pengkajian keperawatan

Health Assessment

Nursing AssessmentHealth historyPhysical exam

Nursing HistoryPatient profileChief complaintPast historyFamily historyMedicationsAllergiesReview of systems

PainPalliative/provocative Quality/quantityRegio/ radiationSeverety Time

Examination TechniquesInspection

Palpation

Percussion

AuscultationCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

InspectionVisual assessment of the patient and surroundings

Findings that may be significant:Patient hygieneClothingEye gazeBody languageBody positionSkin colorOdorCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

InspectionIf the emergency response was to the patient's home, make a visual inspection forCleanlinessPrescription medicinesIllegal drug paraphernaliaWeaponsSigns of alcohol useCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

PalpationA technique in which the hands and fingers are used to gather information by touch

Palmar surface of fingers and finger pads are used to palpate forTextureMassesFluidCrepitusAnd assess skin temperature

Palpation may be either superficial or deepCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

PercussionUsed to evaluate for presence of air or fluid in body tissuesSound waves heard as percussion tones (resonance)

Procedure Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

AuscultationBest performed in a quiet environment

Requires a stethoscopeBody sounds produced by movement of fluids or gases in patient's organs or tissues

Note:IntensityPitchDurationQualityCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

StethoscopeUsed to evaluate sounds created by cardiovascular, respiratory, and gastrointestinal systems

StethoscopesAcoustic MagneticElectronicCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Blood Pressure CuffSphygmomanometer

Measures systolic and diastolic blood pressure

Manual or electronicCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Comprehensive Physical ExaminationMental status

General survey

Vital signs

Skin

Head, eyes, ears, nose, and throat (HEENT)Chest

Abdomen

Posterior body

Extremities

Neurological examCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Mental StatusFirst step in patient care encounter Patients appearance and behaviorLevel of consciousnessA healthy patient is expected to be alert, responsive to touch, verbal instruction, and painful stimuliCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Mental StatusAppearance and behaviorPosture, gait, and motor activityDress, grooming, personal hygieneBreath or body odorsFacial expressionMood and affectSpeech and languageThought and perceptionsMemory and attentionCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

General SurveySigns of distressCardiorespiratory insufficiencyLabored breathingWheezingCoughPainWincingSweatingProtectiveness of a painful body part or areaAnxietyRestlessnessAnxious expressionFidgety movementCold, moist palmsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Skin Color Varies from person to personVaries based on ethnicityMay range in tone from pink or ivory to deep brown, yellow, or oliveObserve for skin not exposed to sun (e.g., palms)Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Height and BuildDescriptions include: Average, tall, short, lanky, muscular

May also be affected by age and lifestyleCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Sexual DevelopmentDetermine if age appropriate

Observe for normal changes associated with ageCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

WeightObserve general appearanceObese to emaciated

Recent changes may be key findingRecent weight loss or gain

Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

PulseRateRhythmQualityConsider ECG monitoring


Tympanic TemperatureAccuracy questionable

Pull ear back

Insert gentlyCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Rectal TemperatureRisk of perforationAvoid in uncooperative, or immuno-suppressed patientStabilize thermometer


EyesVisual AcuityHave patientRead printed materialCount fingers at a distanceDemonstrate ability to tell light from darkUse eye chart(e.g., Snellen chart)Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

EyesPupilsFindings may indicate neurological issues

Examine response to light (PERRL)Pupils are equal, round, and react to lightCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Anatomical RegionsSkin Texture TurgorHairFingernails and toenails

Head, ears, eyes, nose, throatCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Head and FaceInspect skull for shape and symmetryPalpate for swelling, tenderness, lesions, indentationsInspect face for symmetry, expression, edema, involuntary movements Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

SinusesReturn to Head and Neck

EyesDetermine if contacts are presentDetermine that both eyes can seeAssess visual acuityInspect orbital area for edemaExamine eyes for drainage or rednessDetermine structural integrityCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Cardinal Fields of GazeReturn to Head and Neck

