Chapter 2 and 3 (health hx and physical exam techniques)

Interview phases

preintroductory, introductory, wokring phase, summary/closing phase

Preintroductory phase

review of client medical record before meeting, nurse introduces themselves, and be eye level with client

Working phase

collection of information - biographical data, reason for seeking car, hx of present health concern, past health hx, fm hx, lifestyle and health practices, and developmental level

Introductory

nurse explains reason for interview, explains reasons of notes and HIPAA, makes sure client is comfortable

Summary/closing phase

nurse summarize information, validates problem and goals, discuss next plans and any further questions

Types of communication

Nonverbal and verbal

Nonverbal communication

Appearance: nurse must be professional

Demeanor: professional

Facial expression: neutral and friendly. Uses at the right time

Attidue: nonjudgmental attitude

Nonverbal communication to avoid

Excessive/insufficient eye contact

Distraction

Standing over client

Verbal communication

Opened ended questions

Close ended questions

Use of laundry list

Rephrasing

Well placed phrases

Inferring

Verbal communication to avoid

Bias

Rushing interview

Reading questions on list

COLDSPA

character, onset, location, duration, serverity, pattern, associated factors

PQRST

provocative, quality, radiates, severity, timing

ADPIE

asses

diagnosis

plan

implement

evaluate

ADLs

activites of daily living

Therapeutic communication

connecting with pt and creating a safe atmosphere for them. Pt should not feel intimidated

All examinations

Gloves and gown - protect examinar from blood, body fluids, secretions, excretions, contamination etc.

Vital signs

Sphygmomanometer - meausre BP

stethoscope - auscultate blood sounds during BP measure

Nutrtional status exam

Thermometer (oral, rectal, tympanic) - meaure body temp

analog watch - take pulse rate and RR

pain rating scale - determine perceived pain level

skinfold calipers - measure skinfold thickness of subcutaneous tissue

Skin, nail and hair exam

Flexible tape measure - measure midarm circumference

Skin marking pen - mark measurements

Platform scale with height attachment - height and weight

Exam light/ penlight - adequate lighting

Mirror - client self examination

Metric ruler - measure skin lesions

Magnifying glass - enlarge visibilty

Woods light - test for fungus

Braden scale - predict one’s risk to develop pressure injury

PUSH (pressure ulcer scale for healing) - determine degree of healing of pressure injury

Head and neck exam

Stethoscope - auscultate thyroid

Water - help client swallow during thyroid gland examination

Eye exam

Penlight - test pupillary constriction

Snellen chart - test distant vision

Newspaper - test near vision

Opaque card - test for strabismus

Ophthalamoscope - view red reflex, examine the retina of eye

Ear exam

Tuning fork - test for bone and air conduction of sound

Otoscope - view ear canal and tympanic membrane

Mouth, throat, nose, and sinus exam

Penlight - light to view mouth and throat to transilluminate the sinuses

4 × 4 gauze - grasp tongue

Tongue depressor - depress tongue to view mouth and throat, test tongue strength

Otoscope with wide tip attachment - view internal nose

Thoracic and lung exam

Stethoscope (diaphragm) - auscultate breath sounds

Metric ruler and skin marking pen - measure diaphragmatic excursions

Heart and neck vessel exam

Stethoscope (bell and diaphragm) - auscultate heart sounds

Two metric rulers - measure jugular venous pressure

Peripheral vascular exam

Sphygmomanometer and stethoscope - measure BP and auscultate vascular sounds

Flexible metric measuring tape - measure extremities for edema

Tuning fork - detect vibratory sensation

Doppler ultrasound device and conductivity gel - detect pressure and weak pulses not found by stethoscope

Abdominal exam

Stethoscope - bowl sounds

Flexible measuring tape and skin marking pen - measure size and mark area of percussion of organs

Two small pillows - place under knees and head to relax abdomen

Musculoskeletal exam

Flexible measuring tape - size of extremities

Goniometer - measure degree of flexion and extension of joints

Neurologic exam

Cotton tip applicators and substances to smell and taste - test and smell perception

Same equipment as eye exam - vision and extraocular movements and papillary response

Objects to feel - test for stereognosis (ability to recognize objects by touch)

