Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide Chapter Two: The Physical Examination Experienced clinicians will perform each physical exam in approximately the same order every time. This consistency will ensure that relevant information is not forgotten. Typically, a clinician will assess the skin, neurological, and musculoskeletal systems first, since these systems affect all parts of the body. Often, the clinician will then continue the assessment from the top of the head to the feet; hence, the term “head to toe assessment.” The physical exam may include any or all of the following techniques. When more than one technique is required, the techniques should be performed in this order: • Inspection: Looking at the body or body part • Auscultation: Listening to the sounds the bodymakes • Percussion: Tapping on body parts to hear the tympani or dullness produced by the presence of gas, fluids, or solid masses • Palpation: Pressing on the body part to feel masses or body organs 2.1 Skin Equipment needed for the skin exam includes a ruler to measure any lesions and a magnifying glass to closely examine any lesions. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.). • Wash hands before starting the exam, any time the hands or gloves become soiled, and upon completion of the exam. • Provide a quiet, well-lit, and private place for theexam. • Ensure that the examination room is warm, since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about presence or history of: o Family history of skin disorders o Itching o Lesions or unexplained bruising o Use of lotions o Change in skinmoisture o Change in skin turgor o Contact with any environmental allergens (poison ivy, paints,etc.)

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