Download
1 / 26
E N D
Review of systems : (ROS) • This includes a collection of data about the past and present health of each of the client’s systems. This review of the client’s physical, sociologic, and psychological health status may identify hidden problems and provides an opportunity to indicate client strengths and liabilities.
Physical systems: • which includes assessment of? • General review, skin, hair, head and face, eyes, ears, nose and sinuses, month and throat, neck nodes, and breasts. • Assessment respiratory and cardiovascular systems. • Assessment of gastrointestinal system. • Assessment of urinary system. • Assessment of genital system. • Assessment of extremities and musculoskeletal system. • Assessment of endocrine system. • Assessment of hematopoietic system. • Assessment of social system. • Assessment of psychological system
The review of systems is a series of questions about all body sys-tems that helps to reveal concerns or problems. In clinic settings, patients usually fill out forms that give pertinent information, and then the nurse reviews answers during the interview. Some nurses ask questions related to each body system (eg, cough in the respiratory system) systematically before proceeding to the physical assessment. Others integrate questions while
physically examining each region (eg, chest pain when assessing the heart). Sequence and format vary with setting, urgency of the problem, and style of the nurse. • Questions are not mutually exclusive. For example, weight gain or loss is part of the general health state, but it also provides information about fluid balance, edema, and appetite. The nurse adapts questions to the patient, directs comfortable and logical conversation, omits questions that do not apply, and adds questions that seem pertinent.
General Health State. Weight gain or loss, fatigue, weakness,malaise, pain, usual activity, fever, chills. • Nutrition and Hydration. Conditions that increase risk of malnutrition or obesity. Nausea, vomiting. Normal daily intake, weight and weight change, dehydration, dry skin, fluid excess with shortness of breath or edema in the feet and legs. Diet practices to promote health. • Skin, Hair, and Nails. History of skin, hair, or nail disease. Rash,itching, pigmentation or texture change, lesions, sweating, dry skin, hair loss or change in texture, brittle or thin nails, thick or yellow nails.
Head and Neck. History of high or low thyroid level. Headaches,syncope, dizziness, sinus pain. • Eyes. History of poor vision or vision problems, glaucoma, cata-racts, hearing loss, ear infections. Use of contact lenses or glasses, change in vision, blurring, diplopia, light sensitivity, burning, red-ness, discharge. Last eye examination. • Ears. History of ear or hearing problems. Ear pain, change in hear-ing, tinnitus, vertigo. Last hearing evaluation, ear protection • Nose, Mouth, and Throat. History of mouth or throat cancer.Colds, sore throat, nasal obstruction, nosebleeds, cold sores, bleeding or swollen gums, tooth pain, dental caries, ulcers, enlarged tonsils, dry mouth or lips. Difficulty chewing or swallowing, change in voice. Last dental cleaning.
Thorax and Lungs. History of emphysema, asthma, or lung cancer.Wheezing, cough, sputum, dyspnea, last chest x-ray, last tuberculin skin test. • Heart and Neck Vessels. History of congenital heart problems,myocardial infarction, heart surgery, heart failure, arrhythmia, murmur. Chest pain or discomfort, palpitations, exercise tolerance. Results of last screening for cholesterol and triglycerides.
Peripheral Vascular. History of high blood pressure, peripheral vascular disease, thrombophlebitis. Peripheral edema, ulcers, circulation, claudication, redness, pain, tenderness. • Breasts. History of breast cancer or cystic breast condition. For adolescents, concerns about breast changes. Pain, tenderness, discharge, lumps, last mammogram, frequency, and date of last self-examination.
Abdominal-Gastrointestinal. History of colon cancer, gastrointestinal bleeding, cholelithiasis, liver failure, hepatitis, pancreatitis, colitis, ulcer or gastric reflux. Appetite, nausea, vomiting, diarrhea. Food intolerance or allergy, constipation, diarrhea, change in stool color, blood in stool. Last sigmoidoscopy, colonoscopy, and stool for occult blood.
Abdominal-Urinary. Renal failure, polycystic kidney disease, urinary tract infection, nephrolithiasis. Pain, change in urine, dysuria, urgency, frequency, nocturia, incontinence. For children, toilet training, bed-wetting. • Musculoskeletal. History of injury, arthritis. Joint stiffness, pain,swelling, restricted movement, deformity, and change in gait or coordination, strength. Pain, cramps, weakness.
Neurological. History of head or brain injury, stroke, seizures.Tremors, memory loss, numbness or tingling, loss of sensation or coordination. • Male Genitalia. History of undescended testicle, hernia, testicularcancer. Pain, burning, lesions, discharge, swelling. Change in penis • Or scrotum, protection against pregnancy and sexually transmitted infections. Testicular self-examination.
