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Copy of Putting it All Together

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Rebecca Sutter

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Transcript of Copy of Putting it All Together

Putting it All Together
NURS 425 Fall 2013

PHYSICAL EXAM
COMMUNICATION
An opportunity to Improve Communication among healthcare team!
What is SBAR?
Communication:
Occurs when one person sends a message and another person receives it.
The Benefits of SBAR:
The nurse gets straight to the point
Has all essential pieces of information
Provider knows what the nurse is asking for
The guessing game is omitted.
B= Background:
What is the clinical background information that is pertinent to the situation.
R= Recommendation:
What action/recommendation is needed to correct the problem. What do you want?
S= Situation:
What is going on with the patient. A concise statement of the problem
A= Assessment:
What did you find? Analysis and considerations of options.
What is SBAR stand for:
S= Situation
B= Background
A= Assessment
R= Recommendation
B= Background:
What is the clinical background information that is pertinent to the situation.
END
Communication
An opportunity to Improve Communication among healthcare team!
What is SBAR?
Communication:
Occurs when one person sends a message and another person receives it.
The Benefits of SBAR:
The nurse gets straight to the point
Has all essential pieces of information
Provider knows what the nurse is asking for
The guessing game is omitted.
R= Recommendation:
What action/recommendation is needed to correct the problem. What do you want?
S= Situation:
What is going on with the patient. A concise statement of the problem
A= Assessment:
What did you find? Analysis and considerations of options.
END
What is SBAR stand for:
S= Situation
B= Background
A= Assessment
R= Recommendation
B= Background:
What is the clinical background information that is pertinent to the situation.
Upper Extremity
The Physical Exam
Palpate the following lymph nodes: preauricular, postauricular,occipital, posterior cervical, cervical/tonsillar, sumbandibular, submental, cervical, and supraclavicular
Palpate the thyroid, cricothyroid, and cricoid cartilage
Palpate the trachea
Locate, assess the isthmus of the thyroid
Inspect the eyes: lids, sclera, conjunctiva, iris
Assess extraocular movement
Assess pupil size, accomadation and response
Check eye using ophthalmoscope
Head, Neck & Eyes
HNE
ENT
Check ears with otoscopy
Check nose patency
Check nose using speculum
Using a light, Inspect the lips, tongue, mucosa, teeth, gums, parotid duct, uvula, pharynx, tonsils, and soft and hard palates
With the aid of a tongue depressor, inspect teeth and gums
Ear, Nose & Throat
HEART
Inspect jugular venous pulse
Inspect the precordium
Palpate the precordium, the point of maximal impulse, the brachial pulse, radial pulse, ulnar pulse, popliteal pulse, dorsalis pedis, posterior tibial pulse, and carotid pulse
Ascultate the aortic area, pulmonic area, tricuspid area, mitral area
Listen for cardiac murmurs and cardiac gallups
Chest
Inspect chest for shape, symmetry of respiration, pulsations, and respiratory effort
Inspect for thoracic expansion
Tactile fremitus
Percuss the posterior and anterior chest
Assess diaphragmatic excursion
Check posterior then anterior breath sounds
Check vocal resonance
ABD
Inspect abdomin for color, contour, symmetry, movement, scars
Auscultate all four quadrants
Auscultate aortic, renal, and iliac arteries
Percuss the liver and spleen
Palpate all four quadrants lightly and then deeply
Palpate the right costal margin and then the left costal margin
Palpate the aortic pulse
Inspect for CVA tenderness
BACK
Asses gait for normal walking, toe walking, and heel walking
Assess alignment of spine and hips
Palpate spine
Inspect range of motion of the spine
