Assessment Of patient.

Physical Assessment.

Assessment is a very important component in nursing services. Observation is necessary for assessment Observation means planning nursing care by collecting patient information.

Assessment is the first step in the nursing process in which the needs of the patient are found out using certain types of tests and different resources.

The patient’s data is collected and the information related to his family history and his community is scutinized and analyzed to plan the nursing care for the patient.

Assessment of the patient’s health status and accurate observation is the nurse’s responsibility.

Importance Of Observation. Importance of Observation.

The mental, physical, social and spiritual condition of the patient can be known.

If there is any changes or improvement in the patient’s condition, it can be known through observation.

Accurate observation helps the physician in the diagnosis and treatment of the patient.

The cause of the patient’s illness can be known through observation.

Maximum benefit and comfort can be provided to the patient in his care.

Skillful observation can be used to plan nursing care.

The data obtained through observation can know the causes of life and death of the patient and can save the life of the patient.

By observing the symptoms of the complications caused by the disease in advance, it can be prevented.

Observation is also necessary to prevent accidents and to maintain safety measures.

Appropriate health teaching can be given to the patient and his relatives through observation skills.

Nurses can also increase their knowledge with the help of observation and observation and related data are very useful for research.

One can also analyze their services by making careful observations.

Accurate observation can be done through our sense organs like eye, nose, ear, taste, smell, touch etc.

Physical Examination.

Definition.
A detailed inspection or study of the physical and psychological condition of the patient is called physical examination.

Examination to know the general physical condition or function of any part of the body through detailed inspection is called physical examination.

Purposes of Physical Examination.

To know the physical and mental well being of the patient.

To know the cause of the disease and the prognosis of the disease…
For diagnosis of disease in early stage.

It can be known how much the patient’s condition has improved and how bad the condition has become.

What kind of treatment and what kind of nursing care to give to the patient can be planned.

It can be known whether the patient is medically fit for any work.

For people who are healthy, use health-preserving procedures, such as self-breast examination.

Methods of Physical Examination. What are the methods of physical examination?

Inspection.

In this method, the general condition of the patient is known from the observation of his body, which means that the general appearance of the patient is seen, such as what is the color of the patient’s skin, whether there are any rashes on the skin or not, if there is any difference in the body, it can be checked. A history of the patient can also be taken.

In the inspection, the doctor listens to all the complaints of the patient and the history is written accordingly, so the history of the patient’s illness and the present complaint and body function can be known through this method.

Palpation.

Palpation is a manual examination in which a part of the body is touched, pressed, felt and examined.

Fingers are used for palpation.

Abdomen organ size and its position can be known by palpation.

Apart from this, it can be known if there is any tumor or tumor in the neck.

Tenderness anywhere in the axilla, groin or extremity can be checked.

Percussion.

In this method the hand of the patient’s body is placed on the part of the KVT and with the help of the other hand tapping on it with the fingers.

By listening to the sound of the internal organ through tapping, information related to it can be gathered and the condition of the internal organ’s KKVT can be understood.

Whether the patient’s bladder is full or not can be known by percussion and examination of the chest cavity, abdomen, menial cavity and back can be done by percussion.

Auscultation.

In this method, the sounds inside the body are listened to with a stethoscope or phetoscope, while heart sounds and lung sounds are heard from the chest cavity.

Also intestinal sounds can be heard from the abdominal cavity.

This method is also used for blood pressure measurement.

Manipulation.

This method is used to know the flexibility of the organ.

As the net is moved to check if the neck is rigid or not.

An idea of ​​its normal condition can be obtained by the moment of the extremity as the action of flexion and extension is performed.

Special Equipment.

For physical examination some special equipment is used through which special area can be examined.

As ear can be examined through otoscope.

The eye can be examined through an ophthalmoscope.

Indication of Physical Examination.

At the time of admission.

Before and after any diagnostic and therapeutic procedure.

At discharge

When the patient follows up.

When there are camps related to health.

Nurses Responsibility During Physical Examination.

A complete physical examination of the patient’s body is done to diagnose any disease the patient is informed about and mentally prepared for.

A nurse has many responsibilities in physical examination such as preparing the patient, preparing the necessary equipment, knowing the information related to the patient’s disease, etc.

First is to inform the patient that the doctor is about to be examined.

If the patient has his own separate room then a bed screen should be placed around the patient’s bed to close the windows and doors and if the patient is admitted to the general ward.

Asking relatives to leave during physical examination of the patient.

During the examination, the necessary instruments and equipments for the doctor should be kept ready in the tray.

Before the doctor comes to examine the patient, the nurse should know all the information related to the patient’s disease, related investigations, vital signs, etc. and should tell the doctor.

Exposing the part of the patient’s body to be examined Covering the adjacent part with a cloth.

There should be sufficient light in the room during the examination, if there is no adequate light then proper light should be given by torch.

