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Fundamental Nursing Skills and Concepts

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4-Percussion-striking or tapping a part of the body. Least used method. ... 186 table 12.1 percussion sounds. Physical Assessment Environment. Easy access to a ... – PowerPoint PPT presentation

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Title: Fundamental Nursing Skills and Concepts


1
Fundamental Nursing Skills and Concepts
  • Chapter 12
  • Page 185

2
Purposes of Physical Assessment
  • To evaluate the clients current physical
    condition
  • To detect early signs of developing health
    problems
  • To establish a baseline for future comparisons
  • To evaluate the clients responses to medical and
    nursing interventions
  • The overall goal of a physical assessment is to
    gather objective data about a client.
  • Achieved on admission, at the beginning of each
    shift, and anytime there are changes in a clients
    condition.

3
Four Basic Physical Assessment Techniques
  • Inspection-----1
  • Palpation------3
  • Percussion----4
  • Auscultation---2

4
Techniques
  • 1-INSPECTION-purposeful observation-most
    frequently used. Looking.
  • 2-Auscultation-listening to body sounds. Heart,
    lung, abdominal sounds.
  • 3-Palpation-lightly touching the body or
    applying pressure. Light palpation feel the
    surface of the skin, pulsation in pulse,
    vibration in the chest. Deep palpation,
    depressing 1 (2.5 cm) with forefingers of 1-2
    hands. Palpation provides information about
    size, shape, consistency and mobility of normal
    tissue and unusual masses, symmetry, temp.,
    moisture, tenderness, unusual vibrations.

5
Techniques
  • 4-Percussion-striking or tapping a part of the
    body. Least used method. Produces vibratory
    sounds. The quality of the sound aids in
    determining the location, size and density of
    underlying structures. Pg. 186 table 12.1
    percussion sounds

6
Physical Assessment Environment
  • Easy access to a restroom
  • A door or curtain that ensure privacy
  • Adequate warmth for client comfort
  • A padded, adjustable table or bed
  • Sufficient room for moving to either side of the
    client
  • Adequate lighting
  • Facilities for handwashing
  • A clean counter for placing examination equipment
  • A lined receptacle for soiled articles

7
Equipment needed for physical assessment
  • Gloves Assessment form
  • Exam gown Pen
  • Drapes
  • Scale
  • Stethoscope
  • B/P cuff
  • Thermometer
  • Pen light
  • Tongue blade

8
The Nurse Gathers General Data pg.188
  • Physical appearance in relation to clothing and
    hygiene- clean, well dressed, dressed
    appropriately for season, unclean, unshaven,
    dirty clothes.
  • Level of consciousness-responsive, follows
    commands, lethargic.
  • Body size-thin, flabby, heavy for height.

9
The Nurse Gathers General Data pg.188
  • Posture-stooped, erect.
  • Gait-swaying, unsteady, slow, purposeful.
  • Coordinated movement-weak, strong, overbalanced.
  • Use of ambulatory aids-canes, walkers, wheel
    chairs or assistance of family.
  • Mood- alert, listless, cheerful, talkative.
  • Emotional tone-depressed, irritable, sad, lonely.
  • The nurse observes and interacts with the client
    before the actual physical exam to gather this
    general information.

10
Selecting a Approach for Data Collection
  • Head-to-toe approach
  • Body systems approach
  • The nurse always drapes and positions the
    patient. Stay with the patient to make them feel
    comfortable and at ease. Always inform as to what
    is being done. Teach appropriately.

11
Data collection
  • Height , weight , vital signs , on every patient.

12
Body Systems Approach
  • Collecting data according to the functional
    systems of the body.
  • Examination of structures in each system
    separately
  • Organizes data collection according to the
    functional systems of the body. (ie. Skin, m/m,
    nails hair are included in the integementary
    system)

13
Head-to-toe data collection
  • Gathers data from top of the body working toward
    the feet.
  • Prevents overlooking data, and reduces the number
    of body position changes.
  • Generally takes less time.
  • Six general areas

14
Data Collection
  • Head and Neck
  • Chest
  • Extremities
  • Abdomen
  • Genitalia
  • Anus Rectum

15
Head and neck
  • Mental status assessment, level of pts. cognitive
    functioning, attention, concentration, memory,
    ability to think abstractly.
  • Alert and oriented (chart it) usually that is all
    that is necessary.
  • Unstable due to head injury, overdose, a more
    intense assessment is necessary.
  • Head and neck are they symmetrical?

