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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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Guides and directs your physical assessment
Actual or potential health problems
Discharge and referral needs
Use of effective communications skills
Emotional reactionsHealth History
Direct – sinus tenderness
Indirect- lung percussion
Blunt percussion- organ tenderness (CVA tenderness)Assessment techniques Percussion
Start with a general inspection first
Proceed for specific observation of the system
Expose only the part being examined
Examine the unaffected area or parts first
Examine external parts first, then internal
Compare one side to the other side
Proceed from head to toeAssessment techniques Auscultation
S1: Lub: mitral valve closure
S2: Dub: Aortic valve closure
Measure strength of pulse and equality
Assess carotid, radial, and pedal
Also assess brachial, posterior tibial, and dorsalis pedis
Documentation of PulsesPeripheral Pulses
Pleural friction rubAdventitious/AbnormalBreath SoundsNote whether the sound occur during inhalation or exhalation, or both.
heard primarily when the pt exhales
Epigastric, umbilical, suprapubic
Have patient empty bladder
Position patient supine with knees slightly flexed
Note the abdominal shape and contour.
The abdomen should be flat to rounded in people of average weight.
A protruding abdomen may be due to obesity, pregnancy, ascites, or abdominal distention.
A slender person may have a slightly concave abdomenDifferent Sequence of Assessment
-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