Visual FieldsAsk the patient to look at his or her noseTest peripheral vision by extending your arms with elbows at right angles and wiggle both index fingers simultaneously

Observe eyes for normal position and alignment


Ophthalmoscopic ExaminationUsed to evaluate:CorneaForeign bodiesLacerationsAbrasionsInfectionAnterior chamberHyphemaHypopyon FundusOptic nerveRetinaVitreousEyelidCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Cornea and ScleraExamine conjunctiva and sclera

Palpate lower orbital rimCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Ophthalmoscopic ExaminationInspect:Size, color, and clarity of the discIntegrity of vesselsAssess for retinal lesions and appearance of the maculaCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Ophthalmoscopic ExaminationNormal findingsClear, yellow optic nerve discReddish pink (European-American) or darkened retina (African-American)Light red arteriesDark red veins3:2 vein-to-artery ratio


Otoscopic ExaminationSelect speculum

Turn on otoscope

Insert speculum into ear canal, slightly down and forward

Look for foreign bodies, lesions, discharge

Inspect tympanic membrane Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Otoscopic ExaminationNormal findingsCerumen is dry (tan or light yellow) or moist (dark yellow or brown)Ear canalNot inflamed Tympanic membrane Translucent or pearly grayCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Mouth and PharynxLips

Gums

Mouth and tongue

PharynxCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

OropharynxReturn to Head and Neck

NeckInspect Use spinal precautions if trauma is suspected

Palpate tracheaMidline position normalCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

NeckPalpate Place both thumbs along sides of distal tracheaSystematically move toward headDo not apply bilateral pressure to carotid arteries Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Return to Head and Neck Slide

Measuring JVD

Head and Cervical SpineTemporomandibular joint (TMJ)

Inspect and palpate cervical spine

Range of motion Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ChestRibsProtect thoracic organs Support respiratory movements of diaphragm and intercostal musclesAnatomical landmarks for examinationCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

InspectionGeneral appearance of chest

Chest wall configurationInspect for symmetryChest wall should be symmetricalCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Chest Wall AbnormalitiesBarrel chest

Funnel chest (pectus excavatum)

Pigeon chest (pectus carinatum)

Thoracic kyphosis

ScoliosisCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ChestPalpationTracheal position

Respiratory excursionCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Breast Exam Techniques

Documenting the Breast Exam

Respiratory EffortAssess:Respiratory rate, rhythm, symmetry, and qualityPatient positionAccessory musclesRetractions (intercostal, supraclavicular, or both)Nasal flaringPausing to take a breathCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Respiratory PatternsEupneaTachypnea BradypneaHyperpneaHyperventilationDyspnea OrthopneaParoxysmal nocturnal dyspneaApneaCheyne-Stokes respirationKussmaul breathingBiots respirationsCentral neurogenic hyperventilationCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

AuscultationPatient in sitting position (if possible)Instruct to breathe deeply and slowly through open mouth Use diaphragm of stethoscope Evaluate anterior and posterior lung fieldsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Vesicular Breath SoundsMost of lung fieldsLungs considered "clear" make normal vesicular breath sounds

Harsh vesicular breath sounds

Diminished vesicular breath soundsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Bronchovesicular Breath Sounds Major bronchi and upper right posterior lung fieldLouder and harsher than vesicular breath soundsMedium pitchEqual inspiration and expiration phasesHeard throughout respirationCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Bronchial Breath SoundsOnly over trachea

Highest in pitch

Coarse, harsh, loud sounds

Short inspiratory phase and long expirationBronchial sound anywhere but over trachea is abnormal Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Abnormal Breath SoundsAbsent

Diminished

Incorrectly located bronchial sounds

Adventitious DiscontinuousContinuousCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Discontinuous Breath SoundsCracklesFormerly called ralesHigh-pitched discontinuous soundsUsually at end of inspirationDisease of small airways or alveoliCoarse crackles: wet, low-pitched soundsFine crackles: dry, high-pitched soundsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Continuous Breath SoundsWheezes

Rhonchi

Stridor

Pleural friction rubCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

PulseAssess:RateRhythmIntensity

Palpate pulses simultaneously on both sides of body Except carotid Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Cardiac Circulation