Reflex (percussion) hammer - deep tendon reflexes

Cotton ball and paper clip - light, sharp, and dull touch, and two point discrimination

Tongue depressor - test for rise of uvula and gag reflex

Tuning fork - vibratory sensation

Genitalia and rectal exam (M at birth)

Gloves and water soluble lube - comfort for client

Penlight - scrotal illumination

Specimen card - Detect occult blood

Genitalia and rectal exam (F at birth)

Vaginal speculum and lube - client comfort

Bifid spatula, endocervical broom - inspect cervix through dilatation of vaginal canal

Large swabs - obtain endocervical swab, cervical scrape, and vaginal pool sample

Liquid Pap medium - vaginal exam

Specimen card - pap smear and detect occult blood

Hand hygiene

cleaning hands with soap and water, antiseptic wash or hand rub, surgical hand antisepsis

Alcohol based hand sanitizer

Use

• before touching pt

• after touching pt

• after glove removal

• after contact with blood, body fluids, or contaminated surfaces

• before performing aseptic task or handling invasive medical devices

Washing with soap and water

Use

• when hands are soilded

• after spores exposure

• handling someone with diarrhea

Sitting position

Client is upright.

Position is good for evaluating head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities

Supine position

Client is lying down legs together, faced up. Allows for abdominal muscles to relax.

Areas assessed are neck, head, chest, breasts, axillae, abdomen, heart, lungs, and extremities.

Dorsal recumbent position

client lays down faced up with knees bent, legs separated, and feet flat.

Assess head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses.

Sims position

client lies on right or left side with lower arm behind body and upper arm flexed at shoulder and elbow. Lower leg is flexed at knee and upper leg is flexed at a sharper angle forward.

Assess rectal and vaginal areas.

Standing position

client at resting position

Assess posture, balance, and gait.

Prone position

client lies face down with head to the side.

Assess hip joint and back

Knee chest position

Client is kneeled with weight on chest. 90 degrees with between body and hips. Arms above head and head is to one side.

Assess rectum

Lithotomy position

Client lies on back with hips at the edge of table and feet is supported by stirrups.

Assess female parts, reproductive tracts, and rectum.

Inspection (technique)

Involves use of vision, smell, and hearing to identify abnormalities.

Palpation

Use of hand to touch and feel for texture, temp, moisture, mobility, etc. of abnormality.

Light <1 cm deep, moderate 1-2 cm deep, deep 2.5 to 5 cm deep, bimanual checks for symmetry of body.

Use of

• finger pads for fine discriminations, pulses, texture, size, consistency, shape, crepitus

• Ulnar/palmar surface for vibrations, thrills, fremitus

• Dorsal surface for temperature

Percussion

Tapping body parts to produce sound waves.

Direct, indirect or blunt percussion

Identifies

• eliciting pain

• determining location, size, and shape

• density

• abnormal masses

• eliciting reflexes

Auscultation

Use of stethoscope to listen to heart sounds, blood movement, bowel movement, movement of air.

Percussion tones

• resonance (heard over part air and part solid) - loud (intense), low pitch, long (length), hollow. Ex. lung

• Hyper resonance (heard over air) - very loud (intense), low pitch, long, booming. ex. lung with emphysema

• tympany (heard over air) - loud, high pitch, moderate, drum like. Ex. puffed out cheek, gastric bubble

• Dullness (heard over more solid tissue) - medium, medium, moderate, thud like. Ex. diaphragm, pleural, effusion, liver.

• Flatness (heard over very dense tissue) - soft, high pitch, short, flat. ex. muscle, bone, sternum, thigh

Respiratory rate (RR)

bpm, breaths per min

Oxygen saturation (SPO2)

percentage

Temperature range

hypothermia = < 96.8 F / 36 C

normal = 96.8 F to 100.4 F / 36 C to 37.9 C

hyperthermia = > 100.4 F / 38 C = low grade fever

Areas to take temp

Orally

Axillary

Rectally (most accurate for core temperature)

Tympanic membrane

Temporal artery

Parts of diaphragm (bell and diaphragm)

Bell listen to low pitched noise Ex. Bruits, bo, murmurs

Diaphragm listen to high pitched noise Ex. Heart sounds, lung, bowl.