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Unit IVA

PHYSICAL EXAMINATION

  • General Survey to Examination of the Nose

General Survey Assessment

  • Initiation of Assessment: Begins when the nurse first meets the client.

    • Determines the reason the client is seeking health care.

Examination Process

  • Initial Steps: General survey followed by the taking of:

    • Vital signs

    • Height and weight measurements

Components of a General Survey

  1. Physical Appearance

    • Sex/Gender

    • Age

  2. Skin Color

    • Light, Medium, Dark shades

Fitzpatrick Skin Type Scoring Matrix

Genetic Traits

  • Eye Color

  • Hair Color

  • Skin Color

  • Freckles (on unexposed areas)

Sensitivity to Sun Exposure

  • Reaction to prolonged sun exposure:

    • Severe burns, moderate burns, occasional blistering or resistance to burns.

Intentional Sun Exposure

  • Tanning Habits: Frequency and duration of sun or artificial tanning exposure.

Fitzpatrick Skin Score Types

  • Type I (0-6): Pale white, always burns, never tans.

  • Type II (7-13): White skin, very sensitive.

  • Type III (14-20): Light brown, sensitive skin, sometimes burns.

  • Type IV (21-27): Moderate brown, sometimes burns.

  • Type V (28-34): Dark brown, resistant to burns.

  • Type VI (35+): Deeply pigmented, very resistant skin.

Body Structure Assessment

Stature and Nutritional Status

  • Ideal Weight Charts: Variation by height and gender.

Body Types

  • Ectomorph: Light build.

  • Mesomorph: Larger bone and muscle structure.

  • Endomorph: Gains fat easily, solid but generally soft structure.

Symmetry Assessment

  • Physical Proportions: Body parts should look equal bilaterally.

Mobility Assessment

  • Gait and Range of Motion: Smoothness, evenness, and coordination of movement.

Behavior Assessment

Facial Expressions

  • Maintains eye contact and communicates effectively.

Mood and Affect

  • Appropriateness of Response: Emotional tone aligns with context.

Speech Clarity

  • Well-articulated and understandable communication.

Dress and Personal Hygiene

  • Clothing should be appropriate for demographics and well-groomed appearance.

Physical Assessment Overview

  1. General Survey: Observe overall appearance, age, grooming, and distress signs.

  2. Skin Assessment: Examine lesions, color, texture, and integrity.

Examination of Skin Lesions Classification

  • Types of Lesions: Macule, papule, plaque, nodules, tumors, vesicles, bulla, pustules, scales, etc.

Abnormal Findings for Skin Assessment

  • Signs of Diseases: Jaundice, cyanosis, or rashes indicating pathology.

Nail Assessment

Inspection and Abnormal Findings

  • Nail color, cleanliness, and any deformities or abnormalities.

  • Clubbing: Associated with cardiovascular issues.

Examination Procedures for Head, Face, Neck

General Inspection

  • Symmetry and Shape: Structures should be normal and symmetrical.

Specific Findings

  • Thyroid Examination: Assess for masses and gland enlargement.

Examination of the Nose

Inspection and Palpation

  • Evaluate structural integrity, tenderness, and internal condition.

Sense of Smell

  • Test ability to identify scents; absence indicates possible anosmia.

Complete Nose and Sinuses Assessment

  • Detailed inspection: Nasal mucosa, airflow patency, and internal structure inspection with tools.

Conclusion

  • After detailed assessment, report any anomalies or areas warranting further examination.