When inspecting the face for facial symme- try, what would you have the patient do?

SECTION IV: ROLE PLAY

H. The integration of the and data guides the

11. When inspecting the face for facial symme- try, what would you have the patient do?

(Mark all that apply.)

Raise eyebrows

Frown

Grin

Stick out tongue

Close eyes

SECTION III: CASE STUDY

Activity D

Lucy Linquist, a 27-year-old elementary school teacher, comes to the emergency department after being in a motor vehicle accident. She complains of pain in the abdomen. Vital signs are as follows:

T 36.9°C; pulse 125; BP 80/50; R 26; and pain 7/10.

What physical assessment would be indicated for this patient?

The patient is found to have a ruptured kidney.

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CHAPTER 22 PUTTING IT ALL TOGETHER 109

What diagnostic tests would you expect to be run on this patient?

SECTION IV: ROLE PLAY

Demographics: 19 year old, single, lives in dormitory. College freshman.

Scenario: Comes to the student clinic for a physical assessment before playing college volleyball.

Past medical history: No chronic illness; childhood illness (mumps, measles, whooping cough). No

disabilities.

Family history: None signifi cant.

Behavior during interview: Calm, relaxed, communicative.

Presenting information: Appears well groomed.

Physical fi ndings during assessment: Temperature 37°C tympanic, pulse 120, R 16, BP 100/62.

Using the information from the role play, write an assessment note for a comprehensive physical examina- tion for this patient.

Nursing diagnosis or problem:

Signature Date

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SECTION V: DOCUMENTATION

FORM FOR USE IN PRACTICE

COMPREHENSIVE ASSESSMENT

Patient Name Date/Time

Overview.

Identifying Data Source and Reliability

Common or Concerning Symptoms Onset

Location Duration

Characteristic symptoms Associated manifestations Relieving factors

Treatment History

Medications (current) Medications (past) Surgeries

Illnesses Family History Cancer Diabetes

Other Chronic Illnesses Genetic Testing Lifestyle Habits Alcohol Tobacco

Sexual preference Sexual partners (#) Overview

Age—stated age versus apparent age

Emotional state—compare verbal description and nonverbal indicators Developmental stage—compare with behavior

Cultural background

Health requirements and learning needs Mental Status

a. Level of consciousness b. Facial expressions c. Speech

d. Thought processes and perception e. Mood

f. Grooming and hygiene

g. Posture, gait, and body movements

*If changes are noted, then a mini-mental status examination should be performed.

Vital Signs a. Temperature b. Pulse c. Respirations

d. Blood pressure—arm at heart level e. Pain

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CHAPTER 22 PUTTING IT ALL TOGETHER 111

Body Measurements a. Height

b. Weight

c. Body mass index and ideal body weight

Integument—assess throughout examination as you examine each part of the body.

a. Inspect for color, lesions, scars, rashes, or any changes in the skin.

b. Palpate for moisture, temperature, and texture.

c. Palpate for skin turgor.

d. Inspect the hair for color, distribution, and texture.

e. Inspect and palpate the nails for size, shape, color, texture, angle, refi ll, and any changes.

Head

a. Inspect the skull for size and shape.

b. Inspect the scalp for tenderness, lesions, and bumps.

Face

a. Inspect facial features for symmetry.

Cranial nerve VII, facial: symmetry of face—raise eyebrows, frown, close eyes, smile, puff out cheeks.

b. Palpate temporal and masseter strength.

c. Assess temporomandibular joint for pain, crepitus, and swelling.

d. Assess sensation to sharp and light on face—forehead, cheeks, and chin. (Continue assessing arms and feet for sharp and light touch.) Cranial nerve V, trigeminal.

Eyes

a. Inspect eyelids.

b. Inspect eyelashes.

c. Inspect eyebrows.

d. Inspect lacrimal apparatus.

e. Inspect conjunctiva.

f. Inspect sclera.

g. Inspect cornea.

h. Inspect lens.

i. Inspect pupils. Cranial nerve II, optic; cranial nerve III, occulomotor

− Direct light reaction; consensual light reaction j. Test confrontation. Cranial nerve II, optic

k. Test six cardinal directions of gaze. Cranial nerve III, occulomotor; cranial nerve IV, trochlear; cranial nerve VI, abducens;

−Convergence; −Near reaction (accommodation); − Cover–uncover test l. Ophthalmoscopic examination—check optic disc for color, size, and shape.

Ears

a. Inspect auricle, lobe, and tragus for position, shape, ulcers, lesions, or discharge.

b. Palpate auricle and tragus for tenderness or lumps.

c. Palpate mastoid fi rmly for tenderness.

d. Otoscopic examination—inspect inner canal, tympanic membrane, and cone of light.

e. Hearing acuity

− Cranial nerve VIII, acoustic; − Whisper test; − Weber (518 Hz on top of head); −Rinne (518 Hz on mastoid bone and compare to air conduction)

Nose and Sinuses

a. Inspect for symmetry, alignment, and deformity.

b. Palpate for tenderness and patency.

c. Palpate frontal and maxillary sinuses.

d. Inspect mucous membrane, septum, and turbinates for infl ammation, polyps, ulcers, and deviation.

e. Sense of smell—have patient identify two different scents with eyes closed. Cranial nerve I, olfactory Mouth and Pharynx

a. Inspect lips, oral mucosa, gums, roof of mouth, and fl oor of mouth for color, lesions, and moisture.

b. Inspect dentition for condition, number, and placement.

c. Tongue

− Inspect for size, shape, color, moisture, lesions, and texture.

