Physical Exam & History Taking-fall

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Physical Exam & History Taking:

Physical Exam & History Taking Dr. Wegdan Bani-Issa University of Sharjah /Health Sciences Fall 2012-2013

Why we perform P/E & Health Hx :

Why we perform P/E & Health Hx Health history proceed physical exam. Helpful in establishing the a nurse-client relationship Identify problem symptoms & abnormal findings Linking findings to an underlying process of pathology

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History clustered into two forms of data Subjective data elicited and identified by patients. Source of sub; client and families and sig. others, health care professionals Method to obtain it: client interview Requires interviewing skills, caring ability and empathy

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Objective data: directly or indirectly observed or measured Source: physical assessment, documents Methods to obtain: observation and PE Skills: inspection, palpation, percussion, auscultation (RR, X-ray) Both subjective and objective focus on functional health patterns

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Client profile: biographical data What is your name? Tell me about your background Where were you born? What is your ethnic origin? how old are you? What is the closest healthcare facility to you?

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Reason for seeking healthcare and current understanding of health : use COLDSPA C haracter: describe the sign or symptoms O nset: when did it begin? L ocation: where is it? Does it radiate? D uration: how long does it last? S everity? How bad is it? P attern? What makes it better? Bad.. A ssociated Factor? What other symptoms occur with it?

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Treatment/Medication Describe the treatments and medications. How has your illness treated in the past? What is being planned for your treatment now? Do you understand the purpose of yr treatment? Purpose, how it makes you feel?

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Past illness & hospitalization Allergy history and tobacco use

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Developmental history To determine physical, cognitive, psychosocial development of client. Ht, Wt, growth chart

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Health perception-health & management pattern Describe your health… How would you rate your health on 1 to 10 scale Perception of illness: Describe current health problems How it affect normal activity, what do you believe cause your illness Health management habits Compliance with prescribed medication and Tx

Nutritional assessment :

Nutritional assessment Nutrition is important to maintain health and prevent disease. first step toward the development of a nutritional care plan and toward the treatment of malnutrition as a result of either over- or undernutrition . Nutritional status: degree of balance between nutrient intake and nutrient requirements

Nutritional status :

Nutritional status Optimal nutritional status: is achieved when sufficient nutrient are consumed to support day-to-day body needs and any increased metabolic demands Undernutrition : when nutritional reserves are depleted or intake is inadequate to meet day-to-day needs or added metabolic demands Overnutrtion : consumption of nutrients in excess of body needs

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Assessment of a persons nutritional status provides information on: Obesity. Undernutrition . Weight loss. Malnutrition. Deficiencies in specific nutrition. Metabolic abnormalities. Effect of medications on nutrition.

Tips for detecting nutritional assessment :

Tips for detecting nutritional assessment Clinical examination BMI Biochemical assessment Dietary data Food record 24-hour recall Diet Cultural and religious considerations

Tips for detecting nutritional problems::

Tips for detecting nutritional problems: Physical conditions: Chronic illnesses (DM, neurologic, or cardiac problems). Family history. Anorexia or bulimia. Depression or anxiety. Sever trauma. Chemotherapy., radiation therapy, or bone marrow transplantation. Physical limitation (paralysis) Burns. Drug and diet: Liquid diet or nothing by mouth for more than 3 days. Strict vegetarian diet. Excessive alcohol intake. Mouth, tooth, or dental problems. Lifestyle factors: Lack of support from family or friends. Financial problems.

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Eyes: Night blindness, corneal swelling, softening, or dryness, Red conjunctiva indicate riboflavin deficiency. Pale or red eyes, smooth , swollen, atrophy or hypertrophy Throat and mouth : Cracks at corner of mouth indicate riboflavin or niacin deficiency. Beefy, red tongue indicate vitamin B12 deficiency. Soft, spongy, bleeding gums indicate vitamin C deficiency. Swollen neck indicate iodine deficiency.

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Cardiovascular: Edema indicate protein deficiency. Tachycardia and hypotension indicate fluid volume deficit. GI: Ascites indicate protein deficiency.

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Musculoskeletal : Bone pain and bow leg indicate vitamin D or calcium deficiency. Muscle wasting indicate protein, carbohydrate, and fat deficiency. Pain in calves and thighs indicate thiamine deficiency. Neurologic: Altered mental state indicate dehydration and thiamine or vitamin B12 deficiency.

Performing the assessment::

Performing the assessment: Evaluate the patient general appearance by assessing his: Posture. Speech. Height and weight. Skeletal deformities. Physical movement.

Other indicators …:

Other indicators … Body Mass Index (BMI) is used to determine who is overweight. BMI = wt Kg/ht in m² BMI 25 or more is considered overweight. BMI 30 or more is considered obese. BMI < 18.5 is underweight

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Waist circumference Mid-arm circumference: ( MAC) men = 29.3 (cm) , less than 17.6 severely malnourished women (standard)= 28.5; severely malnourished less than 17.1 Triceps skin fold thickness : (SFT): men (standard = 12.5, severely malnourished = 7.5; women TSF standard = 16.5, severely malnourished < 9.9

Analysis of Data:

Analysis of Data Use collaborative approach Assess in conjunction with clinical indicators and patient health needs. Compare with dietary guidelines.

Sequencing of the Assessment:

Sequencing of the Assessment Skin Head and neck Thorax and lungs Breasts Cardiovascular system Abdomen Genitalia Neurologic system Musculoskeletal system

Note::

Note: The assessment may be modified based on the person’s presenting problem, age, general condition, and other factors.

