50. Assessing Blood Pressure  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.  Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. drjma 27-50
  • 51. Assessing Blood Pressure  Orthostatic Hypotension (postural hypotension) • Sudden drop in systolic pressure when client moves from a lying to a sitting to a standing position drjma 27-51
  • 52. Assessing Blood Pressure  False Readings • Clients who have recently eaten, ambulated, or experienced an emotional upset • Improper cuff width • Improper technique in deflating cuff • Improper positioning of extremity • Failure to recognize an auscultatory gap drjma 27-52
  • 53. The Physical Examination  Techniques • Inspection • Palpation • Percussion • Auscultation drjma 27-53
  • 54. Integumentary System  Skin  Hair and Scalp  Nails drjma 27-54
  • 55. Skin Assessment  Skin assessment provides a noninvasive window to observe the body’s physiological functions. drjma 27-55
  • 56. Skin Assessment  Color  Lesions  Moisture  Temperature  Texture  Mobility and Turgor  Edema drjma 27-56
  • 57. Integumentary System  Hair • The amount and texture of hair vary with age, sex, race and body part. • Vellus • Terminal hair  The scalp should be smooth, clean, intact, and free of lumps or tender areas. drjma 27-57
  • 58. Integumentary System  Nails • Clubbing • Koilonychia (spoon nail) • Beau’s line • Paronchia drjma 27-58
  • 59. Physical Examination  Head • Skull and face assessment involves inspection and palpation. • The client’s face has its own unique characteristics related to race, state of health, emotions, environment. drjma 27-59
  • 60. Physical Assessment  Eyes • Conjunctive and sclera are assessed for color, redness, swelling, exudate, foreign bodies • Visual acuity • Fundoscopy drjma 27-60
  • 61. Physical Assessment  Ears • Auditory screening • Inspection and palpation of external ear • Placement, symmetry • Otoscopic assessment  Nose and Sinuses • Inspection and palpation • Use of a penlight drjma 27-61
  • 62. Physical Examination  Mouth and Pharynx • Breath • Lips • Tongue • Buccal mucosa • Gums and teeth • Hard and soft palate • Pharynx drjma 27-62
  • 63. Physical Examination  Neck • Neck muscles • Lymph nodes of head and neck • Thyroid gland • Trachea drjma 27-63
  • 64. Physical Examination  Thorax and Lungs • Landmarks for inspection, auscultation, and percussion • Anterior and posterior examination • Shape and symmetry • Thoracic expansion • Tactile fremitus drjma 27-64
  • 65. Thorax and Lungs  Auscultation of Normal Breath Sounds • Vesicular sounds • Bronchovesicular sounds • Bronchial sounds drjma 27-65
  • 66. Thorax and Lungs.  Auscultation of Adventitious Breath Sounds • Crackles • Rhonchi • Wheezes • Pleural friction rub • Stridor drjma 27-66
  • 67. Heart and Vascular System  Heart • Landmarks for inspection, palpation, auscultation • Heart sounds • Palpation for thrills and heaves • Abnormal auscultatory findings - Murmurs - Bruits drjma 27-67
  • 68. Heart and Vascular System  Vascular System • Blood perfusion of peripheral vessels - Peripheral pulses compared bilaterally - Skin temperature, color drjma 27-68
  • 69. Physical Examination  Lymphatic System • Lymphatic drainage • Lymph nodes drjma 27-69
  • 70. Breasts and Axillae  Palpation of four quadrants of breasts  Palpation of supraclavicular, infraclavicular, and axillary nodes  Education and encouragement of questions about breast self-examination (BSE)  Breast cancer can also occur in males. drjma 27-70
  • 71. Breasts and Axillae  Drainage patterns of the left breast. drjma 27-71
  • 72. Abdomen  Inspection • Contour • Symmetry • Umbilicus • Surface motion • Scars drjma 27-72
  • 73. Abdomen  Auscultation • All four quadrants in a systematic fashion • Beginning with the RLQ - Tympany - Dullness - Bruits - Hyperactive or hypoactive bowel sounds drjma 27-73
  • 74. Abdominal Quadrants drjma 27-74
  • 75. Abdomen  Light palpation in all four quadrants beginning with the RLQ • Resistance • Tenderness • Rebound tenderness • Organ enlargement drjma 27-75
  • 76. Female Genitalia and Anus  Cultural Considerations  Inspection and Palpation • Mons pubis and vulva • Labia majora, labia minora • Clitoris • Urethral meatus and vaginal introitus • Perineum and anus drjma 27-76
  • 77. Male Genitalia, Anus, and Rectum  Testes and male gonads  Seminal vesicles and bulbourethral glands  Epididymis, vas deferens, ejaculatory ducts  Scrotum, penis, spermatic cord  Anorectral exam including the prostate  Monthly testicular self-examination (TSE) drjma 27-77
  • 78. Musculoskeletal System  Inspection  Palpation  Range of Motion (ROM)  Bilateral Comparison drjma 27-78
  • 79. Musculoskeletal System  Muscle • Hypertrophy • Atrophy • Hypertonicity • Hypotonicity drjma 27-79
  • 80. Musculoskeletal System  Joints • Arthritis • Osteoarthritis • Crepitus drjma 27-80
  • 81. Neurologic System  Mental Status • Physical appearance and behavior • Communication • Level of consciousness drjma 27-81
  • 82. Mental Status  Cognitive Abilities and Mentation • Attention • Memory • Judgment, insight • Spatial perception • Calculation • Abstraction • Thought process and content drjma 27-82
  • 83. Neurological Assessment  Sensory Assessment • Exteroceptive sensations • Proprioceptive sensations • Cortical sensations • Dermatome map drjma 27-83
  • 84. Neurological Assessment  Cranial Nerves Assessment  Motor Assessment  Cerebellar Assessment  Reflex Assessment drjma 27-84
  • 85. drjma 27-85