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− Articulation of words; Cranial nerve XII, hypoglossal; − Range of motion—assess at-rest, raised, sticking out, and side-to-side movements; – Taste; Cranial nerve VII, facial; cranial nerve IX, glossopharyngeal;

d. Pharynx—inspect rise of palate and uvula; cranial nerve IX, glossopharyngeal; cranial nerve X, vagus Neck

a. Inspect anteriorly for symmetry, masses, enlarged glands, or deviation.

b. Inspect trachea position.

c. Inspect thyroid.

d. Palpate thyroid.

e. Palpate lymph nodes (preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superfi cial cervical, posterior cervical, deep cervical chain, supraclavicular).

f. Test sternomastoid and upper trapezius muscle strength; cranial nerve XI, spinal accessory g. Test head and neck range of motion (fl exion, extension, rotation, and lateral bends).

Posterior Thorax

a. Inspect shape, deformities, retractions, symmetry, and skin integrity.

b. Palpate for − Tenderness

− Tactile fremitus

− Respiratory expansion

c. Percuss lung sounds and diaphragmatic excursion.

d. Auscultate lung sounds.

Anterior Thorax (can also be performed with patient lying down if preferred) a. Inspect for shape, deformities, retractions, symmetry, and skin integrity.

b. Palpate for − Tenderness

− Tactile fremitus

− Respiratory expansion

c. Percuss sounds and diaphragmatic excursion.

d. Auscultate lung sounds.

Cardiovascular (can also be performed with patient lying down if preferred) a. Inspect carotid arteries for pulsations.

b. Palpate carotid arteries.

c. Auscultate carotids with the Bell while patient holds breath.

d. Inspect external jugular vein.

e. Inspect precordium.

f. Auscultate heart with the diaphragm at the right sternal border 2nd intercostal space (ICS), left sternal border 2nd ICS, left sternal border 3rd ICS, left sternal border 4th ICS, left sternal border 5th ICS, and left midclavicular line (MCL) 5th ICS.

g. Auscultate heart with the Bell at the right sternal border 2nd ICS, left sternal border 2nd ICS, left sternal border 3rd ICS, left sternal border 4th ICS, left sternal border 5th ICS, and left MCL 5th ICS.

h. Auscultate with the Bell at the apical impulse while in the left lateral decubitus position (listening for mitral murmur, S3, S4).

Breasts

a. Inspect with

− Arms at side

− Hands pressed into hips

− Arms raised over head Axillary Nodes

a. Palpate axillary nodes (central, lateral, pectoral, subscapular).

Patient Lying Down Breast Examination

a. Place the arm that is on the side of the breast being examined under the head.

Abdomen

a. Inspect for contour, pulsations, bulges, and skin integrity.

b. Auscultate for bowel sounds and aortic pulsation.

c. Abdominal refl ex—lightly stroke inward in all quadrants.

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CHAPTER 22 PUTTING IT ALL TOGETHER 113

d. Lightly palpate all four quadrants noting masses, tenderness, and patient’s expression.

e. Palpate for the liver, kidneys, and spleen.

Peripheral Vascular

a. Inspect arms and legs for color, swelling, hair distribution, and nail bed color.

b. Palpate − Carotid − Radial − Brachial − Femoral

− At this time palpate the remaining lymph nodes: inguinal lymph nodes (vertical then horizontal groups).

− Posterior tibial

− Dorsalis pedis

c. Palpate for pitting edema in feet and legs.

Musculoskeletal

a. Inspect for deformity, swelling, nodules, redness, and muscle bulk.

b. Palpate for tenderness, crepitus, swelling, and increased warmth.

c. Palpate strength and range of motion

− Hips (fl exion, extension, abduction, adduction, internal and external rotation)

− Knees (fl exion and extension)

− Ankles (dorsifl exion, plantarfl exion, inversion, eversion)

− Toes (fl exion, extension, abduction, adduction) Patient Seated

Neurologic—Motor

a. Inspect body position, noting tremors.

b. Deep tendon refl exes − Biceps

− Triceps − Brachioradialis − Patellar − Achilles

Neurologic—Sensory (if not incorporated previously then complete now)

a. Pain and light touch—if the patient is unable to feel pain and light touch, then assess for vibration and temperature.

Musculoskeletal

a. Inspect for deformity, swelling, nodules, redness, and muscle bulk.

b. Palpate for tenderness, crepitus, swelling, and increased warmth.

c. Palpate strength and range of motion

− Shoulders (fl exion, extension, abduction, adduction, internal and external rotation)

− Elbows (fl exion, extension, pronation, supination)

− Wrists (fl exion, extension, radial and ulnar deviation)

− Fingers (grip and fl exion, extension, adduction, abduction)

− Thumb (fl exion, extension, opposition, abduction, adduction) Patient Standing

Musculoskeletal—Spine

a. Inspect for deformity, symmetry, and skin integrity.

b. Palpate spinous processes.

c. Assess range of motion (fl exion, extension, lateral bends, rotation).

Neurologic

a. Perform Romberg, gait, balance, and other appropriate neurologic screenings.

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114

CHAPTER 23 SECTION I: LEARNING OBJECTIVES

Learning Objectives The student will:

Gather a history on an infant, child, and

Dalam dokumen Student Laboratory Manual for Bates’ Nursing Guide to Physical Examination and History Taking (Halaman 116-122)