Heart SoundsS1Instruct patient to breathe normally and then hold breath in expiration

S2Instruct patient to breathe normally again and then hold breath in inspiration Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Pericardial Friction RubInflammation of pericardial sac

Scratching, grating, or squeaking qualityLouder during inspiration

Differs from pleural friction rubs by continued presence during breath holdingCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Heart MurmursProlonged extra sounds

Caused by disruption in flow of blood through heartMost caused by valvular defectsSome seriousOthers benign Have no apparent causeCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

BruitAbnormal sound or murmur Heard while auscultating carotid artery, organ or glandMay be local obstructionOften low pitched Hard to hearCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ThrillsVibrations or tremors

May indicate blood flow obstructionMay palpate over aneurysm or on precordiumSerious or benignCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

AbdomenInspection Skin

Umbilicus

Contour

Abdominal movementCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

PercussionEvaluate four quadrants of abdomen: TympanyAir in stomach and intestinesDullnessSolid abdominal organs and solid masses

Proceed from tympany to dullnessChange in sound easier to detectCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Female GenitaliaIf possible, use same-gender paramedics to examineChaperone if possibleInspect external genitalia for:SwellingDiscoloration or rednessBleedingTraumaLesionsDischargeCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Female GenitaliaNormal vaginal dischargeClear or cloudy with little or no odorYellow-green dischargeFrothy, gray-green discharge with foul odorWhite, curdlike discharge with no odorGray discharge with fishy, foul odorCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Male GenitaliaInspect for bleeding or trauma

PenisShaft nontender and flaccidPriapism

Urethral openingFree of blood and discharge

ScrotumNontender and slightly asymmetricalCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Male GenitaliaAnusExam indicated if:Rectal bleedingTrauma to areaMost patients find side-lying position most comfortableProtect patients privacyCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Male GenitaliaInspect sacrococcygeal and perineal areas for:LumpsUlcersInflammationRashesExcoriationsInflamed external hemorrhoids commonAdults and pregnant womenCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Musculoskeletal SystemAssess function and structurePatient positionEvaluate head, neck, shoulders, and upper extremities with patient in a sitting positionEvaluate chest, back, and ilium with patient standingEvaluate hips, knees, ankles, feet with patient supineObserve general appearance, body proportions, and ease of movementCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

General PrinciplesExamine normal tissues before those injured, inflamed, or otherwise affected

Inspect and palpate each body partThen test range of motion and muscle strength

Note differences between right and left Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ExtremitiesEvaluate: Skin and tissue over muscles, cartilage, bonesJoints for injury, discoloration, swelling, massesCirculatory status Skin color and temperatureDistal pulsesStructural integrity of bones, joints, and tissuesMuscle toneCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Abnormal FindingsSigns of inflammationSwellingTendernessIncreased heat Redness of overlying skinDecreased functionAsymmetryCrepitusDeformitiesDecreased muscle strengthAtrophyCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

JointsBones move freely over one anotherNo clicks, crepitation, or painMove each joint through full range of motionNormal if no pain, deformity, limitation, or instabilityNote:Limited range of motionUnusually increased joint mobility Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Hands and WristsInspect for swelling, redness, deformity, nodules, muscular atrophyPalpate jointNote swelling, tenderness, deformityRange of motionTest muscle strength by hand gripCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Clubbing of Fingernails

ElbowsInspection Examine in flexed and extended positionNote deformity, swelling, nodules

PalpationLateral and medial epicondyles of humerusGroove on sides of olecranon process

Range of motionCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Shoulders and Related StructuresInspect shoulders, shoulder girdle, scapulae, and related posterior muscles Symmetry of size and shapeNote swelling, deformity, muscular atrophyCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Shoulders and Related StructuresPalpate for tenderness in:Sternoclavicular jointAcromioclavicular jointSubacromial areaBiceps grooveNote any tenderness or swellingRange of motionCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Ankles and FeetSkin integrity