Assess strength of the lower extremity
Assess sensation of the L2-S1 dermatomes
Check lower extremity reflexes
Perform the Patrick/FABERE tests
Inspect hip, knees, ankles, and feet
Palpate hip
Assess hip strength and range of motion during passive flexion/extension, passive rotation, passive abduction/adduction
Inspect and palpate knee
Assess knee strength and range of motion
Perform special maneuvers on knee
Palpate ankle/foot
Assess ankle/foot strength and range of motion
UE
Inspect and palpate shoulder
Assess shoulder range of motion and strength
Inspect and palpate elbow
Asses elbow range of motion and strength
Inspect and palpate wrist/hand
Assess wrist/hand range of motion and strength
Heart & Blood Vessels
Chest/Lung
Abdominal
Back
Lower Extremity
LE
Inspect hip, knees, ankles, and feet
Palpate hip
Assess hip strength and range of motion during passive flexion/extension, passive rotation, passive abduction/adduction
Inspect and palpate knee
Assess knee strength and range of motion
Perform special maneuvers on knee
Palpate ankle/foot
Assess ankle/foot strength and range of motion
Lower Extremity
LE
Upper Extremity
UE
Inspect and palpate shoulder
Assess shoulder range of motion and strength
Inspect and palpate elbow
Asses elbow range of motion and strength
Inspect and palpate wrist/hand
Assess wrist/hand range of motion and strength
BACK
Asses gait for normal walking, toe walking, and heel walking
Assess alignment of spine and hips
Palpate spine
Inspect range of motion of the spine
Assess strength of the lower extremity
Assess sensation of the L2-S1 dermatomes
Check lower extremity reflexes
Perform the Patrick/FABERE tests
Back
Neuro
Check orientation to person, place, time
Assess cranial nerves:
Check extraocular eye movement, palpate facial muscles, check facial sensation, assess facial muscle competency, check hearing, check palatal symmetry, make sure tongue works properly, assess upper/lower muscle coordination, observe gait, check sensation ability at extremities, perform Romberg Sign test, check reflexes
Neurological
ABD
Inspect abdomin for color, contour, symmetry, movement, scars
Auscultate all four quadrants
Auscultate aortic, renal, and iliac arteries
Percuss the liver and spleen
Palpate all four quadrants lightly and then deeply
Palpate the right costal margin and then the left costal margin
Palpate the aortic pulse
Inspect for CVA tenderness
Abdominal
Chest
Inspect chest for shape, symmetry of respiration, pulsations, and respiratory effort
Inspect for thoracic expansion
Tactile fremitus
Percuss the posterior and anterior chest
Assess diaphragmatic excursion
Check posterior then anterior breath sounds
Check vocal resonance
Chest/Lung
Palpate the following lymph nodes: preauricular, postauricular,occipital, posterior cervical, cervical/tonsillar, sumbandibular, submental, cervical, and supraclavicular
Palpate the thyroid, cricothyroid, and cricoid cartilage
Palpate the trachea
Locate, assess the isthmus of the thyroid
Inspect the eyes: lids, sclera, conjunctiva, iris
Assess extraocular movement
Assess pupil size, accomadation and response
Check eye using ophthalmoscope
Head, Neck & Eyes
HNE
VS
Take blood pressure
Take pulse
Take respirations
Vital Signs
ENT
Check ears with otoscopy
Check nose patency
Check nose using speculum
Using a light, Inspect the lips, tongue, mucosa, teeth, gums, parotid duct, uvula, pharynx, tonsils, and soft and hard palates
With the aid of a tongue depressor, inspect teeth and gums
Ear, Nose & Throat
HEART
Inspect jugular venous pulse
Inspect the precordium
Palpate the precordium, the point of maximal impulse, the brachial pulse, radial pulse, ulnar pulse, popliteal pulse, dorsalis pedis, posterior tibial pulse, and carotid pulse
Ascultate the aortic area, pulmonic area, tricuspid area, mitral area
Listen for cardiac murmurs and cardiac gallups
Heart & Blood Vessels
FIGURE 20.10 PALPATING THE BLADDER.