The examination room or unit should be kept clean and tidy and should be at a normal temperature.

A nurse should remain with the patient during physical examination of any female patient.

When examining the male patient’s private parts, vet outside after proper preparation by the nurse.

Keeping the patient in a suitable comfortable position during the procedure of examination and also giving suitable position for examination.

During the examination, providing necessary equipment and materials to the doctor and giving information where necessary.

Physical Examination Tray.

For physical examination a large tray is taken in which all the following instruments are kept.

Torch. To examine the mouth, eyes, ears, nose and other body parts.

Gloves. Certain types of examinations require sterile gloves to prevent cross infection.

Tongue depressor. Depress the tongue to visualize the back of the mouth examination of the KVT.

Laryngoscope. For examination of larings and rings.

Tuning fork. It is used for ear examination as well as to conduct a hearing test in which hearing examination is performed by vibrating the mastoid bone near the frontal bone.

Measure tap. Abdominal CVT, thoracic CVT and head circumference are measured with the help of this tape. Apart from this length can also be measured by Ana.

Stethoscope. It is used to listen to body sounds.

Sphygmomanometer. It is used for blood pressure measurement.

Hammer. It is used for joint examination, muscle tone and neurological examination.

Otoscope. To examine the inside of the ear.

Nasal speculum. The nose can be used to examine the inside of the KVT.

Ophthalmoscope. This equipment is not used to examine the inside of the eye.

Vaginal Speculum. It is used for examination of vaginal CVD in females.

Proctoscope. It is used to examine the rectum and its internal structures.

Lubricants. Vaseline is used for lubrication of articles or instruments before use.

Swab stick. This stick is used to collect pus, serum or any other sample during physical examination.

Cotton swab. To clean some area or part during examination.

Test tubes and slides. A test tube or slide is useful for collecting samples taken during physical examination.

Lotion bowl. To clean hands after examining the doctor.

Small napkin. To dry hands after cleaning hands.

TPR tray. To check vital signs like temperature pulse and respiration.

Preparation of the patient.

Psychological Preparation.

Explain the procedure in detail to the patient to alleviate his anxiety and fear.

Explain all the steps of the procedure so as to win the patient’s trust and cooperation.

Staying with a female patient during physical examination can win her trust.

Physical preparation.

The patient should be clean and the part saved as needed.

Giving the patient a comfortable position so that it is easy for the doctor to examine.

Empty the patient’s bladder before starting the physical examination.

Before the examination, if necessary, the patient’s bowel should also be emptied.

When the doctor starts the examination, keep the patient properly covered to open only the necessary parts.

Procedure of Physical Examination.

At the beginning of the physical examination, the doctor talks to the patient for a few minutes so that the patient’s fear can be removed and the patient can also be observed.

Physical examination is done according to the sequence in which head, eye, ear, nose, throat, mouth, neck etc.

To remove the upper part of the patient’s clothing for examination of the chest and breast.

The nurse should cover the patient’s chest when the doctor is doing the examination of the mind.

A nurse holds a towel over the patient’s chest while the doctor performs a back examination.

The lower extremity is examined by lifting the lower portion of the blanket up to the pubic region.

In the examination of the hand, the condition of the skin and the part of the nails are checked.

Examination of the patient’s private parts is done as per requirement, for this the patient should be given a comfortable position.

Care of Patient and Articles.

Helping the patient get dressed after the procedure is over and getting back into a comfortable position in bed.

Clean and dry used instruments with soapy water and sterilize necessary articles.

Put all the equipment in its place.

If any specimen is collected, it is properly labeled and immediately sent to the laboratory for examination.

Developing skill in observation.

Observation requires perfect concentration What is to be observed and its meaning and how it is recorded are important matters during observation.

The skill of observation can be developed through systematic and regular practice.

Observation shows normal body functioning, human behavior and abnormal changes.

It is necessary to have accurate knowledge for observation. Senses like hearing, touching and smelling and vision skills can be used to assess the patient’s health and investment.

Methods of Observation.

Observation can be done using any of our four senses, seeing, hearing, and touching.

In addition to this sense one should have an understanding of what to observe while observing the patient following points should be kept in mind.

What is to be observed is to be observed and what is to be found out.

What is the normal structure and normal function of the body, it is very important to know the normal data from this normal.

Observation should be done from head to toe to get complete information.

Specific and objective observations should be made as long as necessary.

Observation is a continuous process and it is very important to record its findings properly and accurately.

Accurate and meaningful observation can be made by correct use of sense organs viz.

Sight. Special expressions, color of the skin and mucus membrane, condition of the wound, lesions, discharge from the body cavity etc. can be seen.

Smell. Odor of any medicine, discharge from body cavity, discharge from wound, odor during breathing and vomiting etc. can be known by sense of smell.

