StudentShare
Contact Us
Sign In / Sign Up for FREE
Search
Go to advanced search...
Free

Physical Assessment Patients - Essay Example

Cite this document
Summary
This essay "Physical Assessment Patients" focuses on the extent of the patient’s state of well-being in order to form a correct diagnosis. It takes place after thorough history taking and involves four principal aspects: inspection, palpation, percussion, and auscultation. …
Download full paper File format: .doc, available for editing
GRAB THE BEST PAPER92.1% of users find it useful
Physical Assessment Patients
Read Text Preview

Extract of sample "Physical Assessment Patients"

Physical Assessment Physical Assessment Introduction Physical assessment is necessary as it helps to estimate the extent of the patient’s state of well-being in order to form a correct diagnosis. It takes place after thorough history taking and involves four principle aspects: inspection, palpation, percussion and auscultation. The preferred method to perform a patient’s physical assessment is the head-to-toe method. It begins by systematically examining the patient, beginning from the head and working towards the toes (Ralph & Taylor, 2011). 1. Vital signs When a patient walks in the examination room, it is necessary for the vital signs to be measured. Temperature of a healthy individual ranges from 36-37.5 degrees Celsius and may be measured through the oral, temporal, axillary, tympanic and rectal route. For this purpose, a disposable, electronic or tympanic thermometer is required (Amugi-crouch& Meurier, 2011). Since temperature of the patient is within such a narrow range and is required to take accurately, the presence of a thermometer is essential, as it cannot be measured without it. Pulse is measured directly by the monitor that is used to measure other vital signs. However, if the machine is not available, it can be felt by palpating the pads of the first three fingers against the patient’s wrist and counting the pulse beats in one minute, starting from zero. Blood pressure is measured by using a sphygmomanometer. It comprises of two parts: systolic and diastolic and is measured in mmHg. Normal Findings: Temperature of the patient is between 36-37.5°C.Normal pulse rate is 60-100 (mean of 70) beats per minute. The systolic blood pressure normally ranges from 100-140mmHg. The diastolic blood pressure, on the other hand normally ranges from 60-90 mmHg. Abnormal Findings: Hyperthermia, pyrexia or fever occurs when the temperature exceeds 38°C. An excessively high temperature- such as above 40°C is known as hyperpyrexia. Hypothermia where in the temperature of the patient is below 35°C A pulse rate of under 60 beats per minute is termed bradycardia and may occur in hypoxia, ischemic heart disease etc. A pulse rate of over 100 beats per minute is termed as tachycardia. It may occur in stress, anxiety, pyrexia and pain (Amugi-crouch & Meurier, 2011).Hypertension occurs when the blood pressure readings remain consistently over 140mmHg for systolic and 90mmHg for diastolic blood pressure. It may result from the excess consumption of caffeine and in excessively cold environments. Hypotension occurs when the blood pressure readings fall below 100mmHg for systolic and 60mmHg for diastolic blood pressure (Talley & O’Connor, 2009). It may result because of shock, pulmonary embolus and cardiac failure (LeMone et al 2012). Nursing Plan in abnormal findings: The plan taken will be primarily to stabilize the vital signs since otherwise the patient may enter cardiac arrest. For example, a patient with high blood pressure will be given antihypertensive drugs such as ACE inhibitors to bring blood pressure back to normal. 2. The Integumentary System A thorough inspection of the skin pigmentation according to the patient’s race and nationality must be done. Notice the skin on extremities and look overall for swellings, erythema, red streaks, skin lesions, cyanosis and extreme sweating and edema. Examine the scalp for baldness Normal Findings: Skin is free of lesions, swelling of skin or lymph nodes, no erythema or red streaks. Abnormal Findings: Pallor may result because of anemia, shock and syncope. Central cyanosis of lips, earlobes, oral mucosa and tongue suggest chronic cardiopulmonary disease. 3. Cardiovascular system Palpate the precordium through the chest walls. Start the palpation from the apex, then move to the left border of the sternum and finally move towards the base of the heart. This should be followed by the auscultation using a stethoscope. This auscultation should be done in the anatomic regions corresponding to the heart sounds which include the areas of the aortic, pulmonic, tricuspid and mitral valves. Listen for S1 sound at the apex and S2 sound at the base of the heart. Inspect the contours and skin of the breast and the nipple. Palpate and examine the four quadrants for mass or swollen lymph nodes. Normal Findings: The normal heart sounds which are S1 and S2 are audible at the all the anatomic regions. Abnormal sounds of the heart like murmurs are not audible. The heart rate is between 60 to 100 beats per minute (Singh, 2012). Breast skin and contours are normal. No mass palpated. Abnormal Findings: Heart sounds may be absent or slow. Murmurs and ectopic beats may be present. Breast may either have lesions, nipple may be inverted. Mass may be palpated. Axillary lymph nodes may be swollen as often are in breast tumor patients. Differential diagnosis may include chronic congestive heart failure, atherosclerotic plaque which may cause thromboembolism. Plan of action: These conditions may be treated after further laboratory tests and giving adequate medicines. 