ASSESS HEART SOUNDS

Factors that affect accuracy include:
Hemoglobin level
Circulation
Activity
Carbon monoxide poisoning
Nail polish
Body temperature

PULSE OXIMETRY

Patient description
Duration
Location
Quantity
Quality
Aggravating or alleviating factors
Limitations
REASSESS post pain relieving med or technique


PAIN ASSESSMENT

Listening for Korotkoff sounds with stethoscope

First sound is systolic pressure
Change or cessation of sounds occurs—diastolic pressure

The brachial artery and popliteal artery are commonly used

ASSESSING BLOOD PRESSURE

Rate
Beats per minute
tachycardia bradycardia
Rhythm
Regular or irregular
Volume
Strength or amplitude
Presence or absence of bilateral equality
Compare corresponding artery

CHARACTERISTICS OF THE PULSE

LOCATION FOR APICAL PULSE

Attention to life cycle, holism, and culture must not detract from importance of assessment skills themselves
Assessment skills require hands-on expertise refined to a high level
Nurse is first and often only health professional to see an individual in many communities
Nurse is only health professional continually present at bedside in hospitals

HIGH-LEVEL
ASSESSMENT SKILLS

Interval of assessment varies with illness and wellness needs
Ill people seek care because of pain or abnormal signs and symptoms
This prompts an assessment: gathering complete, episodic, or emergency data base
Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices
Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health

FREQUENCY OF ASSESSMENT

Follow-up data base
Status of all identified problems should be evaluated at regular and appropriate intervals
Note changes that have occurred
Evaluate whether problem is getting better or worse
Identify coping strategies being used

COLLECTING FOUR TYPES
OF DATA (CONT.)

Complete total health data base
Includes complete health history and full physical examination
Describes current and past health state and forms baseline to measure all future changes
Yields first diagnoses

COLLECTING FOUR TYPES OF DATA

Assessment: collection of data about an individual’s health state
A clear idea of health is important because it determines assessment data to be collected

EXPANDING THE CONCEPT OF HEALTH

Comprehensive plan of care
Evaluate and update plan
Record revised plan and keep it up-to-date
Communicate revised plans to multidisciplinary team
Be aware this is a legal document, and accurate recording is important for evaluation, insurance reimbursement, and research

CRITICAL THINKING (CONT.)

Interventions
Determine specific interventions that will achieve expected outcomes
Interventions aim to prevent, manage, or resolve health problems
This is the health care plan
Evaluation and corrective thinking
Analyze outcomes and apply them for evaluation
Do stated outcomes match individual’s actual progress?
Continually think, “what could be done differently or better?”

CRITICAL THINKING (CONT.)

Identify patterns
Helps to see whole picture and discover missing pieces of information
Missing information
Identify gaps in data or need for more specific interviewing or laboratory data to make diagnosis
Health promotion
Identify and manage known risk factors for individual’s age group and cultural status

CRITICAL THINKING (CONT.)

Inferences or drawing valid conclusions
Interpreting data and deriving correct conclusions
Clustering related cues
Assists seeing relationships among data
Relevance
Look at clusters of data and consider which are important for health problem
Inconsistencies
Recognize subjective data at odds with objective data

CRITICAL THINKING (CONT.)

Refer to established outcomes
Evaluate individual’s condition and compare actual outcomes with expected outcomes
Summarize results of evaluation
Identify reasons for failure to achieve expected outcomes
Take corrective action to modify plan of care
Document evaluation in plan of care

NURSING PROCESS: EVALUATION

Determine patient readiness
Review planned interventions
Collaborate with other team members
Supervise by delegating appropriate responsibilities
Counsel person and significant others
Involve person in health care
Refer for continuing care
Document care provided

NURSING PROCESS: IMPLEMENTATION

Establish priorities
Develop outcomes
Set time frames for outcomes
Identify interventions
Document plan of care

NURSING PROCESS: PLANNING

Interpret data
Identify clusters of cues
Make inferences
Validate inferences
Compare clusters of cues with definitions and defining characteristics
Identify related factors
Document the diagnosis

NURSING PROCESS: DIAGNOSIS

Diagnostic reasoning
Nursing process
Critical thinking

CLINICAL REASONING MODELS

Slide 28-*

Slide 28-*

Cover and reposition patient
Safety check
Bed low position, call light within reach
Personal items within reach
Open privacy curtain
Wash hands
Clean stethoscope w alcohol
Record findings

