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Chapter 3
Collecting Objective Data: The Physical Exam
35
Nursing
Undergraduate 2
09/08/2016

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Term
Collecting Objective Data
Definition
*Data collected by the nurse directly
*Physical Exam- Head-to-toe
*Gather all equipment prior to start of exam
Term
Physical Examination Preparation
Definition
*Comfortable, warm temperature
*Private area free of interuption
*Quiet area with adequate lighting
*Firm examination table or bed
*Bedside table/tray to hold equipment
Term
Standard Precautions
Definition
*Assume that every person is potentially infected or colonized with an organism that can be transmitted
*Apply the following infection control practices:
1. Hand Hygiene
2. Gloves
3. Mask, eye protection, face shield
4. Gown
5. Patient care equipment/ Patient placement
6. Linen; occupational health and blood borne pathogens
Term
Client Approach and Preparation
Definition
*Establish nurse-client relationship
*Explain the procedure and the physical assessment that will follow, describing the steps of the examination
*Respect client's requests and desires
*Explain the importance of the examination
*Leave room while client changes clothes
*Provide necessary container in case of sample
*Begin exam with less-intrusive procedures
*Explain procedures being performed
*Explain to client why position changes are necessary
Term
Client Positioning
Definition
*Sitting Position
*Supine Position
*Dorsal Recumbent
*Sim's Position
*Standing Position
*Prone Position
*Knee-chest Position
*Lithotomy Position
Term
Sitting Position
Definition
Sit upright on exam table/bed
Term
Supine Position
Definition
Lying down with legs together[image]
Term
Dorsal Recumbent Position
Definition
Lays down on table, knees bent, legs separated, and feet flat on the table (May be more comfortable for patients with back pain)[image]
Term
Sim's Position
Definition
Patient lays on side, with lower arm placed behind the body and the upper arm flexed at the shoulder. The lower leg is slightly flexed at a sharper angle and pulled forward [image]
Term
Standing Position
Definition
Stands still in a normal, comfortable, resting posture
Term
Prone Position
Definition
Patient lies down on the abdomen with the had to the side- used to assess back and hip joints[image]
Term
Knee-Chest Position
Definition
*Kneels on table/bed with the weight of the body supported by the chest and knees. A 90 degree angle should exist between the body and the hips[image]
Term
Lithotomy Position
Definition
Patient lies on back with the hips at the edge of the table and the feet supported in stirrups[image]
Term
Four Components of the Physical Exam
Definition
*Inspection
*Palpation
*Percussion
*Auscultation
Term
Physical Examination: Inspection
Definition
*Inspection uses all of the sense: vision, smell, and hearing
*Begins the moment you meet your patient and is ongoing
*Inspection is ALWAYS first in the examination process- due to all others may alter appearance of what is being inspected
*Guidlines
-Room at comfortable temperature
-Good lighting
-Look and observe before touching
-Completely expose part being examined
-Note characteristics (color, size, location, symmetry, odors, sounds)
-Compare apperances (symmetry)
Term
Physical Examination: Palpation
Definition
*Consists of using parts of the hand to touch and feel the following characteristics:
-Texture (Smooth/rough)
-Temperature/Moisture
-Mobility (fixed.moveable/still/vibrating)
-Consistency (Soft/hard/fluid filled)
-Strength of pulses (Strong/ medium/large)
-Shape (Well defined/irregular)
-Degree of tenderness
Term
Parts of the Hand Used for Palpation
Definition
*Finger Pads- sensitive to fine discrimination, pulses, texture, size, crepitus
*Palmar Surface- Vibrations, thrills, fremitus
*Dorsal Surface- Temperature
Term
Four Types of Palpation
Definition
*Light- Place dominant hand lightly on surface of the skin of the patient
*Moderate- Depress the skim 1-2 cm with dominant hand and use circular motion to feel body organs/masses
*Deep- Dominant hand on the skin and non-dominant hand on top of your dominant hand- depress 2.5-5 cm to feel very deep organs
*Bimanual- Using two hands, placing one on each side of the body part-one hand to apply pressure and the other hand to feel structure (breast exam)
Term
Physical Examination: Percussion
Definition
*Involves tapping on body part to produce sounds waves
*Sounds waves or vibrations enable examiner to assess underlying structures
*Purposes:
-Eliciting pain
-Determining location, size, and shape
-Determining density
-Detecting abnormal masses
-Eliciting reflexes
Term
Types of Percussion
Definition
*Direct Percussion- Direct tapping of a body part with one or two fingers to elicit possible tenderness (tenderness over the sinuses)
*Blunt Percussion- Used to detect tenderness over organs- place one hand flat on surface and use the first of other hand to strike the back of the hand
*Indirect or Mediate Percussion- Most commonly used. Produces sound or tone that varies with density of underlying structures
Term
Physical Examination- Auscultation
Definition
*Type of Assessment technique that requires the use of a stethoscope
*Can hear sounds not audible to ear
*Sounds include: heart sounds, lung sounds, blood flow through vascular system, bowel sounds
*Sounds classified according to:
- Intensity (loud/soft)
-Pitch (High/low)
-Duration (Length)
-Quality (musical, crackling, raspy)
*Technique:
-Eliminate distracting noise
-Expose the body part (NEVER through clothing)
-Diaphragm of stethoscope for high-pitched sounds (heart, bowel, breath)
-Bell of stethoscope for low-pitched sounds (abnormal heart, bruits)
-Place earpieces into outer ear canal
Term
Resonance with Percussion
Definition
*Heard over part air and part solid
*Intensity-Loud
*Pitch-Low
*Length-Long
*Quality-Hollow
*Heard over normal lung
Term
Hyper-resonance with Percussion
Definition
*Heard over mostly air
*Intensity-Very loud
Pitch-Low
Length- Long
Quality- Booming
*Heard over lung with emphysema
Term
Tympany
Definition
*Heard over mostly air
*Intensity- Loud
*Pitch- High
*Length- Moderate
*Quality- Drum-like
*Puffed out cheek, gastric bubble
Term
Dullness
Definition
*Heard over more solid tissue
*Intensity- Medium
*Pitch- Medium
*Length- Moderate
*Quality- Thud-like
* Heard over Diaphragm, Plural effusion, Liver
Term
Flatness
Definition
*Heard over very dense tissue
*Intensity- Soft
*Pitch- High
*Length- Short
*Quality- Flat
*Muscle, bone, sternum, thigh
Term
Resonance with Percussion
Definition
*Heard over part air and part solid
*Intensity-Loud
*Pitch-Low
*Length-Long
*Quality-Hollow
*Heard over normal lung
Term
Skinfold Calipers
Definition
Measures skinfold thickness of subcutaneous tissue[image]
Term
Flexible Tape Measure
Definition
Measures mid-arm circumference.
Term
Wood’s Light
Definition
Test's for fungus[image]
Term
Braden Scale for Predicting Pressure Sore Risk
Definition
Predicts Pressure Sore Risk
Term
Opaque Card
Definition
Tests for strabismus
Term
Ophthalmoscope
Definition
Views the red reflex and examines[image] the retina of the eye
Term
Otoscope to view the ear canal and tympanic membrane
Definition
*Views the ear canal and tympanic membrane
*With wide-tip attachment to view the internal nose
[image]
Term
Doppler Ultrasound Device and Conductivity Gel
Definition
Detects pressure and weak pulses not easily heard with a stethoscope
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