4. Respiratory System Inspect the chest walls for symmetry. Inspect the spine to be in the center. Spinal column inspection along with shoulders and hips for general symmetry. Palpate the chest for tenderness. Auscultate to listen to breath sounds with normal and deep breathing. Examine color of sputum (if present) and send to laboratory (Amugi-crouch & Meurier, 2011). Normal Findings: Chest is in line with shoulders and hips and is symmetrical. No breathing abnormalities. Abnormal Findings: Kyphosis, scoliosis, coughing, wheezing, dyspnea, excessive sputum due to infections or other diseases(Amugi-crouch & Meurier, 2011). 5. Abdomen Ensure the patient has an empty bladder and is asked to lie in a supine posture. Inspect the contours and skin for striae, rashes and dilated veins on the abdomen. Look for scar marks. Palpate superficially through all nine quadrants and then deeply. Percuss all four quadrants to assess dullness and tympany. Auscultate to listen to gut sounds. (Bickley et al 2009) Normal findings: The color of the skin is consistent and no other lesions are seen. Scars or striae or scar may be visible in a few patients because of previous surgery. The abdomen can be flat or round or have a scaphoid shape. Thin people may have peristalsis and show the pulsation of the aorta. Abdominal breathing is evident. The liver usually cannot be palpated in a normal adult Abnormal Findings: Abdomen may be generally distended because of flatulence. Striae are seen in obesity or pregnancy. Gut sounds are absent in cases of obstruction or inflamed peritoneum. Routine Health Screenings and Immunization: Blood pressure: Get patient tested every two years if it remains in normal range between 18-65 years and once a year if any other disease may have possibly caused it. If more, discuss monitoring with patient. Bone Mineral density: Discuss if this test is required before 60 years, after which get it screened for females. Cholesterol: Between 20-35 years of age get patient screened if there is increased risk of heart disease. From 45 years onwards get screened regularly. Breast Cancer: Discuss with patient if there is requirement before 40 years. After 50 years, get screened every two years especially for females. Cervical Cancer: Get a Pap smear done of 21 year old female or those who have been sexually active for 3 years. Until 50 years get a smear done every three years. Diabetes: Get screened before 40 years if there is patient history of hypertension. After which discuss screening plan with patient. Gonorrhea/Chlamydia and HIV: Get post pubertal patients screened if there is increased risk of either of these diseases. (Buttaro, 2008) Conclusion With routine examination of clients and patients, nurses can suggest differential diagnosis. In emergencies the plan of care is required to be prompt. However, in long term or less severe cases, advice from the physicians can be sought in order to proceed with the line of treatment. This is true especially in cases of medical anomalies or diseases that require surgical intervention. The physical assessment therefore should be able to provide adequate information with which prompt and proper plan of care can be established. References Altman, G. (2004). Delmars physical assessment skills. Clifton Park, NY: Delmar Learning. Amugi-crouch, A., & Meurier, C. (2011). Vital Notes for Nurses: Health Assessment. Oxford: John Wiley & Sons. Bickley, L. S., Szilagyi, P. G., & Bates, B. (2009). Bates guide to physical examination and history taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Buttaro, T. M. (2008). Primary care: A collaborative practice. St. Louis, Mo: Mosby/Elsevier. LeMone, P., Burke, K. M., Bostick, J. E., & LeMone, P. (2012). Clinical handbook for medical-surgical nursing: Critical thinking in patient care. Boston: Pearson. Ralph, S. S., & Taylor, C. M. (2011). Sparks & Taylors nursing diagnosis reference manual. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Singh, N. R. (2012). Nursing: The ultimate study guide. New York: Springer. Talley, N. J., & OConnor, S. (2009). Clinical examination: A systematic guide to physical diagnosis. Chatswood, N.S.W: Elsevier Australia. Read More
Cite this document
  • APA
  • MLA
  • CHICAGO
(“Head-to-Toe Assessment Essay Example | Topics and Well Written Essays - 1250 words”, n.d.)
Retrieved from https://studentshare.org/nursing/1656385-head-to-toe-assessment
(Head-to-Toe Assessment Essay Example | Topics and Well Written Essays - 1250 Words)
https://studentshare.org/nursing/1656385-head-to-toe-assessment.
“Head-to-Toe Assessment Essay Example | Topics and Well Written Essays - 1250 Words”, n.d. https://studentshare.org/nursing/1656385-head-to-toe-assessment.
  • Cited: 0 times

