In this paper, the discussion topic will be on physical assessment and with details about what is done within the assessment. Also, what will be discussed is the systematic methods of checking each body system and the specific points to address when physically assessing an adult female patient versus an adult male patient. The physical examination is one of the first steps toward providing safe and competent nursing care (Potter &Perry, 2013). A registered nurse is in a unique position to determine each patient current health status, distinguishing variations from the norm, and recognize improvements or deteriorations in his or her patient condition within the scope of the nursing profession (Potter & Perry, 2013). A complete physical assessment …show more content…
Also depending on the body parts assessed, it can be difficult to perform an exam. So making sure your extra room has special exam tables will make positioning easier and body more accessible. Equipment is the vital part to a physical assessment. Equipment need to be arranged in the order of the exam so it can be easily accessible and easy to use. Preparing the equipment is equally as important (i.e. warming the diaphragm before placing on a patient's skin). Also make sure that equipment functions properly before using it. (i.e. making sure equipment that has bulbs and batteries operate if not replace the bulbs and batteries). Items that are typically used when conducting a physical examination: sphygmomanometer, stethoscope, thermometer, penlight, and otoscope/ophthalmoscope. Also nasal speculum, tongue depressor, skin marker, tape measure/ruler, reflex hammer, cotton balls, vaginal speculum, gloves, lubricant, eye chart, and drapes or gowns for client. There are four specific assessment techniques of a physical assessment, which are inspection, palpation, percussion, and auscultation. A general survey is also done to document an overview of the client and beginning of a physical …show more content…
Also, there are abnormal or adventitious breath sounds: wheezing, rhonchi, rales, pleural friction rub and stridor. Also during physical exam if a cough is present an assessment is done, to determine whether it is non-productive or productive including describing the secretion expectorated. Assessment of the breasts is done for both male and female clients. Breast assessment begins by inspecting the breast for size and symmetry. Noting of any obvious masses, dimpling, or inflammation of the breast to be documented. Also, nipples and areola are assessed to determine symmetrical, size, shape and color and any discharge. Another area of breast assessment is the axillary lymph nodes for enlargement or inflamed lymph nodes. Following the thoracic assessment is the abdominal assessment determining the status of the client's gastrointestinal and genitourinary systems. Note any wounds scars, drains, tubes, dressing, or
At the multidisciplinary meeting, the nurse will collect and assess the information provided by the other disciplines and family members stating that the patient is not at her prior level of functioning and then analyze the information to develop a diagnosis of deconditioning. Next, the nurse identifies outcomes for the patient to get stronger, achieve prior level of function, have activities of daily living (ADL’s) met in a safe environment by planning for home health, equipment, and 24/7 supervision through family or placement in a facility. This will be implemented by coordinating delivery of a walker and a 3 in 1 chair prior to discharge to daughter’s home with the home health agency nurse, physical therapist, and aide scheduled to start that day. In a week, the nurse evaluates that outcomes are being met by following up with patient, daughter, and home health agency evaluating that the patient is getting stronger, ADL’s are being met, and will soon be able to return to living independently. To achieve these standards of practice, every nurse should be aware of her own nurse practice act to ensure to be functioning with in the laws of the nurse’s state and to ensure the best outcomes and safety of the patients. In closing, it is every nurses duty to be the best nurse they are capable of being by looking at the scope of nursing practice which gives us the framework to achieve
First of all, this case is associated with biopsychosocial approach which recognizes that, it is the approach that considers human behavior to be the result of interactions of integrated biological, psychological, and social systems. This approach helps us to recognize the ways in which women’s biology, psychology, and their social world intertwine within each other affect their reactions to alcohol and alcohol interventions. In order to explain some of the concepts and theories, we must first sort through the facts that have been presented in the case study. This particular case is concerned with developing a better understanding of the relationship between Casey, and alcoholism.
The first way effective nurses can compensate for a doctor’s deficits is by meeting the physical needs of a patient, something doctors
After obtaining vital signs, a physical assessment would include inspection, auscultation, percussion and palpation of the abdomen. Inspection consists of visual examination of the abdomen noting its shape, skin abnormalities, abdominal masses, and the movement of the abdominal wall with respiration (Walker, 1990). Abnormalities detected on inspection combined with the patient’s history provide clues to intra-abdominal pathology (Diekmann, n.d). Auscultation of the abdomen is performed before percussion and palpation which can alter bowel motility (Jensen, 2015). Auscultation allows detection of altered bowel sounds, rubs, or vascular bruits. Normal peristalsis creates bowel sounds that may be altered or absent by disease. Percussion is performed to identify organ size and detect the presence of fluid, gas or masses. Palpation includes both light and deep techniques (Jensen, 2015). Light palpation detects areas of tenderness, distention, ascites, presence of masses, and bladder distention; whereas deep palpation, an advanced skill assesses
The nurse needs to describe what focused health assessments they think would best suit the patient. The nurse needs to work out a way in which we can help decrease Alice’s heart rate and blood pressure. To do this the nurse would perform a neurological assessment and a head to toe assessment. These two assessments will give the nurse more information about Alice’s nervous system, if she is in any pain and what further assessments and treatment need to be completed. A neurological assessment is a technique of gaining specific data in relation to the role of a patient’s nervous system (Ruben Restrepo).
