體格檢查概論課件

體格檢查概論ppt課件匯報(bào)人：xxx20xx-03-15體格檢查基本概念與目的常見體格檢查方法介紹全身各系統(tǒng)體格檢查要點(diǎn)特殊人群體格檢查注意事項(xiàng)體格檢查結(jié)果分析與報(bào)告撰寫體格檢查中常見問題及解決方案目錄CONTENTS01體格檢查基本概念與目的定義體格檢查是指對人體形態(tài)結(jié)構(gòu)和機(jī)能發(fā)展水平進(jìn)行檢測和計(jì)量，包括運(yùn)動史和疾病史詢問、形態(tài)指標(biāo)測量、生理機(jī)能測試、身體成分測定以及特殊檢查等多個(gè)方面。分類體格檢查可以根據(jù)不同的目的和對象進(jìn)行分類，如常規(guī)體格檢查、職業(yè)體格檢查、運(yùn)動體格檢查等。體格檢查定義及分類了解受檢者身體形態(tài)、機(jī)能和健康狀況，發(fā)現(xiàn)疾病的早期跡象和潛在的健康問題，為疾病的預(yù)防、診斷和治療提供依據(jù)。目的體格檢查是健康管理的重要組成部分，通過定期檢查可以及早發(fā)現(xiàn)疾病的跡象，避免病情惡化，同時(shí)及時(shí)糾正不良的生活習(xí)慣，保持健康的生活方式。意義體格檢查目的與意義以下附贈各項(xiàng)管理制度英文版（不需要可刪）急救藥品、器材管理制度:1.Rescuedrugsandequipmentshouldbe"fivefixed"(fixedquantityandvariety,designatedplacement,designatedpersonstorage,regulardisinfectionandsterilization,regularinspectionandmaintenance)and"twotimely"(timelyinspectionandmaintenance,timelyreceiptandsupplementation).Theitemisclearlymarkedandcannotbeusedarbitrarily.2.Thenecessaryrescueequipmentiscomplete,ingoodperformance,andinstandbycondition.3.Therescuedrugsarecomplete,withcleardruglabelsandnodiscoloration,deterioration,expiration,ordamage.Theyshouldbeplacedandusedintheorderofdrugexpirationdates(fromrighttoleft).4.Emergencydrugsanditemsforeachdepartment'srescuevehicleshallbeuniformlyequippedaccordingtorequirements.Specializedemergencydrugsanditemsmustbereviewedandapprovedbythedepartmentdirectortodeterminethetype,quantity,specifications,anddosagetobeequipped.Rescuevehiclesmustbeplacedindesignatedlocationsandmanagedbydesignatedpersonneltoensuresafetyandeaseofuse.5.Afterusingrescuedrugsandequipment,theyshouldbefullyreplenishedwithin24hours.Iftheycannotbereplenishedduetospecialreasons,theyshouldbenotedonthehandoverregistrationformandreportedtotheheadnurseforcoordinationandresolutiontoensuretimelyuseduringpatientrescue.6.Thereisaregistrationbookfortheprovisionofdrugsandequipment.Ensureconsistencybetweenaccountsandmaterials,andhandoverbetweenshifts.7.Managementofsealedrescuevehicles:Beforesealing,theheadnurse(ornurseincharge)andanothernurseshallcountthedrugsandequipmentaccordingtotheregistrationbookofdrugandequipmentequipment,verifytheiraccuracy,andsealthemwithaseal.Twopeopleshallsignandfillinthesealingtime.Nurseschecktheconditionofthesealsoncepershiftandcompletethehandover.Theresponsiblenursescheckonceaweek,andtheheadnurseandresponsiblenursesopenthesealsandinspectthedrugsandequipmentintheambulanceonceamonth,withrecordskept.8.Nonsealedrescuevehiclemanagement:Eachshiftshallcountthedrugsandequipmentaccordingtotheregistrationbookandcompletethehandover.Theresponsiblenurseshallinspectonceaweek,andtheheadnurseshallinspectonceeverytwoweeksandkeeprecords,ensuringthattheaccountsmatchthematerials.護(hù)理文書書寫制度:

1.Nursingstaffstrictlyfollowthelatestrequirementswhenwritingnursingmedicalrecords.2.Thecontentofnursingrecordsshouldbeobjective,truthful,accurate,timely,complete,andstandardized.3.Allnursingdocumentsshouldbewrittenwithablueblackorcarboninkpen.4.AllnursingdocumentsshouldbewritteninArabicnumeralsfordateandtime,withdatesinyears,months,anddays,usinga24-hoursystem,specifictominutes.5.WritingshoulduseChinese,medicalterminology,andcommonlyusedforeignlanguageabbreviations;Completerecorditems;Thetextisneat,thehandwritingisclear,andthelayoutisclean;Accurateexpression,fluentsentences,simpleandconcise:correctformatandpunctuation,notypos.6.Whenerrorsoccurduringthewritingprocess,doublelinethemonthewrongwords,keeptheoriginalrecordclearanddistinguishable,signthemodifier,indicatethemodificationtime,continuetowritethecorrectcontent,anddonotusescraping,sticking,paintingorothermethodstocoveruporremovetheoriginalhandwriting.Eachpageshouldbemodifiednomorethantwotimes,otherwisetheoriginalrecorderwillpromptlycopyagain(exceptformodificationsmadebysuperiors).7.Nursingrecordswrittenbyinternnurses,probationarynurses,orunregisterednursesshouldbereviewedandsignedbynurseswithlegalprofessionalqualificationsinthismedicalinstitution.8.Furthertrainingnursescanonlywritenursingdocumentsafterbeingrecognizedbythemedicalinstitutionreceivingthetrainingfortheirworkability.9.Superiornursingstaffhavetheresponsibilitytoreviewandmodifythewrittenrecordsofsubordinatenursingstaff.Whenmakingmodifications,reddoublelinesshouldbeusedtomarkerrors,writethemodifiedcontent,signandindicatethemodificationtime.10.Temperaturerecords,medicalorders,patientcarerecords,andsurgicalinventoryrecordsshouldbearchivedontime.適用范圍體格檢查適用于各個(gè)年齡段的人群，特別是老年人、兒童、孕婦以及患有慢性疾病或特殊疾病的人群。注意事項(xiàng)進(jìn)行體格檢查前，受檢者需要了解檢查的項(xiàng)目和要求，做好相應(yīng)的準(zhǔn)備工作，如穿著寬松舒適的衣服、避免劇烈運(yùn)動等。