16
Eyes
  • Similar in size and distance from the center of
    the face.
  • Iris- same color
  • Sclera- white, yellow, orange?
  • Corneas- clear
  • Eyelashes-present, sparce, missing
  • Drainage-present, no drainage

17
Visual Acuity
  • Ability to see far and near
  • To assess far vision grossly, the nurse asks the
    client to cover one eye at a time and from a
    distance of approximately 20 feet the number of
    fingers the nurse raises.
  • Snellen eye chart (tool for assessing far vision)
  • Jaeger chart (visual assessment tool assessing
    near vision), small print.

18
Eyes
  • Pupil size-figure 12.9 top 191 is a pupil gauge
    in millimeters to assess pupil size.
  • Pupil response is shown in fig. 12.10 (A)
  • Nursing guidelines 12-2 pg. 191
  • Visual acuity-ability to see far and near. Ask
    pt. Do you wear glasses, contact lenses, have a
    false eye (prothesis) or consider yourself blind?
  • Assess gross vision-ask pt. to cover one eye at a
    time- from a distance of approximately 20 feet
    count the number of fingers the nurse raises.

19
Eyes
  • Snellen assesses far vision- cover 1 eye _at_ 20 .
    Ability to read smallest line of letters with and
    without corrective lenses. Then compare to norms.
  • Jaegar- tests near vision
  • Normal vision-ability to read printed letters
    seen by most people with out prescription lenses
    _at_ a distance of 20.
  • 20/20 vision line read _at_ 20 as compared with
    norms.
  • Where others can read the chart _at_ 200 recorded
    as 20/200.
  • Written as a fraction, pt. sees at 20 feet what
    the norms see at 200 feet.

20
Eyes
  • Normal pupils are round and equal in size
  • Consensual response-brisk, equal, and
    simultaneous constriction of both pupils when one
    eye and then the other is stimulated with light
  • Accommodation-ability to constrict when looking
    at a near object and dilate when looking at an
    object in the distance. Fig. 12.10 (B) pg. 191
  • PERRLA-pupils, equally, round, and react to light
    and accommodation. Normal findings.

21
Eyes
  • Extraoccular movements-focus on and track the
    nurses finger. 6 positions, both eyes should
    move in a coordinated manner, smoothly. If no
    movement in one eye, may indicate cranial nerve
    damage. Irregular or uncoordinated movement, may
    be neurologic pathology.

22
EARS
  • Observe for appearance, size, shape, location.
  • Move skin behind and in front and underlying
    cartilage.
  • Check for tenderness
  • Illuminate ear canal, visualize ear canal.
    Children pull down and back. Adults pull up
    and back.
  • Cerumen yellowish, brown waxy secretion
    (normal).
  • Does the pt. use a hearing aide device?
  • Voice test or Weber or Rinne test used for
    hearing.
  • pg. 192

23
Hearing test
  • Weber test using a tuning fork to assess bone
    conducted sound, strike and place on forehead.
    Ask is sound heard equally in both ears? If not
    bone conducted sound would be unequal indicating
    hearing loss in one ear.
  • Rinne test using a tuning fork, strike the
    tuning fork and then place the stem first on
    mastoid area then to ear canal to determine a
    problem with ear structure. The client indicates
    when the sound stops. Assessment technique for
    comparing bone conduction of sound. Ears are
    tested separately.

24
Hearing test
  • Audiometry measurement of hearing acuity at
    various sound frequencies, to identify a persons
    range of hearing acuity.

25
Hearing Acuity
  • Ability to hear and discriminate sound
  • Weber test (assessment technique for determining
    equality or disparity of bone conducted sound)
  • Rinne test (assessment technique for comparing
    air versus bone conduction of sound)

26
Nose
  • Inspect while pt. is in a SNIFFING position.
  • Septum midline?
  • m/m moist, free of drainage, lesions, deviated
    septum, growths, fissures, flaring of nostrils?
  • Document your findings.

