Physical Assessment

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  • Topic: Snellen chart, Abnormal posturing, Eye chart
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  • Published : January 9, 2013
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Physical Assessment
Instruments:
a. weighing scale

b. penlight

c. gloves

d. magnifying glass/slides (diascopy)

e. thermometer

f. drapes (bed sheet)

g. lubricants (oil, water based)

h. BP apparatus

i. Stethoscope

j. Disposable pods

k. tape measure

l. tongue depressor

m. ophthalmoscope (eyes)

n. otoscope (ears)

o. Snellen Eye Chart (Rosen Baum Chart)
p. nasal speculum (nose)

q. vagina speculum

r. alcohol

Client’s Position
a. Supine

b. Prone

c. Dorsal Recumbent

d. Lithotomy

e. Knee-chest/ Genupectoral

f. Sim’s Position

g. Side-lying position

h. Standing/erect

i. Sitting

Purpose of PA:
1. Screening of well-being
2. Validating of the complaints
3. Monitoring of current health problem
4. Formulation of diagnosis and treatments
Standard Pre-caution and Transmission-based Pre-cautions
1. Universal Pre-caution- to protect health care personnel and patients. -prevent exchange of blood and body fluids
3 ELEMENTS OF STANDARD PRE-CAUTIONS
1. Respiratory hygiene/ cough etiquette
2. Safe Infection Practices
-intramuscular
-intradermal
-subcutaneous
3. Use of masks for any invasive procedure involving the spinal or epidermal spaces Skin-epidermis- C
L
G
S
B
-dermis
Cutaneous
Aponeurosis Galea
Loose conn
Periosterum
Skull
Dura
Arachnoid
Piamatter

2. Transmission-based Precautions- transferring microorganism to one person to another -contact precaution
-droplet precaution
-airborne precaution
HEPA filters- high efficiency particulate air
Hand washing- most important control practice
-alcohol-based and non-bacterial soap and water
Atelectasis- lungs collapsed

Emphysema-for chronic smokers; too much air in the lungs that caused the lungs to expand

Pneumothorax- when air is in the nasal pleural

ASSESSMENT TECHNIQUE (IPPA)
1. Inspection- using one’s own senses
a. vision- fully expose a body part
-overhead lightning
Tangential lightning- oblique lightning/ lighting at an angel to produce a shadow or determine a contour 2. Palpation- act of touching a patient in a therapeutic manner; short fingernails -warm hands prior to placing on patient

-if patient feels pain during palpation, STOP then continues to the other parts that don’t hurt -tell them where, when and how the touch will occur
3. Percussion- sounds
a. dull
b. tympanic (air)- stomach
c. resonance- btw. The ribs
d. flat
Techniques: direct and indirect
4. Auscultation- listening to the body organs; voluntary or involuntary produced by the body 2 types:
-direct
-indirect- electronic device that produces sounds
+Doppler Stethoscope

General Survey
I- PHYSICAL/PSYCHOLOGICAL PRESENCE
Basic Components of a Comprehensive Examination: General Survey Begins at the 1st contact
e.g ambulant- able to walk by themselves

cuddled- carried by their parents eg. Baby

perWHEELCHAIR/ wheeled in

Gurney- bed with wheels

Stretcher

Overall Impression of Client
e.g- ambulant-can see that the patient can control his/her muscles SigN- nakita
SyMptom- sinabi mo

II- METHODS OF DATA GATHERING/GENERAL SURVEY
Equipment
Interview-Stethoscope
Measurement-watch w/ a single hand
Inspection/observation

A. Physical Presence
Observe patient’s:
1. Stated age vs Apparent age- pt’s stated chronological age should be congruent w/ apparent age -some ‘appears’ older/younger than chronological age
Dwarfism- endocrine deficiencies of growth hormone—younger but w/ premature aging later

Genetic Syndrome (Turner’s)- ‘old’ person facial expression.

Chronic disease, severe illness (cancer, AIDS)- caused by prolonged sun exposure-old-looking person Tripod Position- leaning forward position

Apple vs Pear

III- BODY POSTURE, GAIT AND MOTOR ACTIVITY
Gait-manner of walking
Gives clues about:
-motor behavior...
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