同時(shí)，在檢查過程中要積極配合醫(yī)生或檢查人員的工作，保持放松的心態(tài)，不要隱瞞病史或癥狀。適用范圍及注意事項(xiàng)02常見體格檢查方法介紹觀察患者面色、表情、體型、姿態(tài)等檢查皮膚、黏膜顏色、皮疹、出血點(diǎn)等觀察各部位器官的形態(tài)、大小、位置等視診法03特殊觸診如胸膜摩擦感、心包摩擦感等01淺部觸診評估皮膚溫度、濕度、彈性等02深部觸診評估臟器大小、形態(tài)、位置及壓痛等觸診法用手指或叩診錘直接叩擊被檢查部位直接叩診間接叩診叩診音判斷以左手中指第二指節(jié)緊貼被檢查部位，用右手中指指端叩擊左手中指第二指節(jié)前端根據(jù)叩診音的變化判斷病變情況，如濁音、實(shí)音、鼓音等030201叩診法將耳直接貼于被檢查部位進(jìn)行聽診直接聽診借助聽診器進(jìn)行聽診，可提高聲音的傳導(dǎo)效果間接聽診包括心率、心律、心音、呼吸音、腸鳴音等聽診內(nèi)容聽診法03全身各系統(tǒng)體格檢查要點(diǎn)意識狀態(tài)顱神經(jīng)檢查深淺反射病理反射神經(jīng)系統(tǒng)檢查要點(diǎn)評估患者清醒程度、反應(yīng)速度等。檢查腱反射、腹壁反射等深淺反射是否存在及是否正常。包括視力、聽力、嗅覺、味覺等感官功能，以及面部肌肉、眼球運(yùn)動等。檢查巴賓斯基征等病理反射是否出現(xiàn)。觀察心前區(qū)隆起與凹陷、心尖搏動、心前區(qū)異常搏動等。心臟視診確定心尖搏動、震顫、心包摩擦感等。心臟觸診確定心臟濁音界有無擴(kuò)大。心臟叩診聽取心率、心律、心音、心臟雜音及心包摩擦音等。心臟聽診心血管系統(tǒng)檢查要點(diǎn)胸部視診觀察胸廓外形、對稱性、皮膚、呼吸運(yùn)動等。胸部觸診檢查胸廓擴(kuò)張度、語音震顫、胸膜摩擦感等。胸部叩診確定肺部叩診音分布及肺界等。胸部聽診聽取正常呼吸音、異常呼吸音、啰音、胸膜摩擦音等。呼吸系統(tǒng)檢查要點(diǎn)腹部視診檢查腹壁緊張度、壓痛、反跳痛、肝脾觸診等。腹部觸診腹部叩診腹部聽診01020403聽取腸鳴音、血管雜音等。觀察腹部外形、對稱性、皮膚、腹壁靜脈、胃腸型及蠕動波等。確定肝濁音界、移動性濁音、腸鳴音等。消化系統(tǒng)檢查要點(diǎn)檢查腎臟腫大程度、質(zhì)地、表面光滑度及有無壓痛等。腎臟觸診確定腎臟叩擊痛是否存在。腎臟叩診評估膀胱充盈程度、觸診膀胱有無壓痛或腫物等。膀胱檢查泌尿系統(tǒng)檢查要點(diǎn)肌肉檢查觀察肌肉外形、對稱性、有無萎縮或肥大，觸診肌肉硬度及有無壓痛等。關(guān)節(jié)檢查觀察關(guān)節(jié)外形、對稱性、有無紅腫或畸形，觸診關(guān)節(jié)有無壓痛或活動受限等。脊柱檢查觀察脊柱生理彎曲是否存在、有無側(cè)彎或后凸畸形等，觸診脊柱有無壓痛或叩擊痛等。運(yùn)動系統(tǒng)檢查要點(diǎn)04特殊人群體格檢查注意事項(xiàng)老年人患病率高，多種疾病并存；起病隱匿，癥狀不典型；病情變化快，易發(fā)生意識障礙；合并癥多，治療矛盾多。重視全面檢查，避免遺漏；詳細(xì)詢問病史，注意癥狀變化；關(guān)注老年人心理健康；合理安排檢查順序和時(shí)間。老年人體格檢查特點(diǎn)與注意事項(xiàng)注意事項(xiàng)特點(diǎn)兒童體格檢查特點(diǎn)與注意事項(xiàng)特點(diǎn)兒童處于生長發(fā)育期，體格檢查需關(guān)注生長發(fā)育情況；兒童疾病種類與成人不同，需注意特定疾病篩查；兒童配合度較差，需耐心引導(dǎo)。注意事項(xiàng)關(guān)注生長發(fā)育指標(biāo)，如身高、體重、視力、聽力等；重視兒童心理行為發(fā)育評估；注意檢查方法和技巧，減少兒童恐懼和不適。孕婦生理狀態(tài)特殊，需關(guān)注母嬰健康；孕期疾病對胎兒有影響，需及時(shí)診斷和治療；孕期檢查項(xiàng)目較多，需合理安排。特點(diǎn)詳細(xì)詢問病史，了解孕產(chǎn)史和家族史；重視孕期營養(yǎng)和健康管理；關(guān)注孕期并發(fā)癥和合并癥的篩查和治療；合理安排檢查時(shí)間和順序，減少孕婦不便。注意事項(xiàng)孕婦體格檢查特點(diǎn)與注意事項(xiàng)05體格檢查結(jié)果分析與報(bào)告撰寫異常情況判斷標(biāo)準(zhǔn)生理指標(biāo)異常如血壓、心率、呼吸頻率等超出正常范圍。形態(tài)結(jié)構(gòu)異常如脊柱側(cè)彎、雞胸、漏斗胸等骨骼結(jié)構(gòu)異常。器官功能異常如肝功能、腎功能等實(shí)驗(yàn)室檢查指標(biāo)異常。神經(jīng)系統(tǒng)異常如肌張力異常、反射異常等。結(jié)合受檢者的年齡、性別、職業(yè)等因素，對各項(xiàng)指標(biāo)進(jìn)行綜合分析。綜合分析對比分析趨勢分析原因分析將受檢者的檢查結(jié)果與正常參考值進(jìn)行對比，找出異常指標(biāo)。對受檢者歷次檢查結(jié)果進(jìn)行動態(tài)觀察，分析指標(biāo)變化趨勢。針對