Hearing. There is a sense of listening to the patient’s voice, breathing sound, sneezing, coughing, crying, etc.

Touch. Chest movement, irregularity of pulse, smoothness of any structure, hardness or its alarm, dryness, hotness or coldness etc. are known by touch.

Principal of Observation.

Sound knowledge helps the nurse make comprehensive observations.

Observation should always be purposeful specific and well planned.

Observation should always be systematic.

Notes made during observation should always be systematically recorded so that it can be obtained in the form of base line data.

Role of Nursing Observation.

As the nurse stays with the patient 24 hours a day, she can observe the changes in the patient well.

The nurse can observe any changes in the patient’s habits or any subsequent changes through the habit of observation.

Its records are helpful in diagnosis and treatment in medical and surgical nursing.

Observation techniques depend on habit, knowledge, interest, attention and sympathetic understanding.

Observation of Common Signs and Symptoms.

Sign.
A sign means changes or signs in the patient’s body that can be verified or seen. Like vital sign, swallowing, cyanosis, AD etc.

Symptoms.
Symptoms are the symptoms that the patient experiences and tells us in the form of a complaint that we cannot see or verify such as pain, headache, nosia etc.

Main subjective symptoms.

Pain and Tenderness.
Pain can be continuous or intermittent, gradually or sharply increasing.

Pain has characteristics of dull, acute or sharp depending on its nature.

Pressure on this painful part which causes pain with stiffness is called tenderness.

Emotion.
Emotion means feeling. The nurse should also assess the patient’s emotional status while assessing the patient. During that emotional disturbances are seen.

Other Sensation.
Other sensations include sight, smell, hearing, touch and taste.

Apart from this, symptoms related to temperature, hunger, thirst, equilibrium etc. are also included.

Main Objective Symptoms.

Hair and Scalp.

Hair should be clean, shiny, thick or thin, soft or dirty, free form pediculi etc.

The scalp should be observed for a clean rash or any infection.

Face.
By observing the patient’s face, many things come to mind.

Pale face, jaundice, cyanosis, swelling on the face, recesses on the face, one, can be known if there is any kind of injury.

Apart from this, pain, stress, depression, fatigue etc. can also be noted from the expression of the face.

Eye.
While observing the eye, eyebrow, eye lasis, pupil, eye lead, eye muscles, etc. are observed.

Any kind of discharge or secretion should be seen around the eye.

The size of the pupil should be checked whether it is dilated or constricted.

Checking the patient’s vision including double vision, loss of vision or photophobia etc.

Jaundice, sunken eye, redness, infection, etc. can be known by looking at the eye’s color, size and shape.

Mouth and Throat.

While performing the examination of the mouth and throat, the first step is to check the condition of the lips for redness, swelling or chapping, and for dryness.

To check if there is any kind of bad smell coming from the patient’s mouth.

Checking the condition of the tongue, whether the tongue is clean, moist, dry, swollen, fissures or ulcers etc. Also check for coated tongue if there is a white coating on the tongue.

To check the condition of the teeth in which it is natural or artificial, to see whether there is dental caries or not, to see whether the teeth are loose or strong and to check whether there is any complaint of pain in the teeth etc.

Apart from this, checking the condition of the mucus membrane of the mouth including any ulcers or bleeding.

Checking whether the patient’s respirations are odorless or foul smelling. Also check for alcoholic smell.

Checking for redness in the throat and size of tonsils and infection.

Nose.

One should know whether one can breathe easily through the nose, whether there is bleeding or any other kind of discharge from the nose, whether there is any problem in the sensation of smell.

Ear.

Also checking whether the ear can be heard clearly, whether there is any wax deposit in the ear or any discharge coming from the ear.

It should be observed whether there is a problem in the yearning sensation or not, besides checking whether there is any ulcer or infection or pain in the inner ear canal.

Neck.

To check for any tumor, swelling, ulcer etc. in the throat area.

To see if the movement of the neck is normal or the movement is restricted.

Observing whether the neck vein is prominent or not.

Chest.

Checking the size and shape of the chest for any type of abor line.

Observation of chest movement during cuffing and breathing.

Breast.

Checking for any type of growth or lump in the breast.

Check whether the nipple area is normal or inverted.

Apart from this, breast size and shape etc. are checked.

Abdomen.

Checking the size and shape of the abdomen.

To check whether the part of the abdomen is soft or hard, distended or rigid, any kind of tumor or tumor in that part.

To check whether the patient has any difficulty in taking any food.

Check whether there is indigestion or diarrhea or abdominal pain.

Skin.

How is the patient’s skin? Checking the skin for aberrations, ulcers, scratches, wood, scars, recesses, heels or pressure sores.

Check whether the skin is dry or sticky, warm or cold.

Look at the color of the skin, checking for signs of paleness, cyanotic, redness, jaundice, etc.

