Unit Physical Assessment - Cengage Learning

1 PhysicalAssessment8 Physical Assessment Techniques9 General Survey, Vital Signs, and Pain10 Skin, Hair, and Nails11 Head, Neck, and Regional Lymphatics12 Eyes13 Ears, Nose, Mouth, and Throat14 Breasts and Regional Nodes15 Thorax and Lungs16 Heart and Peripheral Vasculature17 Abdomen18 Musculoskeletal System19 Mental Status and Neurological Techniques20 Female Genitalia21 Male Genitalia22 Anus, Rectum, and ProstateUnit3 Unit3 She must have a respect for her own calling, becauseGod s precious gift of life is often literally placed inher hands; she must be a sound, and close, andquick observer.

2 Florence how to maintain standard precautions during the an environment suitable for conducting a how to perform inspection, palpation, percussion, andauscultation, and which areas of the body are assessed with inspection, palpation, percussion, and auscultation inthe clinical 3 Physical AssessmentInspection, palpation, percussion, and auscultation are the techniques usedby the nurse to assess the patient during a Physical examination. This chapterintroduces the Assessment techniques and equipment used to conduct physi-cal OF Physical ASSESSMENTP hysical Assessment of a patient serves many of general well-being.

3 The findings will serve as baseline infor-mation for future of the complaints that brought the patient to seek health of current health of diagnoses and need for Physical Assessment depends on, among other factors, thepatient s health status, concept of health care, and accessibility to health example, a brittle diabetic with arthritis and glaucoma who has access tohealth care is likely to enter the health care delivery system more often than ahealthy college of the NurseThe professional nurse plays a vital role in the Assessment of patient preparation and the clinical setting in part determine the extentto which the nurse participates in the Assessment process.

4 For example, a nursein primary care may perform a comprehensive Physical Assessment of patients,while a critical care nurse may conduct selected patient assessments to moni-tor and evaluate current health problems. In either case, nurses are expectedto be familiar with and comfortable using Physical Assessment skills. Today snurses are sophisticated professionals who require information in order to makeclinical decisions. The Physical Assessment findings provide this Precautions and Transmission-Based PrecautionsThe transmission of hepatitis, human immunodeficiency virus (HIV), andother infectious diseases is a primary concern for you and for the patient.

5 Standard precautions, formerly known as universal precautions, were developedby the Centers for Disease Control and Prevention (CDC) to protect healthcare professionals and patients. The primary goal of standard precautions is toprevent the exchange of blood and body fluids. Standard precautions shouldbe practiced with every patient throughout the entire encounter. Figure 8-1illustrates the standard precautions recommended by the CDC has developed another level of precautions called transmission-based precautions.

6 These precautions are to be used in conjunction with standard precautions. Contact, droplet, and airborne transmissions of micro-organisms that are known to exist in a patient or are suspected in a patient are targeted. Contact transmission, such as in impetigo, scabies, and varicellazoster virus, are spread directly from person to person. They can also be spreadindirectly from a contaminated inanimate object to a person. Droplet trans-mission occurs when microorganisms are deposited on susceptible body partsvia sneezing and coughing.

7 Suctioning a patient can also transmit ThinkingSelf-Evaluation of StandardPrecaution PracticesThink back to the last day thatyou worked in the clinical setting. Did you consistently use stan-dard precautions? If not, what was the occasionwhen you did not use standardprecautions? What factorsinfluenced this decision? Whatare the short-term ramificationsof this decision? Long-termconsequences?Nursing AlertLatex AllergiesIn accordance with standard pre-cautions, nurses frequently usegloves when dealing with patients body fluids.

8 Be alert to the possi-bility that you, as well as yourpatients, may have latex range from eczematouscontact dermatitis to anaphylacticshock. Ask patients if they haveany known allergy to latex prod-ucts prior to touching patientswhile wearing latex gloves andusing other latex 8 Physical Assessment Techniques 231 Figure 8-1 Standard Precautions. Courtesy of Brevis Corporation232 unit 3 Physical AssessmentPertussis and Haemophilus influenzaeare examples of this mode of transmission spreads microorganisms by air currents and can also be passed through ventilation systems.

9 Measles and the varicellavirus can spread in this mode. Additional information can be viewed on theCDC Web site. Search for Guidelines for Isolation Precautions. HandwashingThe most important infection control practice is handwashing. You must beginevery Physical Assessment with a thorough handwash. Some nurses performthis in the Assessment area with the patient present. It is a nonthreatening wayto start the Physical Assessment and allows the patient time to ask questionsconcerning the CDC has recently issued Guideline for Hand Hygiene in Health-Care Settings(Boyce & Pittet, 2002).

10 These handwashing guidelines recommend theuse of an alcohol-based hand rub, an antimicrobial soap and water, or a nonan-timicrobial soap and water when the hands are visibly contaminated with bodyfluids. Your institution may provide some or all of these methods of hand-washing; regardless, the most important factor is that you use them with everypatient IssuesIn today s litigious society, you must be ever vigilant when engaging in nursingpractice. Documentation issues have previously been addressed. Equally impor-tant is how you execute the nursing Assessment .