Demonstration prresentation on physical examination

IT IS HELPFULL FOR PHYSICAL EXAMINATION HEAD TO TOE
CREATED BY- MR. SANDEEP YADAV MSC. NURSING 1ST YEAR FROM KGMU LUCKNOW UP.

1. PRRESENTATION ON PHYSICAL EXAMINATION Presented By: Sandeep Yadav M.Sc. (N) 1 st year KGMU lucknow

2. OBJECTIVES Define the physical examination Explain the purposes Discuss the indication Enlist the articles Discuss the pre-procedural steps Explain the procedure and demonstrate Dicuss the post procedural steps Discuss about the nursing responsibilities.

3. INTRODUCTION A comprehensive head-to-toe assessment is done on patient admission or in community centre, and when it is determined to be necessary by the patient’s health status. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition.

4. DEFINITION It is the systematic collection of objective information that is directly observed or is elicited through examination techniques.

5. PURPOSES To understand the physical and mental well being of the patient. To detect diseases in early stages. To determine the cause of disease . To understand any changes in the condition of diseases, any improvement or deterioration.

6. INDICATIONS check for possible diseases so they can be treated early identify any issues that may become medical concerns in the future update necessary immunizations ensure that you are maintaining a healthy diet and exercise routine.

7. ARTICLES

8. GLOVES

9. SPHYGMOMANOMETER

10. STETHOSCOPE

11. FETOSCOPE

12. TONGUE DEPRESSOR

13. FLASH LIGHT

14. TAPE MEASURE

15. WEIGHING MACHINE

16. LARYNGOSCOPE

17. OPTHALMOSCOPE

18. OTOSCOPE

19. TUNNING FORK

20. NASAL SPECULUM

21. PERCUSSION HAMMER

22. VAGINAL SPECULUM

23. PRCOTOSCOPE

24. WATCH

25. SCALE WITH HEIGHT MEASURE

26. SNELLEN CHART

27. PULSE OXYMETER

28. COMMUNITY BAG

29. COTTON BALL

30. COTTON APPLICATOR

31. LUBRICANT

32. DISPOSABLE NEEDLE & SYRINGE

33. GAUZE, BANDAGES

34. PAPER TISSUE

35. SPECIMEN CONTAINER

36. PRE-PROCEDURAL STEPS Prepare yourself Prepare environment Prepare the client Psychological preparation of client like—Remain calm ,Explain each procedures, Allow client to feel free to ask questions and mention any discomfort, give comfortable position like—sitting, prone, supine, knee chest, lithotomy etc.

37. Hand hygiene Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.g., name and date of birth ). Use appropriate listening and questioning skills. Listen and attend to patient cues. Ensure patient’s privacy and dignity . Make patient comfortable. Ensure working condition of equipment. Check vital signs.

38. PROCEDURE STEPS

39. IDENTIFICATION INFORMATION Full name ---- Age ---- Gender ---- Father name ---- Mother name ----- Education status ----- Caste & religion ---- Address ---- Occupation ----- Health problem ----

40. EXAMINATION HEAD TO TOE

41. GENERAL APPEARANCE:- Nourished – well nourished/ undernourished Body build—thin/obese Activity—active/dull Look—anxious/worried/happy

42. HEAD & FACE:- Shape of skull—round in shape/oval/flat/any injury/any suture Scalp—cleanliness/hair condition/dandruff / pediculi /infection like ringworm Shape & colour of hairs or any other. Face— colour like pale /flushed / puffiness /fatigue /pain /fear/anxiety/enlargement of parotid gland etc.

43. MOUTH Lips—normal (pink or moist ) /abnormal (swelling / crusts/cyanosis/redness/angular stomatitis ) Odour of mouth—foul smelling or other type smelling Mucus membrane & Gums—ulceration and bleeding/swelling /pus formation /gingivitis /tongue pale or dry/any lesions/ sores/ furrows/ tongue tie / coated Throat & pharynx—enlarged tonsils/redness/pus Teeth—normal/plague/tarter/dental caries/pyorrhea/any other

44. TONGUE FURROWS-TOUNGE TIE

45. TONSILS --- TARTER TEETH

46. PYORRHEA --- GINGIVITIS

47. EYES Eye brows—normal /absent Eyelashes—infection/sty Eyelids-- oedema / lesion/ ectropion ( eversion )/ entropion (inversion) Conjunctiva—pale/red/purulent Eye ball—sunken/protruded Sclera—jaundiced Fundus —congestion/hemorrhagic spots Eye muscles—strabismus(squint) Lens—opaque/transparent Cornea—normal/abnormal Pupils – dialted /constricted/reaction to light Vision—normal / myopia/ hypermetropia / any other/ lacrimal obstruction.