Asking the history of any previous operative procedure on any part of the skin and checking for scars.

Genitalia.

It is very important to observe the private parts in male as well as female patients for any kind of itching, redness, infection, cleanliness or any kind of discharge in that area.

Extremities.

Checking for size shape and symmetrical position of extremity.

Checking fingernail color and clubbing fingers. Checking the shape and size of the nail part.

Observe the skin in the extremity and notify if any abnormality is found.

Checking the extremity for any tenderness, infection, swelling, tumor or deformity.

Check for varicose veins on legs.

Mental Condition.

To check whether the patient is semi-conscious and also to check whether he is alert, dull, depressed, happy, unhappy, etc.

Checking his emotional reaction.

Taking a history of his relationship with family members

Excretion and Secretion.

If there is urine, stool, vomiting, sputum, vaginal discharge and any other discharge from body or VT, its color amount and other characteristic should be observed.

Physical Assessment.

Physical assessment It can be known from the general appearance of the patient that by giving proper attention, it can be known whether the person has grown and developed accordingly.

Height and Weight.

When a patient is admitted to the hospital, his height and weight are recorded and this data is compared with his age.

In heart and kidney diseases, the patient’s vet is checked every week so that the information about his disease condition can be known.

Posture.

Observation of the posture can give an idea of ​​the patient’s condition, for example neck stiffness is seen in meningitis and tetanus.

Apart from this, slow and lethargic moments are seen in a person with depression.

In posture, the body movement of right side and left side is compared and assessed.

Speech.

What the patient speaks and how he speaks should be observed.

A speech disorder is observed based on how one talks about speech.

A patient’s anxiety can be understood through verbal communication, for example, in such a patient, rapid speech repetition in appropriate language, etc. can be understood through speech.

Dysarthria that results in defective speech due to impairment of the tongue and cheek muscles.

Of aphasia i.e. Impairment in speech and communication ability should also be observed.

Level of Consciousness.

Consciousness is an important observation i.e. the awareness in which the patient is aware of the surrounding environment.

If there is a problem in the level of consciousness, it can be known as any problem of the brain.

Respiratory pattern, pupil size, body movement etc. are checked for evaluation of consciousness.

Changes in this level of consciousness can be identified as lethargic, stupor, semiconsciousness or coma.

Vital Sign.

Body Discharges.

Any fluid that comes out of the body is called a discharge.

This body discharge is collected in the form of a specimen i.e. sample and its laboratory test is done, which gives an idea of ​​the normal condition of the body.

Laboratory test and Specimen Collection.

Any body fluid or discharge collected and sent to a laboratory for chemical or microscopic examination is called a sample or specimen.

Aims of laboratory testing.

In order to make an accurate diagnosis and give proper treatment.

To know the normal function of the body.

To know the progress of the disease.

To know the effect of special treatment and drugs.

To assess the patient’s general health before surgery and anesthesia.

To know whether the patient is fit for operation or not.

Types of Specimens.

Urine
Stool means feces
Vomit
Vaginal secretions
Throat swab
Eye secretion
Wound discharge
Blood
Spinal fluid
Other fluids of the body cvt

It is the responsibility of the nurse to take the sample of the patient admitted in the ward, and it is the responsibility of the nurse to collect the sample, label it properly and send it to the laboratory.

Role and Responsibilities of Nurse in Collection of Sample.

Specimen collection is a very important task of the nurse. The nurse is very important to collect the sample with proper method and deliver it to the laboratory on time.

Preparation of the patient.

Prepare the patient physically and mentally according to the type of specimen to be taken.

When, how, and how much the patient’s specimen is to be taken should be specifically explained.

While collecting specimens, the outer side of the container should not be soiled, otherwise the worker may experience difficulty in handling and infection may also spread.

The container in which the sample is to be collected should be clean unbreakable and should not be damaged at any place.

For culture investigation, the specific sample content for the specific test should be such that the label affixed to the sample is clearly visible.

Most specimens should be collected fresh and early in the morning.

Correct method of collection should be adopted. Specimens should be collected in separate bulbs from the laboratory for some type of investigation.

Apart from this, the hospital has different test tubes for the collection of different samples, as indicated in different colors, the sample should be collected in tubes of proper color.

Collection of urine and stool samples should be avoided during the period of menstrual cycle in female patients or if they have to be collected, they should be collected with proper technique so that they are not contaminated by blood. For this, vaginal tampons can also be used.

Preparation of Equipment.

Different types of bottles and containers are available for sample collection which are selected according to the sample requirement as follows.

A large mouth glass bottle is used to collect the urine sample.

A small glass bottle is used for stool examination.

A large glass bottle is used for 24 hour urine collection.

Glass lidded jars are used to collect sputum and stool.

A sterile test tube or bottle is used for culture examination.

A clean slide is used to make the smear.

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