requiered to determine treatment. Lab tests or imaging is often requiered as well. It’s chronic,
The author will also discuss the nursing care required in each area (physical, psychological and social health) and some of the evidence that has supported this in relat...
In this case I will discuss evidence based nursing problem which has a very big impact to the nurses which is evidence- based practices for safe patient handling and movement. Evidence-based practice is critically appraised and scientifically proven evidence for delivering quality health care to a specific population. This is very important because it will help me in reduction of injuries that are associated with patient handling. There are very many approaches that can be used or rather are used in patient handling. These includes manual patient lifting, classes in body mechanics, training in safe lifting techniques, and back belts. Amazingly there has been a strong evidence that this methods still they do not help in reducing nurses or caregiver’s injuries.
read by a trained health worker. If the skin around the prick israised and it
“A guide to taking a patient history” is an article appeared in volume 22, issue 13 of the Nursing Standard Journal in December 2007 written by H. LLoyd and S. Craig. The article talks about the steps and strategies to follow when taking a patient history. It is important to acquire good techniques in assessing a patient starting by the environment, communication skills, and a systematic approach. One must be able to collect accurate data in order to facilitate the procedure.
A laboratory audit ensures that the laboratory has quality systems in place, follows good laboratory practices, and generates data of integrity and quality. If the laboratory standards have not been met changes are applied and then a re-audit is performed after a certain time period to ensure that the changes have been implemented and maintained. Stage 1 involves selecting a topic to be audited and is likely to include processes that have been shown to produce best outcomes for patients. Stage 2 is about defining the criteria and standards. The criteria defines what is being measured and the standards define the aspect of care to be measured and it should be based on the best evidence. Stage 3 is collecting of the data. To ensure that the collection of data is accurate, and that only vital information is collected, certain details of what is to be audited must be established from the outset and sample sizes of data should be of a reasonable size as this will allow you to come to a valid assumption. Stage 4 compares performance with criteria and standards. This stage analyzes the results obtained from the data collection and theses are then compared with criteria and standards. The end of the analysis concludes how well the standards were met and if any standards were not met improvements are likely. In stage 5 once the results have been discussed and published agreements must be made about the commendations for change. An action plan is good to record the ideas for change. Action plan development involves improvement of the audit mainly if measures are found to be incorrectly assessed. Also new process or outcome measures may be
The nursing process is used for nurses to assist their patients need is vital for safe and appropriate care. The nursing process will be used to assist Maureen, which involves assessment, plan, implementation and evaluation (Crisp & Taylor, 2009, p. 257). Night sweats,mood swings, depression, weight gain, anxiety, loss of sleep, hot flashes and frequent trips to the bathroom are only some symptoms that women may experience in a significant change in their end of life of reproductive years known as menopause when the menstruation cycle ceases (Karla, Agarwal & Magon, 2012). The summary of the scenario that will be discussed during this paper involves a 50 year old women, named Maureen who is going through menopause and has she tends to over
As an intended Kinesiology major, I have learned through various courses that physical health is never investigated and fully understood through one perspective. Five primary subdisciplines of kinesiology that can further explain physical health are Biomechanics, Exercise Physiology, Motor Learning, Psychology, and Sociology. A substantial part of physical health is to remain physically active. Therefore, the purpose of Biomechanics is to always improve aspects of physical activity by modifying certain exercises, equipment, or techniques to make them efficient, effective, and safe. An example of a piece of equipment that’s constantly improving is active footwear. Researchers and scientists believe that different styles of shoes can benefit
Musculoskeletal problems are conditions that affect the bones, joints and muscles resulting in pain, inability to move the body or stiffness, swelling etc. Musculoskeletal problems affect different parts of the body which include the neck, wrists, knees, shoulders, back, waist etc. The nursing care involves handling of patients and giving adequate or complete care. In nursing care of patients, some techniques are involved which include lifting, moving or repositioning of patients. Continuous use of these techniques most times affect the body resulting in pains and body aches. In order to prevent these musculoskeletal problems, nurses should make use of lifting devices instead of
Potter, P. A., & Perry, A. G. (2009). Fundamentals of nursing (Seventh ed.). St. Louis, Mo.: Mosby Elsevier.