Quality Nursing Mgt - Patient Assessment
PATIENT ASSESSMENT
- It provides objective information about the person which is essential in the nursing process.
Methods of Examinations: (IPPA)
• INSPECTION - assessing by using the sense of sight. - used to assess: color, rashes, scars and body structures.
• PALPATION – assessing by the use of touch. - used to assess: texture, temperature, vibration, position, mobility of organs, distension, peripheral pulse, tenderness and pain.
• PERCUSSION – tapping body parts to produce sounds. - used to determine: characteristics of tissues, borders of internal organs. - used to elicit: flatness, dullness, resonance, hyper-resonance and tympany.
Resonance – Loud, long low-pitched sound heard over hollow structures such as the lungs and abdomen. Hyperresonance – Loud, very long sound, lower pitched than resonance, heard over areas such as overaerated lung tissue found in COPD. Hyperresonance sound lies between tympani and resonance. Tympany – High-pitched, loud sound of medium duration heard over the stomach or gastric bubble. Dullness – Medium-pitched, slightly louder than a flat sound heard over solid organs such as the heart, liver, or a distended bladder. Flatness – Soft, high-pitched, short sound heard over bone and muscle.
• AUSCULTATION – listening to body sounds by the use of stethoscope. - used to assess: breathing sounds, cardiac sounds and abdominal sounds.
* When assessing the Abdomen, the following sequence is: (IAPerPal) Inspection, Auscultation, Percussion and Palpation. The main reason that auscultation proceeds palpation is to prevent distortion of the bowel sounds.
A. VITAL SIGNS:
1. BODY TEMPERATURE -Balance between the heat produced by the body and the heat loss from the body. 1. Core Temperature - deep
- It provides objective information about the person which is essential in the nursing process.
Methods of Examinations: (IPPA)
• INSPECTION - assessing by using the sense of sight. - used to assess: color, rashes, scars and body structures.
• PALPATION – assessing by the use of touch. - used to assess: texture, temperature, vibration, position, mobility of organs, distension, peripheral pulse, tenderness and pain.
• PERCUSSION – tapping body parts to produce sounds. - used to determine: characteristics of tissues, borders of internal organs. - used to elicit: flatness, dullness, resonance, hyper-resonance and tympany.
Resonance – Loud, long low-pitched sound heard over hollow structures such as the lungs and abdomen. Hyperresonance – Loud, very long sound, lower pitched than resonance, heard over areas such as overaerated lung tissue found in COPD. Hyperresonance sound lies between tympani and resonance. Tympany – High-pitched, loud sound of medium duration heard over the stomach or gastric bubble. Dullness – Medium-pitched, slightly louder than a flat sound heard over solid organs such as the heart, liver, or a distended bladder. Flatness – Soft, high-pitched, short sound heard over bone and muscle.
• AUSCULTATION – listening to body sounds by the use of stethoscope. - used to assess: breathing sounds, cardiac sounds and abdominal sounds.
* When assessing the Abdomen, the following sequence is: (IAPerPal) Inspection, Auscultation, Percussion and Palpation. The main reason that auscultation proceeds palpation is to prevent distortion of the bowel sounds.
A. VITAL SIGNS:
1. BODY TEMPERATURE -Balance between the heat produced by the body and the heat loss from the body. 1. Core Temperature - deep