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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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Presentation Transcript
indications for the physical exam
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
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
skills of physical assessment
Skills of Physical Assessment
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
  • Olfaction
utilization of assessment skills
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
preparation of client and environment
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
organization of exam
Organization of Exam
  • Exam should follow organized and systematic format
    • Why?
  • All physical and emotional findings should be recorded as soon as possible
    • Why?
helpful guidelines for examination
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
types of examinations
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