Contour

Position

Deformities

Nodules

Swelling

Calluses

Corns

SizeCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Ankles and FeetPalpate:Anterior aspects of each ankle jointAchilles tendonMetatarsophalangeal joints

Note tenderness, swelling, deformityCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Ankles and FeetRange of motionDorsiflexionPlantar flexionInversionEversion


PelvisPelvic structural integrity Hands on anterior iliac crests Press down and outHeel of hand on symphysis pubisPress downCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

HipsInspect for symmetryPalpate:Instability, tenderness, and crepitusRange of motion (supine patient)Raises knee to chest, other leg straight Note flexion at hip and kneeCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

KneesInspectionPatella smooth, firm, nontender, midlineAlignment, swelling, and deformityNote atrophy of quadricepsPalpationNote thickening, swelling, tendernessRange of motionBend, straighten each knee without painCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ArmsInspect fingertips to shoulders, noting:Size and symmetrySwellingVenous patternColor of skin and nail bedsSkin texture

Palpate:Radial pulses bilaterallyEpitrochlear nodeIf palpable, note its size and consistencyCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

LegsPatient supine and appropriately drapedInspect from groin and buttocks to feet:Size and symmetrySwellingVenous pattern and venous enlargementPigmentationRashes, scars, ulcersColor and texture of the skinPresence or absence of hair growthCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

LegsPalpate superficial inguinal nodesSwelling and tendernessPalpate pulses: Femoral PoplitealDorsalis pedis Posterior tibialTemperature of feet and legsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

LegsCheck for pitting edema:Press firmly but gently with the thumb for at least 5 secondsOver dorsum of footBehind medial malleolusOver shinsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Abnormal FindingsSwollen or asymmetrical extremities

Pale or cyanotic skin

Weak or diminished pulses

Skin cold to the touch

Absence of hair growth

Pitting edemaCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

SpineInspectionCervical, thoracic, and lumbar curvesLordosis (swayback)Kyphosis (hunchback)Scoliosis (razorback) Height differences of shouldersHeight differences of iliac crest

Cervical SpineInspectionShould be in a midline positionLook for deformities and abnormal posture

PalpationIf patient is alert and denies neck pain, palpate posterior aspect of neck for point tenderness and swellingCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Cervical SpineRange of motionIf no suspected injury:Bend head forward, chin to chest (flexion)Bend head backward (hyperextension)Move head side-to-side (lateral bending)Should be no pain or discomfortCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Thoracic and Lumbar SpineInspect for injury, swelling, discolorationPalpate from first thoracic vertebra Move downward to sacrumRange of motionBend forward at waistBend backward at waist Bend to each side Rotate upper trunk in a circular motionCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Nervous SystemDetail of neurological examination variesDepends on patients complaintPeripheral nervous system vs. CNS problemsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Mental Status and SpeechOriented to person, place, and time

Organizes thoughts and converses freelyIf no hearing or speech impedimentsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Cranial Nerve AssessmentCranial nerve IOlfactory: Test sense of smell with spirits of ammonia

Cranial nerve IIOptic: Visual acuity

Cranial nerve II and IIIOptic and oculomotorSize and shape of pupilsPupil response to lightCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Cranial Nerve AssessmentCranial nerves III, IV, VIOculomotor, trochlear, abducensExtraocular movements Six cardinal directions of gazeCranial nerve VTrigeminalAsk patient to clench teeth while palpating temporal and masseter musclesTest sensation by touching forehead, cheeks, jaw on each sideCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Cranial Nerve AssessmentCranial nerve VIIFacialInspect face: note symmetry, tics, abnormal movementsRaise eyebrows, frown, show both upper and lower teeth, smile, puff out cheeksClose eyes tightly so they cannot be opened, gently attempt to raise eyelidsObserve for weakness or asymmetryCranial nerve VIIIAcoustic: Assess hearing acuity

Cranial Nerve AssessmentCranial nerves IX and XGlossopharyngeal and vagusAbility to swallow with ease; to produce saliva; produce normal voice soundsPatient holds breath: assess for normal slowing of heart rateTesting for gag reflex will test cranial nervesCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Cranial Nerve AssessmentCranial nerve XISpinal AccessoryRaise and lower shoulders, turn head