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Four basic techniques for physical assessment Inspection: it is using the senses of vision, smell, hearing to observe the condition of body part. Expose body part Always look before touching Use good lighting Provide warm room. Observe color size, location, texture, symmetry, odors, sounds

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Palpation : used to determine roughness/smoothness Temperature: warm/hot/cold Moisture (dry/wet/moist) Motion (stillness/vibration) Consistency of structures (fluid filled/solid)

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Technique Examiners’ fingernail should be short The most sensitive part of the body used to detect pulsations Fingertips for fine discriminations, pulsations Palmer/ulner surface for vibration sensation (thrills, fremitus) Dorsal surface (back of the hand) for temperature

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Three types of palpation to be used. Light palpation Deep palpation By manual palpation to palpate breast

Light and Deep Palpation :

Light and Deep Palpation

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Percussion Tapping a portion of the body to elicit tenderness or sounds that vary with density of underlying structure Two types Direct percussion: percussion of the sinus to elicit tenderness or pain directly tap the part with one or two fingertips Indirect percussion: percussion of the lungs striking. To detect sounds like tympanic, dullness, flatness.

Percussion Technique: indirect :

Percussion Technique: indirect

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Sounds: resonance: over part air or solid Hyperesonance: heard over mostly air Tympany: gastric pupple Dullness: solid tissue Flatness: over very dense tissue (bone, sternum, muscle, thigh

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Auscultation : listening to various breath, heart, vasculature, and bowel sounds using a stethoscope. Good stethoscope that has: Snug-fitting war plugs Tubing not longer than 15 inch and internal diameter not greater than 1 inch Diaphragm and bell : diaphragm for detecting high pitch sounds (breath sounds, normal heart, bowel sound) Press firmly on the body part Bell: low pitch sounds (abnormal extra heart sounds, heart murmer and carotid pulse) Press lightly over the body part

Auscultating the Heart :

Auscultating the Heart

Interviewing:

Interviewing Purposes of Interview 1. to establish a trusting & supportive relationship 2. to gather information 3. to offer information The process of interviewing pt requires a highly refined sensitivity to pt feelings & behavioral cues

Tips for assessing severely ill patients :

Tips for assessing severely ill patients When pt’s condition does not allow full assessment Stay calm and always remember to introduce yourself. Stay on the lookout important information. Avoiding jumping to conclusion

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The interviewing process is much fluid & demands effective communication & relational skills It requires not only knowledge of data you need to obtain but also the ability elicit accurate information & interpersonal skills that allow you to respond to pt feelings & concerns

The Approach of Interview:

The Approach of Interview I. getting ready A. taking time for self reflection B. reviewing the chart C. setting goals for the interview D. reviewing your clinical behavior & appearance E. adjusting the environment F. taking notes

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II. The sequence of interview A. greeting pt & explain the purpose of note taking, provide comfort, privacy and confidentiality (introductory phase) B. inviting pt story (working phase) Establishing rapport, obtain C/C Begin with open ended questions “ how I can help you “ use verbal & nonverbal cues “nodding head” “saying ah huh” “go on” Listen to pt without interruptions

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3. establishing an agenda There is specific goals in mind for interview use time effectively sometimes you need to use specific questions “ you have told me about several problems. can you tell me which one you are most concern about”

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4. Expanding & clarifying pts story Guide pt into elaborating areas of history Try to clarify attributes of each symptom; Use language that is understandable & appropriate to pt Try to use pts words and avoid technical ones

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5. Generating and testing diagnostic hypotheses Symptoms- diagnoses? 6.Creating a shared understanding of the problem We should ask pt several questions about his perception of illness It includes pt thought about nature& cause of problem , pt feelings (fear) pts Expectations of health care The effect of problem on his life & others

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Example (about pain) Nurse; has anything like this happen to you or your family before? Pt; I was worried that I might have appendicitis. My uncle died of a ruptured appendix

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7. negotiate a plan It gives basis for planning further evaluation (P/E, lab test, consultation) & negotiating a treating plan 8. planning for follow-up and closing Let pt the end of interview is approaching Make sure pt understand the mutual plans you have developed

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Example “we need to stop now. Do you have any questions about what we covered” As you close review future evaluation, treatment, & follow up.

III-building a therapeutic relationship:

III-building a therapeutic relationship 1. building the relationship; by active listening 2. using guided questions 3.nonverbal communication 4.empathic responses (acknowledge pt feelings) 5.Validation (acceptance of feeling) 6. reassurance

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7.partnering; to make explicit your desire to work with them in ongoing way 8. summarization 9.transition 10. empowering patient;

V- Sensitive topics that call for specific approach:

V- Sensitive topics that call for specific approach Guidelines for broaching sensitive topics 1. be non judgmental 2. explain why you need to know certain information 3.find opening questions for sensitive topics and learn the specific kinds of data needed for your assessment

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Important to notice emotional variations, Angry: approach calm, reassuring, in control manner. Anxiety: approach with simple, organized info, explain your role and purpose Manipulative: provide structure and set limits Depressive: express interest and understanding Sensitive issues: be aware of your thought and feelings. Referral is appropriate when you do not feel comfortable.

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Examples; “what do you like to drink” “have you ever had a drinking problem of alcohol” “have you ever used any drugs other than those required for medical reasons” “when was the last use” “how often substance use”

Beginning physical exam:

Beginning physical exam Preparation for the P/E; 1.Reflect on your approach to patient identify self,be calm,organized, competent 2. Adjust the light and environment 3. Determine the scope of examination 4. Choose the sequence of examination 5. Observe the correct examining position and handedness 6. Make patient comfortable

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