Transcript Chain of Survival and EMSC

Chapter 22
Assessing Health Status
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Chapter 22
Lesson 22.1
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Learning Objectives
Theory
1)
Discuss the types of assessment used in various situations.
2)
Demonstrate the techniques used during physical
examination.
Clinical Practice
1)
Assess the patient’s psychosocial and physical functioning
by gathering information in an organized way.
2)
Perform a basic physical examination on a patient.
3)
Perform a visual acuity test on a patient.
4)
Carry out focused physical assessments of the
cardiovascular, respiratory, gastrointestinal, and neurologic
systems.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 3
Assessment: Data Collection



Performed on an almost continual basis
Initial detailed assessment on admission
Includes:





Physical examination
History and demographic data
Information pertinent to daily care
Current health problems
Focused assessment on every successive
shift
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 4
Assessment: Data Collection (cont’d)

Nurses must be aware of how the illness is
affecting the patient’s life



Not only health, all other areas
Assess for cultural preferences and health
beliefs
Phrase questions in a positive,
nonthreatening way
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 5
Assessment: Data Collection (cont’d)

The initial or admission assessment should
include an interview to determine:

Social data
 Marital status, occupation, visual or hearing
deficits
 Dentures, prostheses
 ALLERGIES—food, drug, or other
 Medications being taken (including OTC and
herbal supplements)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 6
Assessment: Data Collection (cont’d)

Diet







Any limitations or special foods
Smoking
Use of alcohol
Activities of daily living
Previous surgeries
Health problems, current and past
Reason for admission
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 7
Assessment: Data Collection (cont’d)

Physical data

Head and neck
 Chest, heart, and lungs
 Abdomen
 Genitourinary system
 Extremities and musculoskeletal system
 Endocrine system
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 8
Physical Assessment


Provides a complete picture of physiologic
functioning
Comprehensive, in-depth


Includes all systems of the body
Brief, scanning type of examination

Confined to a specific body part or system
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 9
Physical Examination Techniques:
Inspection and Observation

Inspection and observation


Inspect visually the various parts of the body and
the behavioral responses of patients
Visual observation of:
• General appearance
• Contours of the body
• Skin tone and color, rashes, scars, lesions
• Deformities or extremity weakness
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 10
Physical Examination
Techniques: Palpation


Performed using the hands and fingertips to touch
and feel various parts of the body
Used to ascertain:








Size, shape, and position of body parts
Texture, temperature, and moisture of skin
Presence of muscle spasm or rigidity
Pain, tenderness, or swelling
Presence of a growth
Restriction in body part movement
Skin temperature and turgor
Presence of edema
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 11
Physical Examination
Techniques: Percussion

Another method of obtaining information
about body structures



Light, quick tapping on the body surface to
produce sounds
Variations in the sounds reflect characteristics of
organs or structures below the surface
Percussion helps in determining:
• Size of organs
• Location of organs
• Density of organs
• Presence of air or fluids in tissue or in a body cavity
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 12
Physical Examination
Techniques: Auscultation


Listening to presence or absence of body
sounds using a stethoscope
Particularly useful for:


Lung sounds: use the diaphragm for all lobes
Heart sounds
• Use the diaphragm for normal S1-S2 and to count heart
rate
• Use the bell for some abnormal heart sounds

Abdomen (bowel sounds)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 13
Figure 22-7: Auscultate the
heart in each area
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 14
Physical Examination Techniques:
Olfaction (Smelling)

Using the nose to identify odors characteristic
of certain problems, such as:



Breath odor for sweetness, acetone, or alcohol
Wound odors
Odors from discharges such as vaginal infections
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 15
Basic Physical Examination

Height and weight (without shoes)



Infant without diaper (never leave unattended)
Vital sign measurement
Review of body systems




Head and neck, chest, heart, and lungs
Skin and extremities
Abdomen
Genitalia, anus, and rectum
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 16
Review of Body Systems:
Head and Neck






General appearance
Appearance of the eyes
Condition of the hair
Difficulty in hearing or seeing
Pupils equal in size and accommodated to
light
Corneas clear (or is there opacity?)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 17
Review of Body Systems:
Chest, Heart, and Lungs







Is the chest symmetric?
Are shoulders at equal height?
Is there any lordosis, kyphosis, or scoliosis?
Any signs of dyspnea?
Is there a noticeable point of maximal impulse
PMI ?
Heart sounds normal? (S1-S2)
Apical pulse rate normal?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 18
Review of Body Systems:
Lung Sounds

Using the diaphragm of the stethoscope,
listen:




Over the trachea
Over the upper area of the chest
Over the central chest and back
Sounds



