PUTTING IT ALL TOGETHER - PowerPoint PPT Presentation

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Title:

PUTTING IT ALL TOGETHER

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Use appropriate barriers gloves. Systematic method of organization. Outcomes ... Approach: inspection, auscultation, percussion, palpation by system or region ... – PowerPoint PPT presentation

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Title: PUTTING IT ALL TOGETHER


1
PUTTING IT ALL TOGETHER
  • NUR211
  • Kathleen Hancock

2
Nurses Skills
  • Critical thinking
  • Interpersonal
  • Proficient examination skills
  • Proper equipment
  • Use appropriate barriers gloves
  • Systematic method of organization

3
Outcomes
  • Obtain complete health history
  • Perform physical exam
  • Assess mental status
  • Document findings
  • Develop problem list
  • Identify nursing diagnoses

4
History
  • Biographical
  • Current health status
  • Past health history
  • Family history
  • Review of systems
  • Psychosocial

5
  • Organization of PE
  • Head to toe
  • Body Systems
  • Body Regions

6
Helpful Hints
  • Warm hands equipment
  • Short fingernails
  • Privacy, gown drapes, quiet
  • Explain
  • Observe client, especially face

7
Physical Assessment
  • Anatomical landmarks use appropriate landmarks
    for area being assessed
  • Approach inspection, auscultation, percussion,
    palpation by system or region
  • Position dependent on region being assessed
  • Tools all tools of assessment needed for
    complete exam

8
Focused Physical Exam
  • General survey with VS, height, and weight
  • Level of consciousness
  • Skin color, temperature, and texture
  • Gross balance and coordination
  • EOM, pupils, gross vision and hearing
    (Continued)

9
Focused Physical Exam
  • Oral mucosa and say Ah
  • Palpate apical, PMI, auscultate heart sounds
  • Auscultate bowel sounds percuss and palpate
    abdomen
  • Palpate pulses
  • Test sensation and strength on upper and lower
    extremities

10
Physical Assessment by Region
  • General survey vital signs, height, weight
  • Skin, hair, nails
  • Head, face, neck
  • Anterior chest ? Posterior chest
  • Upper extremities ? Abdomen
  • Lower extremities ? Pelvic exam

11
Documentation
  • Document by systems and, to small extent, by
    region
  • Document findings
  • Document pertinent negatives
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