2 components of health assessment
health history taking and physical examination
what informations include in general survey
physical appearance, body structures, mobility, vital signs, behaviour
what to assess in physical appearance?
age, sex, LOC, skin color, facial features
what to assess in body structure?
stature, nutrition, symmetry, posture, position, body built
purpose of physical examinaition
to obtain baseline data about the client’s functional abilities
help to establish nursing diagnosis and plans of care
health promotion and disease prevention
4 physical assessment techniques
inspection, palpation, percussion, auscultation
2 types of palpation
light palpation and deep palpation
light: superficial(about 1 cm)
deep: one hand(about 4-5 cm)
2 types of percussion
direct: strike body directly
indirect: use pleximeter and plexor
how different parts of hand used to palpate?
Fingertips: texture, swelling, pulse
Finger & thumb grasp: shape, consistency of mass
Dorsal hand: temperature
Ulnar edge/base of fingers: vibration
purpose of percussion
location and size of an organ
assess density
detect superficial mass(<5 cm)
what is pleximeter and plexor?
pleximeter: hyperextension of the middle finger
plexor: use the middle finger of the other hand as striking finger
what is the percussion sounds for different location
normal lung :Resonant共鳴
Emphysema: Hyperresonant超共振
stomach: Tympany鼓
liver, spleen: Dull
bone, muscle: Flat
what is the uses of different parts of stethoscope
diaphragm: high-pitched sounds
bell: low-pitched sounds
characteristics of sound
frequency, loudness, quality and duration
sequence of techniques in different systems
abdominal: inspection, auscultation, percussion, palpation
cardiovascular system: inspection, palpation, auscultation