Vesicular
Bronchovesicular
Adventitious
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 19
Figure 22-9: Sites for auscultation of
lung fields (anterior)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 20
Figure 22-9: Sites for auscultation of
lung fields (posterior)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 21
Review of Body Systems:
Skin and Extremities

Inspect skin for:

Rashes or lesions
 Flaking or dryness
 Signs of dehydration or edema (shoe or ring
tightness)
 Turgor
 Capillary refill (less than 3 seconds)

Assess peripheral pulses
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 22
Review of Body Systems:
Abdomen

Bowel sounds should be assessed in all four
quadrants on admission





Normal (5 to 30 sounds/min)
Hypoactive
Hyperactive
Silent
Distention or tenderness
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 23
Figure 22-11: Auscultation
of bowel sounds
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 24
Review of Body Systems:
Genitalia, Anus, and Rectum



Unless patient has a specific complaint in
these areas, the nurse does not visually
assess them
They may be assessed, however, when
bathing the patient, performing perineal care,
or assisting with toileting
Ask the patient if there are any problems with
these areas
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 25
Systematic Way to Perform
an Assessment

A systematic way to perform such an
assessment

Rest and activity
 Nutrition, fluids, and electrolytes
 Safety and security
 Hygiene
 Oxygenation
 Psychosocial and learning
 Elimination
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 26
Focused Assessment


Brief examinations
Occurs when a complete head-to-toe
assessment is not needed
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 27
Question 1
A systematic way to perform an assessment is
to use the acronym RNS HOPE. Which letter is
correctly defined?
1)
2)
3)
4)
H—health
O—oxygenation
P—physical
E—evaluation
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 28
Question 2
Maggie’s patient has been receiving dialysis for several
months. She has a dialysis shunt in her left arm. When
taking vital signs on her patient, it is important for Maggie
to remember:
1)
2)
3)
4)
blood pressure should be measured on both arms
after the patient has been resting for 5 minutes.
blood pressure should be obtained in the left arm only.
blood pressure should be obtained in the right arm
only.
if blood pressure is elevated it should be taken in the
other arm.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 29
Question 3
On auscultation, Maggie notices her patient has rhonchi
in her lungs bilaterally. Rhonchi can best be described
as:
1)
2)
3)
4)
whistling, musical, high-pitched sounds produced by
air being forced through a narrowed airway.
coarse, low-pitched, rattling sounds caused by
secretions in the larger air passages.
croaking sounds heard when there is partial
obstruction.
fine or coarse sounds that are high-pitched.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 30
Question 4
During the physical examination of your patient,
he states, “I have a ringing in my ears.” This is
known as:
1)
2)
3)
4)
vertigo.
tinnitus.
cerumen.
petechiae.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 31
Chapter 22
Lesson 22.2
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Learning Objectives
Theory
3)
Describe how to gather information for a
comprehensive database for a patient.
Clinical Practice
5)
Teach patients the assessment techniques for the
early detection of cancer.
6)
Educate patients about the recommendations for
periodic diagnostic testing.
7)
Assist with a medical examination by positioning
and draping the patient, and organizing the
equipment.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 33
Assessment of the Areas
of Basic Needs

“RNS HOPE”

Rest and activity
 Nutrition, fluids, and electrolytes
 Safety and security
 Hygiene
 Oxygenation
 Psychosocial and learning
 Elimination
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 34
Positioning and Draping


Most examinations begin with patient seated
on the end of the examination table with a
drape over the lap and legs
Patient assumes supine position and drape is
pulled up over the upper body so chest
and/or abdomen can be exposed




Lithotomy position
Knee-chest position
Lateral or Sims’ position
Prone position
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 35
Elements of the Physical Examination





Bladder should be emptied
Ask patient to disrobe and put on an examination gown
Prepare exam table
Necessary equipment for the physical examination is
made ready
Examinations





Pelvic exam and Pap smear
Rectal examination of the prostate
Body systems
Interior of the eye
Ears are examined
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 36
Special Focused Examinations

Neurologic check




Performed at regular intervals on patients who
have had a head injury or brain surgery
Pupil size is measured
Patient is asked to track the nurse’s finger or an
object as it is moved to six different positions
Glasgow Coma Scale is used in most hospitals to
score the neurologic exam
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 37
Evaluation

Topics can include the following:

The need for regular physical examinations
 Recommended periodic diagnostic tests
 The need for immunizations
 The necessity of regular dental examinations
 The warning signs of cancer
 The way to perform self-breast examination
 The method of performing self-testicular
examination
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 38
Patient and Family Teaching

Topics can include the following:

The need for regular physical examinations
 Recommended periodic diagnostic tests
 The need for immunizations
 The necessity of regular dental examinations
 The warning signs of cancer
 The way to perform self-breast examination
 The method of performing self-testicular
examination
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 39