27
Smelling Acuity
  • Ability to smell and identify odors
  • Have the client occlude one nostril and close his
    or her eyes
  • Place substances with strong odors beneath the
    patent nostril for identification

28
Physical Assessment
  • Tongue midline, any lesions, ulcerations, dry,
    note color. Top pg. 194 assessing taste. Note
    odor(halitosis), m/m pink ,moist , intact.
  • Teeth missing, in good repair, mal-positioned,
    dentures?
  • Smiles lips look same symmetrical?
  • Facial skin smooth, unbroken, uniform, color,
    warm, resilient

29
Cont.
  • Alterations in integrity
  • Wound-a break in the skin
  • Ulcer-an open crater-like area
  • Abrasion-area rubbed away by friction
  • Laceration-torn, jagged wound
  • Fissure-crack in the skin, especially in or near
    m/m
  • Scar-mark left by the healing of a wound or
    lesion
  • Table 12-4 pg. 195 common skin lesions

30
Physical assessment
  • Hair-color, texture, distribution of scalp hair,
    eye brows, eye lashes. Any nits? Debris? Lesions?
  • Scalp-palpate scalp for contour. Smooth, intact,
    lesion free scalp. Assess _at_ random by separating
    and looking.
  • Neck-bend head forward, back, side to side.
    Rotate 180
  • Trachea-center of neck
  • Carotid arteries-visible and palpated easily.
  • Lymph nodes-lightly palpate
  • Thyroid gland-assess for enlargement

31
Physical assessment
  • Chest spine-check for turgor (resiliency of the
    skin), elasticity quality and the pressure
    exerted on it by fluid with in the tissue. Pinch
    skin on chest sternum area. Should return to
    original shape within few seconds. This is
    measured in seconds. Prolonged tenting indicates
    dehydration.
  • Chest shape and movement-assessing chest
    excursion page 196. about tenth rib area thumbs
    together. Have patient breathe and note how much
    thumbs move apart. 1 2 normally. Pg. 196 fig
    12.17
  • Top 196- shows chest sizes and shapes.

32
Physical assessment
  • Pg. 196, fig.12.18- shows variations in spinal
    curves
  • A-appears midline-normal
  • B-Scoliosis-pronounced lateral curvature of the
    spine
  • C-Lordosis- natural lumbar curve is exaggerated
  • D-Kyphosis- increased curve in the thoracic area

33
Physical assessment
  • Breasts- teach to examine breasts on routine
    basis. Monthly breast exam about one week after
    menstrural period or on specific date
    post-menopausal is suggested.
  • Study 12.1 page 197 on own, so you will be able
    to teach to your clients. Also table 12.5, pg.
    198 Breast examination guidelines , will be of
    help.

34
Physical assessment
  • Heart Sounds-2 normal heart sounds, S? and S? .
  • S? Lub is louder at the apex or mitral area.
  • S? Dub can be heard here also but louder over
    aortic area.
  • A tiny slurring or splitting sound lubba-dub or
    lub-dubba may indicate the valves do not always
    close at the same time.
  • Abnormal heart sounds, S? and S?.

35
Cont.
  • S? - normal in children, not in adults. May sound
    like lub-dub-dub or ken-tuck-y.
  • S? - heard before S? and may sound like
    lub-lub-dub or ten-ne-ssee.
  • Murmurs, clicks, rubs are abnormal heart sounds,
    need to be reported and further investigated.

36
Normal Lung Sounds
  • Tracheal sounds are loud and coarse. Heard
    equally in length during inspiration and
    expiration and are separated by a brief pause.
  • Bronchial sounds are heard over the upper part of
    the sternum. Harsh and loud. Shorter on
    inspiration than expiration with a pause between
    them.

37
Normal Lung Sounds
  • Bronchovesicular sounds are heard on either side
    of the central chest or back. Medium-range sounds
    of equal length during inspiration and
    expiration, with no noticeable pause.
  • Vesicular sounds are located in the periphery of
    all the lung fields. Soft, rustling quality is
    longer on inspiration than expiration, with no
    pause between.