FINISH

Slide 28-*

Any open wounds
Unusual lesions
Change in mole
Bleeding
Rashes
Bruising
Pruritis
Exam
Incorporate into assessment of each systems

INTEGUMENTARY HISTORY & EXAM

Slide 28-*

Inspect
Edema of joint
Ease of movement
Note strength and tone of muscles
Need assistance? sit up in bed, turn, transfer etc
Perform
ROM Upper and lower extremities

MUSCULOSKELETAL EXAM

Slide 28-*

Inspect urine for
clarity
color
Palpate bladder for distension
Distended bladder feels smooth, round and taut.
Find the base of the bladder 5-7 cm below the umbilicus in the lower right abdomen
If concerned really distended start from umbilicus and go down

GU EXAM

Slide 21-*

NORMALLY PALPABLE STRUCTURES

Slide 28-*

Percuss and state normal findings
Generally tympany predominates
Liver - dull
may need to do liver span
Spleen - dull
difficult to percuss unless enlarged
Costovretebral angle
Hand over 12 rib thumb it with ulnar edge of other hand L and R

GI EXAM

Slide 28-*

Inspect contour and symmetry
Inspect for color, scars, striae
Auscultate all 4 quadrants
Auscultate abdominal aorta

GI EXAM

Slide 28-*

CV EXAM

Slide 28-*

Cardiovascular system
Assess precordium
Palpate anterior chest wall
Apical impulse = apex of heart
Palpate all pulse site bilaterally
You decide if carotid is necessary
Check
capillary refill
Skin color temperature
Check edema

CV EXAM

Slide 18-*

Normal breath sounds and locations in adult and older child
Bronchial: I < E
Trachea and Larynx
Bronchovesicular: I=E
Over major bronchi (not alveoli)
Vesicular: I > E
Over small bronchioles and alveoli


BREATH SOUNDS

Slide 28-*

Auscultate
Patient breathes deeply through mouth
Assess in a pattern
Comparison =side to side
Listen to one full breath (both in and out) in each location
Duration of inspiration and expiration
What do you hear, where?

RESPIRATORY EXAM

Slide 28-*

Palpate posterior chest wall
Tactile fremitus
Palmar base of fingers or ulnar edge of one hand touch person’s chest while they say “ninety-nine”
Symetry
Symmetric expansion
Hands on posterolateral chest wall with thumbs at T9 /10
Slide your hands medially pinch up a fold of skin between your thumbs; ask person take a deep breath with breath thumbs should move apart symmetrically
Temperature

RESPIRATORY EXAM

Slide 28-*

Inspect anterior and posterior chest wall
Inspect skin for lesions
do this at every system
Assess for use of accessory muscle use
Note quality of breathing
Assess position for breathing
Do they need to be on 2 pillows
Do they lean forward over bed side table
Assess facial expression
Look anxious

RESPIRATORY EXAM

Slide 28-*

Assess balance
Romberg feet together arms at side
Close eyes wait 20 seconds
Stand close to person to catch if needed
Negative = no sway
Positive = loss of balance
Assess gait
Walk 10 – 20 ft turn and return to start point
Position patient for comfort and safety (?in bed)

NEURO EXAM

Slide 28-*

Inspect head eyes ear for shape size position
Check face for symmetry
Smile
Stick out tongue
Assess mouth throat with light
use tongue depressor
Simulate gag response

NEURO EXAM

Slide 28-*

Apparent state of health
Facial expression, mood and affect.
Level of consciousness, and orientation
alert and oriented, attentive to your questions, responds appropriately?
Personal hygiene
Speech
clear and understandable, fluent, content appropriate
Hearing
responses and facial expression consistent with what you have said


GENERAL APPEARANCE

.

