Foundations of Nursing lecture quiz 2, Physical Assessment Head to Toe Examination – Flashcards
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define physical assessment. explain
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A physical assessment is part of a holistic health evaluation, assessment is the 1st step of the nursing process, is the orderly collection of objective and subjective information about the patient.
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the role of the LPN in the physical assessment process in the state of Minnesota.
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The role of the LPN in the physical assessment process is to contribute to the process with data collection and to perform focused nursing assessments and to report their findings to the RN and/or physician
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list the purposes of a physical assessment.
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-current physical condition -to detect early signs of developing problems -establish baseline for future comparisons -evaluate the patient's response to medical and nursing interventions -actual and potential health problems -areas of focus for priority health promotion
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differentiate between a head to toe and a body systems approach to physical assessment.
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Head to toe is more of just general over look of whole body, but the body system approach focuses on each system individually, and more in depth of that specific body system for example respiratory, cardiovascular, upper extremities, neurological GI tract, lower extremities
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explain the reasons for a consistent, organized collection of patient data with physical assessment.
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Should be done at the beginning of shift Improves accuracy of findings Reduces the possibility of overlooking important findings Previous data collection provides a baseline for comparisons Efficient use of time
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explain the responsibility of the LPN with abnormal findings during a head to toe examination.
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Abnormal findings directs the nurse to gather additional data and helps to select appropriate nursing measures
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differentiate between the four physical assessment techniques of inspection, auscultation, palpation, and percussion.
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Inspecting-looking over the patient, using eyes, no touch Auscultation-listening to heart, lungs, abdomen Palpation- lightly touching or applying pressure to the body using fingertips, back of hand, or palm of the hand Percussion- tapping using fingers
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explain why the sense of smell is important in physical assessment.
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hygiene, sign of infection
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explain the purpose of a general "once over" evaluation of the patient prior to beginning the in-depth head to toe examination.
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to get details if you need to look more into a specific problem
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explain signs to observe for during the general "once over" evaluation.
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level of consciousness (LOC) signs of distress general appearance skin color posture eye contact personal hygiene
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head to toe- comfort data -what are the normal and abnormal findings
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Normal Findings: No pain or discomfort If pain is present: - Description (location, duration, descriptors or characteristics, intensity, radiation of pain, and precipitating factors) -Use pain rating scale 0-10 -What is the patient's pain goal?
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head to toe-Neurological Data-normal findings
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Normal Findings: -Level of Consciousness (LOC): Alert -Orientation: oriented to person, place and time -Behavior: appropriate to situation -Speech: clear -Able to follow commands -Able to move all extremities with equal strength bilaterally -No gross difficulty with coordination -Pupil size and reaction: pupils are the same size and constrict briskly in response to light -Sensation intact with no numbness or paresthesia -Swallowing ability intact
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head to toe-Upper Extremities
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CMS checks -Normal finding: CMS intact Check capillary refill -Normal finding: Capillary refill in less than 3 seconds Skin turgor check -Normal finding: Skin immediately snaps back with no tenting Check for edema -Normal finding: no edema
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head to toe-Cardiovascular data
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Normal Findings: -Heart sounds: S1 S2 (listen at PMI), regular -Pulse rate: regular, +3 pulse quality -No edema -No distended neck veins (JVD absent) -Extremities: pink and warm -CMS intact Peripheral pulses -apical (PMI) -carotid -temporal -brachial -radial -femoral -popliteal -posterior tibial -dorsalis pedis
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head to toe-Respiratory data
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normal findings -Respirations quiet, regular, non-labored -No cough -No shortness of breath -No cyanosis -Lungs sounds: clear to auscultation On room air Abnormal: Use of supplemental oxygen Oximeter readings: normal > or =92%
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Auscultating lung sounds
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Normal breath sounds Abnormal (adventitious) breath sounds - crackles - rhonchi - wheezes -pleural friction rub 3 important things: location, timing, do they clear with coughing
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GI Data
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Normal Findings: -Abdomen soft and symmetrical - Tolerating diet - No nausea and/or vomiting - Bowel sounds present all 4 quadrants - Passing flatus - Bowel movements: regular in frequency, soft formed brown Abdomen: Inspect, Auscultate, Palpate, Percuss
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head to toe-Genitourinary (GU) data
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Normal Findings: - Empties bladder independently (or urinary catheter patent) - No urgency, frequency, incontinence or dysuria - Urine clear and yellow to amber in color. If patient's condition warrants, examine the external genitalia and anus Inspect for: - abnormal color - pain, tenderness or trauma - presence of obvious lesions or masses - odor or unusual discharge - any swelling or inflammation -presence of itching
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head to toe-Lower Extremities
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CMS checks - Normal finding: CMS intact Check capillary refill - Normal finding: Capillary refill in less than 3 seconds Check for edema -Normal finding: no edema Check dorsalis pedis and posterior tibial pulses
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head to toe-Skin Integrity data
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Normal Findings: -Skin warm, dry and intact - Absence of rashes, bruises, redness - Mouth, lips, gingiva, oral mucosa, tongue: smooth, pink, moist and intact
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head to toe - Incision/Wound data
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Normal Findings: -No redness, swelling, increased warmth or tenderness in surrounding tissue. - Wound edges are well-approximated - No drainage present
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head to toe- Activity data
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Normal Findings: -Normal joint ROM with no swelling or tenderness
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head to toe- safety data
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Normal Findings: - No significant perceptual deficits - Oriented - No communication barriers -Steady on feet
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head to toe-IV data
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IV site / type of access device Normal Findings: No evidence of redness, tenderness, swelling, increased warmth at site(s) or surrounding tissue
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head to toe-Psychosocial data
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Normal Findings: - Displays adequate coping skills to meet emotional needs -Verbalizing feelings
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head to toe-Sleep/Rest data
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Normal Findings: Sleeps / rests adequately between cares