Female Genitalia. History of ovarian or uterine cancer, ovarian cyst,endometriosis, number of pregnancies and children. • Pain, burning, lesions, discharge, itching, rash. Menstrual and physical changes, protection against pregnancy and sexually transmitted infections. Last Pap smear. • Anus, Rectum, and Prostate. History of hemorrhoids, prostatecancer, benign prostatic hyperplasia. Urinary incontinence, pain, burning, itching. For men, hesitancy, dribbling, loss in force of urine stream. • Endocrine and Hematological Systems. History of diabetes mellitus, high or low thyroid levels, anemia. Polydipsia, polyuria, unexplained weight gain or loss, changes in body hair and body fat distribution, intolerance to heat or cold, excessive bruising, lymph node swelling. Result of last blood glucose.
Chapter 3 • ASSESSMENT: • Observation • Interview: • Types of questions • Environment (physical and emotional) Spiritual considerations • Examination • Types of Data To Collect: • - Objective data-observable and measurable facts (Signs) • - Subjective data-information that only the client feels and can describe (Symptoms)
* Assessment: • Data base assessment – comprehensive information you gather on initial contact with the person to assess all aspects of health status. • Focus assessment – the data you gather to determine the status of a specific condition. • Sources of Data: • Primary source: Client • Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers
Disease Prevention: • Primary prevention – protection from a disease while still in a healthy state. • Secondary prevention – early detection and treatment of disease. • Tertiary prevention – prevent complications and to maintain health once the disease process has occurred.
Cardinal technique of physical assessment • The four techniques of inspection, palpation, percussion, and auscultation form the basis for physical assessment. • Inspection means conscious observation of the patient for generalappearance; physical characteristics and behavior; odors; and any speciÞc details related to the body system, region, or condition under examination.
Palpation involves use of the hands to feel the Þrmness of bodyparts, such as the abdomen. • Percussion is using tapping motions with the hands to producesounds that indicate solid or air-Þlled spaces over the lungs and other areas. • Auscultation involves use of a stethoscope to hear movementsof air or ßuid in the body over the lungs and abdomen.
InspectionInspection is the first technique of the overall general survey and for each body part because it provides so much information. It is the only technique performed for every body system. Initial inspections focus on overall characteristics such as age, gender, level of alertness, body size and shape, skin color, hygiene, posture, and level of discomfort or anxiety. • During inspection, adequate exposure of each body part is necessary. Concurrently, the privacy of patients can be maintained with appropriate draping, especially over the breasts in women and genitalia in both men and women. Adequate lighting is essential to • Observe color, texture, and mobility.
Nurse should ask patients for permission to examine body areas, especially when assessments involve compromising modesty.
Palpation employs touch to assess texture, temperature, moisture,size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Palpation should begin with a gentle and slow technique. The patients face can serve as a reliable nonverbal indicator of discomfort such as furrowed brows or grimacing
The finger pads facilitate fine discrimination, because they are the most mobile parts of the hand. The palmar surface of the fingers and joints are best for assessing firmness, contour, position, size, pain, and tenderness. The back of the hand (dorsal) is most sensitive to temperature. Vibratory tremors can sometimes be felt on the chest as the patient speaks; these are best felt with the ulnar, or outside, surface of the hand.
Light Palpation • Light palpation allows the patient to become accustomed to the touch. Tender or painful areas should not be palpated until the end. Helpful measures before beginning include ensuring correct draping and alerting the patient about what will happen and gaining his or her permission to proceed. It may be necessary to warm the hands under running water or to gently rub them together. Short and smooth nails also are necessary to avoid causing discomfort.
Palpation is difficult when patients' muscles are tense. A gentle, calm, and easy touch can assist patients to relax. Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. The nurse places the finger pads of the dominant hand on the patients skin and slowly moves the fingers in circular areas of approximately 1 cm in depth Intermittent palpation using this technique is more effective than a single continuous palpation.
Moderate to Deep Palpation • Moderate palpation facilitates the assessment of the size, shape, and consistency of abdominal organs, as well as any abnormal findings of pain, tenderness, or pulsations. The same gentle circular motion of light palpation is appropriate but with the palmar surfaces of the
PercussionThe third technique of physical assessment is percussion to produce sound or elicit tenderness by tapping the Þngers on the patient, similar to that of a drumstick on a drum. The vibrations that the Þngers produce create percussion tones conducted into the patients body. If the vibrations travel through dense tissue, the percussion tones are quiet; if they travel through air, the tones are loud. The loudest tones are over the lungs and hollow stomach; the quietest are over bone.
Direct percussion involves tapping the fingers directly on thepatients skin With indirect percussion, the examiners • no dominant hand serves as a barrier between the dominant hand and patient. He or she places the non dominant palm on the patient and initiates a quick moderately strong tap with the dominant hand. The ulnar surface of the first is used to percuss the kidneys, gallbladder, or liver for tenderness.
