PHYSICAL ASSESSMENTS

Objective signs and symptoms

you see, hear, feel smell and measure them

Subjective signs and symptoms

perceived by the patient (primarily pain)

Frequent S&S

1. Infection

2. Inflammation

-erythema

-edema

-purulent drainage (pus)

3. Anorexia

4. Diaphoresis (sweeting)

5. Cyanosis (blue)

6. Febrile

7. Jaundice (liver failure)

8. Lethargy (excessive exhaustion)

9. Nausea/ vomiting

10. Pain

11. Pallor (color of skin)

Whats a disease?

Anything that messes with homestasis

Hereditary disease

Parents give it to you

congenital disease

born with it

inflammatory disease

things that get inflamed

Degenerative disease

breaking down

infectious disease

A disease that is caused by a pathogen and that can be spread from one individual to another.

deficiency disease

state of health that occurs when a nutrient is missing from the diet

Metabolic disease

metabolism

neoplastic disease

Diseases that result in new, abnormal tissue growth

Traumatic disease

disease resulting from trauma

Environmental disease

disease caused by the conditions of the surroundings (toxins, particles in the air, water or soil)

Acute disease

brings abrupt and severe S&S (bronchitis, or a cold)

Chronic disease

Develops slowly and persists. General rule lasts for 6 months (diabetes)

Nursing assessment

Techniques

Inspection (visual)

Palpation (hands on) Auscultation (listening to sounds)

The interview portion

Why are you here?

Health history

Family history

Environmental history (where you live)

Psychosocial history (take drugs, smokes, drinks (need to know if they'll go through withdrawal) )

Neurological status

Orient x3 (know where location, who they are, the time) based on how many of the 3 questions they know

Notice color of skin

Turgor skin

Color, normal, pale, blue, yellow, red

Head and Neck

Eye, ear, nose

Thrills, feel vibrations in the vessels. If there's a big enough blockage you can feel it

Mouth and throat

MM (mucus membrane) moist

Redness

Chest and Lungs

Symmetric breathing sounds?

Breast augmentations?

Lungs sounds, crackles or clear or wheezing(on expiratory only)

Heart sounds

Listen for S1 and S2 lub-dub

PVS pulses:

1+- thread rapid and weak

2+ weak

3+ Normal

4+ bounding

Capillary relief take the nail bed and press on it, looking for white. If it doesn't fill it means they have poor peripheral circulation

Abdomen

Auscultate (listen) bowel sounds in all 4 quads

Palpate (touch), non- tender?

GU, any open soars? Or discharge

Rectum for hemorrhoids

Edema - fluid that's shifted from vascular system into tissue- swelling

1+ slight

2+ pitting away in 10 seconds

3+ pit lasting 10>

4+ pitting extreme may last >2+5min