Chapter 21 Nursing care Physical Assessment

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Define various terms associated with physical assessment
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Accommodation response: Adventitious breath sounds: Atelectasis: Auscultation: Cheilitis: Consensual reflex: Dysphagia: Dysphasia: Eructation: Excursion: Guarding: Halitosis: Jaundice: Lethargy: Ophthalmoscope: Otoscope: Palpation: Paresthesia: Percussion: Peristalsis: PERLA: Ptosis: Rales: Retractions: Rhonci: Signs: Solar lentigines: Sordes: Symptoms: Turgor: Wheezes:
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Describe five purposes of physical assessment.
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Establish a patients current condition, a baseline against which future changes may be measured, Identify problems the patient may have or have the potential to develop, to evaluate the effectiveness of nursing interventions, to monitor for changes in body function, to detect specific body systems that need further assessment or testing.
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Differentiate between a comprehensive health assessment, a focused assessment, and an initial head to toe shift assessment.
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Comprehensive health assessment: involves an in depth assessment of the whole person, including the physical mental emotional cultural and spiritual aspects of the patients health. Collected through physical eximination and interview. May take as long as 2 hours to complete. Is generally performed when patient is admitted. Focused assessment: less encompassing and involves and eximination and an interview regarding a specific body system. Provides a cluster of data about just one body system being assessed. Initial head to toe shift assessment: quick overall assessment of the patients condition to establish a baseline against which you can compare later assessments. This baseline is necessary for you to be able to identify changes in the patients condition. Consists of performing a focused assessment of the following systems, neurological, cardiovascular, respiratory, integumentary, gastrointestinal, genitourinary, muscular, skeletal. Also includes vitals, appearance, speech, safety risk factors, tubes and equipment, comfort or complaints, needs.
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Discuss ways to foster rapport and communication when interacting with patients, and its importance.
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Smile, greet the patient using his or her surname, provide for privacy, introduce yourself and explain your intent, exhibit an open and relaxed posture, be professional, demonstrate active listening, be attentive to patients needs, be aware of cultural influences and restrictions, be sincere, be nonjudgmental, use touch purposefully.
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Summarize the six techniques used for physical assessment, including their correct performance.
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Interviewing, Inspection, palpation, percussion, auscultation, and olfaction. They are performed in order, except when conducting an abdominal assessment, auscultation comes before palpation as to not disrupt the bowel sounds.
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Identify assessment techniques and assessment findings relative to specific health conditions.
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Interviewing: personal identity, details, medical history, social history, food and drug allergies, height and normal weight. Inspection: visual observation of anything about the body that you can see with the naked eye. General appearance, affect, body shape and size, posture, pupil size, skin, edema, tubes. Palpation: skin turgor, growths below the skin, edema, distention, Percussion: Used least for assessments, involves striking body parts with the tips of the fingers to elicit sounds that can help determine the size of structures below the surface. Auscultation: Olfaction:
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Distinguish the difference components to be examined during an initial head to toe shift assessment.
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General appearance, vital signs (blood pressure, Temp., pulse, respirations, Sp02,Pain), Neurological examination, head and neck, eyes, oral mucosa, Lips, Teeth, neck, speech, chest and abdomen, abdomen, upper extremities, lower extremities,
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Relate each component of assessment to its associated body system(s)
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Differentiate between normal and abnormal assessment findings of each body system.
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Explain the significance of abnormal assessment findings
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Describe adaptations in assessment techniques that are necessary due to age, size or condition of the patient.
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Describe appropriate patient teaching that may be done during assessment.
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Perform an initial head to toe shift assessment.
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Assess level of consciousness, orientation to the four spheres, speech. Access pupils and pupillary response to light and accommodation. Assess both sclera and conjunctiva for color and moisture. Inspect the face for symmetry and skin color. Assess the lips and oral mucous membranes for color, integrity, moisture, and lesions. Assess teeth and gums for dentures, missing, teeth decay, gum recession bleeding sordes and lesions. assess neck veins for distention. assess any tubes, equipment or dressings of the head and neck to ensure patency and proper function.
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Document the results of an initial head to toe shift assessment
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Discuss information found in the connection features in this chapter
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Identify specific safety features
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Answer questions about the skills in this chapter.
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