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Discuss the purposes of physical assessment.
• The purpose of a physical assessment for routine screening to promote wellness behaviors and preventive health care measures; to determine eligibility for health insurance, military service, or new job; and to admit to a hospital or long-term care facility. This will do the following: to gather a baseline data about the client’s health status supplement/confirm/refute data obtained in the history, confirm and identify nursing diagnoses, make clinical judgments about a client’s changing health status and management, and evaluate the outcomes of care.
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List techniques used to prepare a client physically and psychologically before and during an examination.
• For an examination, proper preparation of infection control, environment, equipment, and physical preparation of a client is the key to success. Under infection control, you need to wear gloves, gown, and other personal protective equipment, and follow hand hygiene policies. With the environment, privacy is required with a well-equipped room like good lighting, soundproof, warm for comfort, help off the table, give a pillow, raise head of table about 30 degrees, and raise bed to make easy to examine. For equipment, check for proper function, keep it available, in order, warm, rub stethoscope before applying to skin, run warm water over the vaginal speculum, if tools require batteries or light bulbs make sure they work good. Finally, prepare client by asking if they need to use the bathroom, collect urine or specimen while going to the bathroom. Also make sure the client is dressed and draped properly and give privacy when undressing and make sure the client stays warm and routinely ask if the client is comfortable. If you need to examine in a different position, explain them the position and adjust the drapes so no body parts are exposed. Constantly, explain terms and purpose and for them to ask questions when they don’t understand. If client is of opposite gender, have a third party in the room of that gender to make them comfortable.
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History and Physical
- • direct the H&P toward the client, not the disease
- • use the data to critically think about a plan of care for this client
- • use data gained to recognize a change in status and modify therapies
- • use physical exam to make evaluations on care given
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Physical Assessment Skills
- • Inspection
- • Palpation
- • Percussion
- • Auscultation
- • Olfaction
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Tool of the Trade
- • Infection Control
- • Environment
- • Equipment
- • Physical prep of the client
- • Psychological prep of the client
- • Age-specific care
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Exam Organization
- • Head to toe
- • Body system
- • compare both side
- • address presenting complaint first
- • palpate what hurts last
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General Survey
- • general appearance and behavior
- • vital signs
- • height, weight, circumference
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Vascular System
- • blood pressure
- • carotids
- • jugulars
- • peripheral system
- • lymphatic system
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Breasts
- • inspection
- • palpation
- • male breasts
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Abdomen
- • inspection
- • auscultation
- • (percussion)
- • palpation
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Female Genitalia
- • client preparation
- • external genitalia
- • speculum exam
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Male Genitalia
- • penis
- • scrotum
- • inguinal ring/canal
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Musculoskeletal System
- • general inspection
- • palpation
- • range of joint motion
- • muscle tone and strength
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Mental and Emotional Status
- • level of consciousness
- • behavior and appearance
- • language
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Intellectual Function
- • memory
- • knowledge
- • abstract thinking
- • association
- • judgment
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Neurological System, Continued
- • cranial nerves
- • sensory function
- • motor function
- → coordination
- → balance
- • reflexes
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