Effectiveness of respiration
Uptake and transport of O2
Transport and elimination of CO2
Estimates arterial blood oxyhemglobin saturation (SpO2)
Noninvasive
Sites finger nail or ear lobe
Normal SpO2 >92
< 70% life threatening
Detects hypoxemia before clinical signs and symptoms

PULSE OXIMETRY

Exercise
Respiratory and cardiovascular disease
Alterations in fluid, electrolyte, and acid balances
Medications
Trauma
Infection
Pain
Anxiety

FACTORS AFFECTING RESPIRATIONS

Age
Diurnal variations
(circadian rhythms)
Exercise
Hormones
Stress
Environment

FACTORS AFFECTING BODY TEMPERATURE

Slide 28-*

Gather equipment
Wash hands (gloves if needed)
ID of client
Introduce self (eye contact)
Explain exam
Provide privacy (pull curtain)
Put into supine position

ASSESSMENT

Efforts at cost containment result in hospital populations composed of people with increased acuity, shorter stays, and earlier discharges than in past
Nurses must make faster, more efficient assessments
Nurses required go to people’s homes for follow-up assessment and diagnosis
First-rate assessment skills grounded in holistic approach and knowledge of age-specific problems are required

CROSS-CULTURAL
CARE (CONT.)

Routine periodic examination might include following services for preventive health care:
Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices
Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health
Immunizations
Chemoprophylaxis for multivitamin with folic acid for females capable of or planning pregnancy

FREQUENCY OF
ASSESSMENT (CONT.)

Emergency data base
Rapid collection of data, often compiled concurrently with lifesaving measures
Diagnosis must be swift and sure
Person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness, and disability are being assessed

COLLECTING FOUR TYPES
OF DATA (CONT.)

Episodic or problem-centered data base
For limited or short-term problems
Collect “mini” data base, smaller scope and more focused than complete data base
Concerns mainly one problem, one cue complex, or one body system
History and examination follow direction of presenting concern
Acute or chronic onset, associated with fever, local or generalized

COLLECTING FOUR TYPES
OF DATA (CONT.)

Biomedical model
Health as absence of disease
Health and disease are opposite extremes on linear continuum
Disease is caused by specific agents or pathogens
A natural progression to health promotion and disease prevention rounds out our concept of health
Guidelines to prevention emphasize link between health and personal behavior

EXPANDING THE CONCEPT OF HEALTH (CONT.)

Data base: organization of assessment data varies depending on conceptual model used
Models provide a framework for:
Determining what to observe
Organizing observations or data
Interpreting and using the information
Nursing diagnoses are clinical judgments about a person’s response to an actual or potential health state

USING A CONCEPTUAL FRAMEWORK AS A GUIDE

Collaborative problems
When approach to treatment involves multiple disciplines
Outcomes
Determine patient-centered expected outcomes
Specific, measurable, results expected to improve person’s problem after treatment
Outcome statements include specific time frame

CRITICAL THINKING (CONT.)

Risk diagnosis
Identify actual and potential risks from full list of both medical and nursing assessment data
Set priorities
When there is more than one diagnosis:
First-level priority problems: emergent, life threatening, and immediate
Second-level priority problems: next in urgency
Third-level priority problems: important to patient’s health but can be addressed after more urgent problems are addressed

CRITICAL THINKING (CONT.)

Identifying Assumptions
Recognize information taken for granted or fact without evidence for it
Organized approach
Use an organized, systematic assessment format
Validation
Check and corroborate accuracy and reliability of data
Normal and abnormal
Distinguish when identifying signs and symptoms

CRITICAL THINKING

Identify expected outcomes
Individualize to patient
Ensure outcomes are realistic and measurable
Include a time frame

NURSING PROCESS:
OUTCOME IDENTIFICATION

Collect data
Review of clinical record
Interview
Health history
Physical examination
Functional assessment
Cultural and spiritual assessment
Consultation
Review of the literature

NURSING PROCESS: ASSESSMENT

Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation

NURSING PROCESS

Attend to initially available cues
Cue: piece of information, sign, symptom, or piece of laboratory data
Formulate diagnostic hypotheses
Hypothesis: tentative explanation for cues used as a basis for further investigation
Gather data relative to tentative hypotheses
Evaluate each hypothesis with new data collected to arrive at final diagnosis

