Nursing Physical Assessment: A Comprehensive Guide - Prof. D. N. Noble, Assignments of Nursing

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Physical Assessment

Part One

Lisa Moore DNP, RN

Nursing Assessment

Identify needs, preferences, and ability of the patient

Nursing assessment includes:  Interview, observation, symptoms, verbal and nonverbal communication, medical and social history, other info about patient

Nursing Assessment

Physical  Vital signs, skin color and condition, consciousness, motor and sensory nerve function, nutrition, sleep, elimination

Psycho/Social  Family and support, occupation, mood and emotional tone, health beliefs, and religion or spiritual views

Types of Assessment

Comprehensive - Admission H & P

Ongoing - usually once per shift

Focused – evaluate specific problem

Emergency - ABC’s, ensure survival

Components of the health assessment

Health history - subjective

Physical assessment - objective

Health History  (^) Chief concern or reason for seeking healthcare  Demographic information  (^) History of present health concern  (^) Health history -  (^) medical hx, meds, allergies, effect of illness on lifestyle/ADL’s  (^) Family history  (^) Psychosocial & Lifestyle history  (^) support network, coping mechanisms, smoking, drinking, nutrition, sleep habits, exercise, mental health, etc)  (^) Spiritual health  Review of systems (ROS)

Preparation for the exam

Enter the room and wash your hands before gloves

Use standard precautions for all patients

Make sure patient is comfortable

Two patient identifiers

Name

Medical Record Number

Respect privacy

Organized approach to exam 

Systematic



Head-to-toe

Introduction

Hello Mr (s)________. My name is _________________ and I am an ACC nursing student. I am here to do a physical assessment. How are you feeling this morning?

Successful Nurses

Look Listen Touch

Inspection

Looking or observing

Color, shape, size, symmetry, position and movement

Good lighting is very important

Stethoscope Tips  (^) Earpieces tilted towards nose  (^) Diaphragm for high pitched sounds:  (^) normal heart, lung, & bowel sounds  (^) Bell for low pitched sounds:  (^) Heart murmurs  (^) Clean between patients!  (^) Warm it up for patient comfort

Palpation

Assessment through touch

 Temperature, moisture,

texture, tenderness,

masses, and edema

May be light or deep, one

hand or two

 Make sure your hands are

clean and fingernails short!

Gloves

Checking Skin Turgor Potter & Perry, 9th^ ed, Figure 31-

Edema

Potter & Perry, 9th^ ed, Fig 31-