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Fundamental Nursing Skills and Concepts

Purposes of Physical Assessment. To evaluate the client's current physical conditionTo detect early signs of developing health problemsTo establish a baseline for future comparisonsTo evaluate the client's responses to medical and nursing interventions. Four Basic Physical Assessment Techniques.

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Fundamental Nursing Skills and Concepts

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    1. Fundamental Nursing Skills and Concepts Chapter 12

    2. Purposes of Physical Assessment To evaluate the client’s current physical condition To detect early signs of developing health problems To establish a baseline for future comparisons To evaluate the client’s responses to medical and nursing interventions

    3. Four Basic Physical Assessment Techniques Inspection Palpation Percussion Auscultation

    4. 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

    5. Gathering General Data Physical appearance in relation to clothing and hygiene Level of consciousness Body size Posture Gait and coordinated movement Use of ambulatory aids Mood and emotional tone

    6. Selecting a Approach for Data Collection Head-to-toe approach Body systems approach

    7. Body Systems Approach Collecting data according to the functional systems of the body. Examination of structures in each system separately

    8. Data Collection Head and Neck Chest Extremities Abdomen Genitalia Anus Rectum

    9. 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 fingers the nurse raises. Snellen eye chart (tool for assessing far vision) Jaeger chart (visual assessment tool assessing near vision)

    10. 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)

    11. 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

    12. Normal Lung Sounds Tracheal sounds are loud and coarse Bronchial sounds are heard over the upper part of the sternum Bronchovesicular sounds are heard on either side of the central chest or back Vesicular sounds are located in the periphery of all the lung fields

    13. Heart Sounds The two normal heart sounds are lub (S1) heard at the apex and dub (S2) heard at the mitral area S3 is abnormal in adults but normal in children S4 is heard before S1-Lub-Lub-Dub

    14. Bowel Sounds Wavelike contractions of the large and small intestines that move fluid and intestinal contents toward the rectum produce bowel sounds Occur 5-34 times per minute Hyperactive-frequent Hypoactive-occur after long periods of silence Absent-no bowel sounds for 2-5 minutes

    15. Nursing Diagnoses Ineffective health maintenance Ineffective therapeutic regimen management Deficient knowledge Noncompliance Health-seeking behaviors

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