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Physical Assessment

Physical Assessment. Indications for the Physical Exam. 1. Routine screening 2. Eligibility prerequisite for health insurance, military service, job, sports, school 3. Admission to a hospital or long term care facility. Physical Exam and Health Assessment.

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Physical Assessment

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  1. Physical Assessment

  2. Indications for the Physical Exam 1. Routine screening 2. Eligibility prerequisite for health insurance, military service, job, sports, school 3. Admission to a hospital or long term care facility

  3. Physical Exam and Health Assessment • A complete health assessment includes both nursing history and physical exam • Information gathered in both the health history and physical exam serves provides a baseline of the client’s functional abilities

  4. Skills of Physical Assessment • Inspection • Palpation • Percussion • Auscultation • Olfaction

  5. Utilization of Assessment Skills • We utilize our assessment skills to: • Gather a database (baseline) • Confirm and identify nursing diagnoses • Make clinical judgments about a client’s changing health status • Evaluate the effectiveness of nursing care

  6. Preparation of Client and Environment • Exam room needs to be well lit and and noises limited or eliminated • Equipment should be within reach and working properly • Client should be prepared with appropriate draping • Client’s dignity, privacy, and comfort should be maintained • Client should be given appropriate explanations and directions before and during exam

  7. Organization of Exam • Exam should follow organized and systematic format • Why? • All physical and emotional findings should be recorded as soon as possible • Why?

  8. Helpful Guidelines for Examination • Compare both sides for symmetry • If client is seriously ill, first assess systems of the body more at risk for being abnormal • If client becomes fatigued, offer rest periods of rest • Record results of exam in specific anatomical and scientific terms • Use common, accepted abbreviations, keep notes brief and concise • Record quickly to avoid keeping client waiting • May use standardized form to record findings in the same sequence that it was gathered

  9. Types of Examinations • Head to Toe exam • A complete physical • Often done on an initial visit to hospital or doctor’s office- serves as a baseline • Head to toe exam includes an assessment of systems • Systems assessment • Used more on a day to day basis w/ hospital clients • Focus is on a particular system that may be affected by pathology • Systems assessment • Guides questioning • Provides clues of related pathology • Example: Pneumonia- exam lungs, breath sounds and any other system affected by poor oxygenation

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