38
Physical assessment
  • Abnormal lung sounds or adventitious sounds are
  • Crackles-(rales), intermittent, high pitched
    popping sounds. Crispy rice cereal distant areas
    during inspiration.
  • Gurgles-(rhonci), low pitched continuous bubbling
    sounds, predominant during expiration.
  • Wheezes-whistling or squeaking sounds, through
    narrowed passages, inspiration and expiration.
  • Rubs-grating, leathery sounds. Heard by 2 dry
    pleural surfaces moving over each other.

39
The nurse
  • Should assess the characteristics of any cough.
  • Should assess the appearance of raised sputum.
  • Should always use the auscultation sequence and
    guidelines on page 198b -199.

40
Extremities
  • Nurse notes-alignment, mobility, strength,
    compares size, temp., nail characteristics,
    checks capillary refill, peripheral pulses,
    checks for edema, skin sensations, deep tendon
    reflexes with a hammer.
  • Muscle strength- grasp - squeeze release nurses
    fingers. As nurse pushes and pulls on forearm
    and upper arm patient is to give resistance.
    Lower extremities have pt. push and pull foot
    against resisting hand. Top pg.200
  • Finger and toe nails- shape and thickness may
    indicate chronic cardiopulmonary disease process
    or a fungus. Fig.12.24, diamond shaped space is a
    normal finding.

41
Extremities
  • Capillary refill time- amount of time it takes
    blood to resume flowing in the base of the nail
    beds after being compressed and released.
    Normally 3 seconds.
  • Edema-excessive amount of fluid with in tissue.
    Pts. with liver, kidney and cardiovascular
    dysfunction are prone to develop edema. Pg. 201
    box 12-2 good chart to know. The nurse presses
    finger into tissue over a bone to assess for
    edema. Indention remains pitting edema.

42
Extremities
  • Quantify severity by using the chart, 1, 2, 3,
    4, 5 Brawny edema
  • Skin sensation-use light touch-sharp, dull, soft,
    cold, and warm objects to touch the skin in
    various places to assess patients sensation.

43
Abdomen
  • Abdomen- 4 quadrants- always inspect,
    auscultate, palpate, and percuss.
  • Can alter bowel sounds and change findings, done
    in any other manner.
  • Bowel sounds-are assessed on admission and one
    time per shift.
  • Abdominal girth- assessed over widest part of
    abdomen, same place every day. Page 202 fig 12.26
    shows measuring abdominal girth. An indelible pen
    mark may need to be placed to insure the same
    place is being assessed daily.

44
Bowel Sounds
  • Wavelike contractions of the large and small
    intestines that move fluid and intestinal
    contents toward the rectum produce bowel sounds.
    Clicks and gurgles are heard with stethoscope.
  • Occur 5-34 times per minute. More frequently
    heard post a meal.
  • Hyperactive-frequent
  • Hypoactive-occur after long periods of silence
  • Absent-no bowel sounds for 2-5 minutes
  • More frequent after the person eats.

45
Genitalia
  • In most cases the genitalia is only inspected.
  • Nurse of the same gender as the patient present.
  • Don gloves, inspect skin, distribution and
    characteristics of hair. Presence of lice. Any
    fissures, ulcerations, bruising, drainage, foul
    odor, trauma? The physician may do internal exam
    of female with a speculum.
  • Men- the prostate gland is palpated during a
    rectal exam. Observe for circumcision and scrotum
    size. Any drainage, foul odor, fissures? Teach
    men testicular self exam page 203.

46
Anus and rectum
  • Position patient on their side with knees bent.
    Buttocks is separated with a gloved hand to
    visualize the external orifice, (fig. 12.28).
  • Should be intact, moist and hairless.
  • External hemorrhoids (saccular protrusions filled
    with blood) may be observed.
  • Rectal fissures (cracks) if constipation is
    chronic.
  • Trauma maybe present due to anal intercourse.

47
Nursing Diagnoses
  • Ineffective health maintenance
  • Ineffective therapeutic regimen management
  • Deficient knowledge
  • Noncompliance
  • Health-seeking behaviors
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