CHECK THESE SAMPLES OF Physical Assessment Patients

Geriatric Category Patients and Their Treatment

This essay "Geriatric Category patients and Their Treatment" is about a time-consuming, continuous nursing activity, as such patients are subject to rapid deterioration, due to one reason or the other, as they are usually afflicted with multiple conditions requiring continuous medication.... Some of the pharmacological and non-pharmacological interventions, such patients' are subjected to, maybe contradictory in nature and may require emergency treatment....
14 Pages (3500 words) Essay

Spiritual Assessment

The provision of the care plan will not only involve the nurses' participation but most importantly, the presence of the chaplain and the patients family will help in filling in the patient's spiritual needs.... In a world where many different religions exist, it is important that a nurse should know the patients spiritual beliefs before conducting spiritual assessment to the patient.... patients also seek care for oneself through prayers and proper visitation....
7 Pages (1750 words) Essay

Challening Role of Nurses

Nurses have a challenging role in the delivery of health care and are required to be skilled and knowledgeable clinicians; one of the essential skills required of nurse clinicians is that of health assessment, including physical assessment ... urses have a challenging role in the delivery of health care and are required to be skilled and knowledgeable clinicians; one of the essential skills required of nurse clinicians is that of health assessment, including physical assessment ...
11 Pages (2750 words) Essay

The Integration of Gordons Health Assessment in Everyday Nursing Care

There are other factors that will affect the reliability of data that can be gathered in making health assessments that will be presented during the interview and physical assessment of the patient.... Some patients may exhibit feelings of anger towards their health care provider stemming from previous encounters with other health care practitioners that left them with a bad impression.... There is also the physical condition of illnesses where patients may be in too much pain or cannot give coherent answers because of adverse reactions to medication....
8 Pages (2000 words) Essay

Issues in Mental Health Assessment

This paper "Issues in Mental Health Assessment" discusses the assessment and care planning or patients that are crucial in establishing accurate diagnosis and treatment.... Precise assessments lead to improved quality of life for ill patients.... These issues are discussed in the hope of coming up with an improved quality of life and improved treatment and interventions for mentally ill patients.... The assessment of mental health patients is seen from the initial admission or consultation of the patient....
9 Pages (2250 words) Case Study

Head-To-Toe Physical Assessment of an Adult Patient

This essay "Head-To-Toe physical assessment of an Adult Patient" sheds some light on the condition of the patient's body and to identify any curable or preventable medical problems.... uring my stay at a local hospital, I had the chance to conduct a head-to-toe assessment of an adult patient.... As Rosdahl & Kowalski (2007) indicate, a head-to-toe assessment is important during admission since the data collected helps provide treatment and nursing care for the patient....
3 Pages (750 words) Essay

Preoperative Medical Assessment

According to Hemanth Kumar, assessing and evaluating patients preoperatively is an important starting point to formulate an effective anaesthetic plan.... The high rate of patient turnover in the clinic, the preoperative assessment prior to the scheduled surgery for patients admitted on the same day of operation can pose challenges in healthcare.... Mainly, such an experience was important to increase my techniques and skills for interviewing future patients and obtaining their mindful clinical history....
7 Pages (1750 words) Assignment

Barriers and Enablers to Pain Management

Pain is very much common in patients with cancer hence to ensure optimal pain management efficacy as well as effectiveness of new drugs, it requires that treatments be investigated before being administered to the patient (Briggs, 2007).... Assessment of pain in patients' is always done with an aim of attempting to identify the mechanisms which produce the pain as well as other factors which does influence that pain to occur (Argoff &Selvershein,2009).... hough, pain is invisible its cause cannot be readily determined especially in those patients' who are suffering from noncancer pain....
11 Pages (2750 words) Essay
sponsored ads
We use cookies to create the best experience for you. Keep on browsing if you are OK with that, or find out how to manage cookies.
Contact Us