Cranial nerve XIIHypoglossalStick out tongue and move it in several directionsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Motor SystemObserve patient during movement and at restAbnormal involuntary movements evaluated for:QualityRateRhythmAmplitudeCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Motor SystemOther body movement assessments:PostureLevel of activityFatigueEmotionMuscle strengthBilaterally symmetricalResistance to oppositionCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Muscle StrengthPatient to move against resistance:No muscular contraction detectedA barely detectable flicker or trace of contractionActive movement of body part with gravity eliminatedActive movement against gravityActive movement against gravity and some resistanceActive movement against full resistanceThis is normal muscle toneCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Lower Extremity EvaluationPatient pushes soles of feet against examiners palmsPatient pulls toes toward head against resistanceShould be easily performed by patient without fatigueCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Muscle StrengthOther methods can be used to evaluate muscle strength, including tests for:FlexionExtensionAbductionUpper and lower extremitiesCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Sensory SystemPatients response to pain and light touchResponse considered in relation to dermatomesPerform light touch on hands and feetIf patient cannot feel or is unconscious, gently prick extremities with sharp object that will not penetrate skinHead to toeCompare symmetrical areasCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Approaching the Pediatric PatientRemain calm, confidentAvoid separating child from parent Establish rapport with parents and childBe honest with child and parentHave one paramedic stay with childCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Approaching the Pediatric PatientObserve child before physical examinationBegin assessment without touching patient

Note:Skin colorLevel of consciousnessRespiratory rateAssess behaviorCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Approaching the Pediatric PatientNote area of body that appears painfulAvoid painful area until end of examinationWarn child before you touch painful area(s) Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

General AppearanceAssess from a distance:Level of consciousnessSpontaneous movementRespiratory effortSkin colorBody positionSeriously ill or injured child does not hide or disguise conditionCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Birth to 6 MonthsMaintain body temperaturePoor head control normal under 3 months of ageInfants are abdominal breathersStomach protrudes and chest wall retracts during inspirationCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Birth to 6 MonthsAssess anterior fontanel:Present up to 18 monthsBulges during cryingFirm if child is supineIf sunken, may be dehydrationBulging fontanel may mean increased intracranial pressure

7 Months to 3 YearsUsually cooperativeMinimal speech, unreliable historyMay have separation anxietyIf possible, have parent hold child for examMay see illness or injury as punishmentApproach slowly and speak in reassuring tonesUse simple and direct questionsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

4 to 10 YearsMay be cooperative May provide limited history of eventMay have separation anxiety and view illness or injury as punishmentApproach slowlySpeak in quiet, reassuring tonesAllow child to "help" Reluctant to show "private partsAdvise of any expected pain or discomfortCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Adolescents (11 to 18 years)Generally calm, mature, helpfulConcerned about modesty, disfigurement, pain, disability, and deathReassure when appropriateRespect patient's need for privacyIf possible, interview privately Consider alcohol, drug use, pregnancyCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Communicating with the Older AdultAllow time for effective communication

Stay close to patient during interview

Repetition of questions may be needed

Do not patronize or offend patientCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient HistoryMultiple health problemsDifficult to isolate injury or illness

Decreased sensory function may disguise signs and symptoms

Watch for illness from medication use or misuse

Consider relationship between drug interactions, disease, and aging processCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient HistoryFunctional ability and daily activitiesWalkingGetting out of bedDressingDriving a carUsing public transportationPreparing mealsTaking medicationsSleeping habitsBathroom habitsCopyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical ExaminationTry to ensure patient comfortOffer clear explanations Answer questionsBe alert to chronic painIf hospital transport necessaryAttempt to calm patientReassure patient he or she will be cared for in hospital Record examination findings Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ConclusionThe Nurse must have a wide range of knowledge and skills to perform a comprehensive physical examination and to make effective clinical patient care decisions.Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Questions?Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

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