Basic Physical Assessment Head-to-toe assessment Major body systems assessment. Purpose. Gather baseline data Supplement, confirm, or refute data in nursing hx Confirm and identify nursing diagnosis Make clinical judgments about changing status Evaluate the physiological outcomes of care.
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S1: Lub: mitral valve closure
S2: Dub: Aortic valve closure
pretibial area & medial malleolus for 5 seconds
1+ to 4+
heard primarily when the pt exhales
Epigastric, umbilical, suprapubic
-Density of abdominal contents
-Screen for abnormal fluid or masses
Tympany – predominantly over the abdomen – gas-filled
Dull over organs in the abdominal cavity (liver, spleen)
CVA tenderness Costovertebral AngleCVA tenderness – positive in pyelonephritis