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10. Identify the steps in selected examination procedures. We practice head to toe
assessment. Therefore, address question 10 in that manner:
General survey
Vital signs
Head
Hair, scalp, face
Eyes and vision
Ears and hearing
Nose
Mouth and oropharynx
Cranial nerves
Neck
Muscles
Lymph nodes
Trachea
Thyroid gland
Carotid arteries
Neck veins
Upper extremities
Skin and nails
Muscle strength and tone
Joint range of motion
Brachial and radial pulses
Sensation
Chest and back
Skin
Chest shape and size
Lungs
Heart
Spinal column
Breasts and axillae
Abdomen
Skin
Abdominal sounds
Femoral pulses
External genitals
Anus
Lower extremities
Skin and toenails
Gait and balance
Joint range of motion
Popliteal, posterior tibial, and pedal pulses
11. Identify expected outcomes of health assessment of the health assessment:
To obtain baseline data about the clients functional abilities
To supplement, confirm, or refute data obtained in the nursing
history
To obtain data that will help establish nursing diagnoses and
plans of care
To evaluate the physiological outcomes of health care and
thus the progress of a clients health problem
To make clinical judgments about a clients health status
To identify areas for health promotion and disease prevention.
12. dont do
13. Explain the 4 methods used in physical examination:
1. Inspection is the visual examination, which is assessing by using the sense of sight.
It should be deliberate, purposeful, and systematic. The nurse inspects with the naked
eye.
2. Palpation is the examination of the body using the sense of touch. The pads of the
fingers are used because their concentration of nerve endings makes them highly
sensitive to tactile discrimination.
3. Percussion is the act of striking the body surface to elicit sounds that can be heard
or vibrations that can be felt. There are two types of percussion: direct and indirect.
Direct=In direct percussion, the nurse strikes the area to be percussed directly with the
pads of two, three, or four fingers or with the pad of the middle finger, example tapping
sinus cavities.
Indirect=is the striking of an object (e.g., a finger) held against the body area to be
examined. Using the tip of the flexed middle finger of the other hand, called the plexor,
the nurse strikes the pleximeter,
usually at the distal interphalangeal joint or a point between the distal and proximal
joints
4. Auscultation is the process of listening to sounds produced within the body.
Auscultation may be direct or indirect. Direct=using unaided ear Indirect= using
stethoscope
14. Identify the purposes of the physical examination: Data obtained in the physical
health examination supplement, confirm, or refute data obtained during the nursing
history. Also, data obtained in the physical health examination help the nurse establish
nursing diagnoses, plan the clients care, and evaluate the outcomes of nursing care.
15. Summarize auscultated sounds that are described according to their pitch, intensity,
duration, and quality.
Normal Breath Sounds:
Vesicular Soft-intensity, low-pitched, gentle sighing sounds created by air moving
through smaller airways (bronchioles and alveoli)
3. List the equipment and supplies used for a health examination: Per book
Penlight or flash light
Nasal spectulum
Otoscope
Opthalmascope
Percussion reflex hammer
Tuning fork
Vaginal speculum
Cotton applicators
Gloves
Lubricant
Tongue Blades