48. INVERSION EVERSION

49. NOSE External nares —crusts or discharge Nostrils—inflammation of the mucus membrane/ septam deviation.

50. NECK Lymph nodes—enlarged and palpable Thyroid gland—enlarged Range of motion—flexion/ extention and rotation

51. LYMPH NODES

52. EAR Discharge / cerumen obstruction / perforation/ fungal infection / any other specify Hearing—normal / abnormal

53. PERFORATION OF EAR

54. SKIN Colour —pallor/jaundice/cyanosis/flushing etc. Texture—dryness/flaking/wrinkling or excessive moisture Temperature—warm/cold and clammy Lesions— macules /papules/vesicles/wound pastule /any other abnormally specify  

55. FLUSHING SKIN

56. FLAKING SKIN

57. NAILS Normal/clubbing/fungal inection /brittles nails/soft/whitish/any others specify

58. BRITTLE NAILS – FUNGAL NAILS

59. EXTREMITIES Movements of joints/tremors/clubbing of fingers/ankle oedema /varicose vein/reflexes

60. ANKLE OEDEMA—VERICOSE VEIN

61. ABDOMEN Skin rashes /scar /hernia / ascitis / distension /palpable spleen/tenderness/presence of gas/fluid or masses present

62. POSTURE Body curve— lardosis / kyphosis /scoliosis Back— spina bifida/curves Gait—normal/abnormal

63. CARDIOPULMONARY SYSTEM Cough/wheezing/crackles/tachycardia/ bradycardia /palpitation/cardiac murmur/any other specify

64. GASTROINTESTINAL SYSTEM Normal/diarrhea/constipation/ulcer/nausea/vomiting/acidity/spasm/abdominal distention/bowel movements/any other

65. FUNDAMENTAL SIGNS Height Weight Temperature Pulse/heart rate(per minute) Respiration(beats per minute) Blood pressure(mm/hg)

66. ACTIVITIES OF DAILY LIVING PERSONAL HYGIENE HABITs Bathing pattern—daily/alternate/no fix/less frequent Water preference for bathing—hot/cold/lukewarm Oral care—one time in a day/morning and evening/more frequent Oral care method—uses finger cleaning/toothbrush/ neem stick Oral care content—use paste/powder/charcoal

67. SLEEPING PATTERN Type of sleeping—sound /disturbed No. of sleeping hours—at night/during day  

68. ILL HABITS Smoking—yes/no if yes-no. of cigarette/ Biri per day Drinking—yes/no, if yes, habitual/social/occasional/addicted/ Chews(tobacco)—yes/ no,if yes, specify brand Any other habit affecting health

69. NUTRITIONAL HABITS Like/dislike of food Food pattern— veg / nonveg / eggtarian Frequency in a day Appetite—good/moderate/poor Any other important information about nutrition

70. ELIMINATION ACTIVITIES Bowel pattern—no. of bowel movement/day Any other difficulty (as constipation,diarrhea ets ) Urinary pattern— friquency of micturition times/day or times/night any other difficulty (as nocturia,dysuria,incontinence etc)

71. REPRODUCTION (FOR FEMALE ) Menstruation—regular/irregular/ dysmenorrhoea If amenorrhea LMP If abnormal, specify sexual disorder/dysfunction

72. FOR MALE Lesions, pain, prostate problems, infections, discharge, testicular pain Pubic region: Assess for normal hair distribution and presence of body lice and see any tenderness, masses present in pubic region. Penis: identified if patient circumcised or uncircumcised. If uncircumcised , ask the pt to retract the foreskin himself

73. Contd.. Palpate the testes for tenderness or masses testes are normally equal in size, however when the male is standing, it is normal for one testicle to be lower in the scrotal sac than the other. Observe the penis and testes for any lesions or rashes.

74. LABORATORY INVESTIGATION/CLINICAL DIAGNOSTIC REPORT Description of the investigation TREATMENT REPORT Description of the treatment

75. PERSON HEALTH CONDITION(ON THE BASIS OF PHYSICAL EXAMINATION,DIAGNOSIS AND TREATMENGT HISTORY)

76. POST PROCEDURAL STEPS Record findings and assessment performa Make patient comfortable Replace all articles back in utility room after cleaning and disinfection Give relevant health education according to history and physical assessment.

77. NURSING RESPONSIBILITIES Provide the psychological support to the patient Provide comfortable position Identify the patient for the procedure Take care of all articles before examination check all articles are working correctly or not Provide comfortable environment to the client like- light, temperature etc. Maintain privacy for the patient Provide health education to the patient

78. CONCLUSION Physical Examination is important for everyone. It is an assessment in which we judge the physical quality of the person. It is an evaluation in which we detect a disease in the person who look and feel well by taking a physical exam . The technique of assessment involves inspection, palpation, percussion and auscultation.

79. Evaluation/recapitalization Define the physical examination Explain the purposes Discuss the indications Enlist the articles Discuss the pre-procedural steps Explain the procedure Discuss the post procedural steps Discuss about nursing responsibilities

80. Bibliography Ghai Sandhya , Textbook of Clinical Nursing Procedures, CBS Publishers & Distributors Pvt. Ltd., Page No. 204 to 212