DIAGNOSTIC REASONING

Subjective data
What patient says about himself or herself during history taking
Objective data
Observed when inspecting, percussing, palpating, and auscultating patient during physical examination
Data base
Formed from these elements, plus patient’s record and laboratory studies

ASSESSMENT:
POINT OF ENTRY IN AN ONGOING PROCESS

Slide 28-*

Pain, stiffness
Limitation of movement
Weakness in one or more limbs
Any limitations in mobility
Stairs
On off toilet
In and out of bed
Car

MUSCULOSKELETAL HISTORY

Slide 28-*

Urinating
How often
Amount
Color
Clarity
Burning or pain with urinating
Voiding pattern

GU HISTORY

Slide 21-*

Light palpation
With four fingers close together, depress skin about 1 cm
Make gentle rotary motion, sliding fingers and skin together, move clockwise around abdomen
Assess
Temperature
Masses
Pulsations
Firmness



GI EXAM

Slide 28-*

GI EXAM

Carolyn Jarvis Physical Examination and Health Assessment 3rd edition.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.

Auscultation of Vascular Sounds

Slide 28-*

Abdominal pain
Surgical pain
?BM or flatus
Soft hard color etc.
NVD
Constipation
Surgical history

GI HISTORY

Slide 28-*

Auscultate heart sounds
5 areas
ID heart sounds
ID valve areas
Assess heart sounds
Rate
Rhythm
ID S1 S2
Check apical vs. radial pulse

CV EXAM

Slide 19-*

Chest pain
Dyspnea
Orthopnea
Fatigue
Cyanosis or pallor
Edema
Past cardiac history

CV HISTORY

Slide 28-*

Percuss
Side to side
Symmetry is important
State findings
Resonance
Hyperresonance
Flatness
Dullness
Tympany
What is normal



RESPIRATORY EXAM

Slide 28-*

Cough
Shortness of breath
Chest pain with breathing
History of respiratory infections/problems
bronchitis, emphysema, asthma, or pneumonia?
Smoking history
Yes, no , former
Cigarettes or cigars? PPD? How long?
Quit date if former

RESPIRATORY HISTORY

Slide 28-*

Assess motor strength lower
ROM against your resistance (5 = normal)
Hip
adduct abduct
Knee
Flexion extension
Foot
plantar flexion
dorsiflexion

NEURO EXAM

Slide 28-*

Assess PERRLA with penlight
Darken room advance light from side
Note direct and consensual light reflex
Assess motor strength upper
ROM against your resistance (5 = normal)
Shoulders abduct, adduct
Elbow flex extend
Grips


NEURO EXAM

Slide 28-*

Questions
Any vision changes hearing changes
Trouble swallowing, speaking
Loss of strength in arms or legs?
Loss of balance any falls?
Weakness
Seizures

NEURO EXAM

Slide 28-*

Measurement
Temperature
Pulse for 30 seconds!!
Respiration
Blood pressure
Pulse oximetry
Rate pain level on 1 to 10 scale, pain tolerance

OBJECTIVE DATA

Slide 28-*

MEASURING APICAL PULSE

Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation

NURSING PROCESS
Collecting Four Types of Data
Critical Thinking
Risk diagnosis:
Identify actual and potential risks from full list of both medical and nursing assessment data
Set priorities
when there is more than one diagnosis:

First-level priority problems:
emergent, life threatening, and immediate

Second-level priority problems
:
next in urgency

Third-level priority problems:
important to patient’s health but can be addressed after more urgent problems are addressed
REMEMBER...
Review you posted Powerpoint!

Don't change answers on exams!

Use your instincts...it is what makes a great nurse!
Pulling it all Together
Complete total health data base
Episodic or problem-centered data base
Follow-up data bas
Emergency data base
END
Critical Thinking
Subjective data:
What patient says about himself or herself during history taking

Objective data:
Observed when inspecting, percussing, palpating, and auscultating patient during physical examination

Data base:
Formed from these elements, plus patient’s record and laboratory studies

CLUSTER DATA TOGETHER TO COME TO A CONCLUSION!
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