Physical Assessment

ASSESSMENT OVERVIEW

-The first step of the nursing process
-Involves data collection
-Holistic assessment (head to toe)
-Data collection leads to Nursing diagnosis

DATA COLLECTION

Leads to nursing diagnosis
-interpret data
-identify related factors
-document diagnosis

SUBEJECTIVE DATA

What the person relates during history taking

OBEJECTIVE DATA

What the health professional observe
-inspecting
-palpating
-auscultation
-percussing
Lab results

TYPES OF DATA BASE

-Complete
-Episodic
-Follow up
-Emergency

COMPLETE DATA BASE

Head to toe
-Complete health history and full physical examination
-Describes the current and past health state and forms baseline
-yields the first diagnosis

EPISODIC OR PROBLEM CENTERED DATA BASE

-For a limited or short-term problem
-Collect a mini data base, smaller in scope
- more focused than complete data base
-concerns only one problem, one cue complex, one body system

FOLLOW UP DATA BASE

The status of any identified problem should be evaluated at regular and appropriate intervals
-what changes occured? did it get better or worse?
-Used in all settings to follow up short term or chronic health problems

EMERGENCY DATA BASE

-Rapid collection of data
-Complied with life-saving measures
-Diagnosis must be swift and sure

LIFE CYCLE INFLUENCES

-Transcultural
-Developmental
-Subjective/Objective data collection
-Risk factors
-Functional Assessment (ADL)
-Environmental
-Self-Care behavior

HEALTH INTERVIEW

Structured interaction between health care provider and client
-Collects subjective data

COMPONENTS OF COMPLETE HEALTH HISTORY

-Bio data and source of history
-Past, present and family history
-Review of Systems (ROS)
-Environmental Health
-Functional (ADL) what is impeding it?
-Self perception of health
-Reason for seeking care (CC)

SYMPTOM CHARACTERISTIC

-Location
-Quality
-Quantity and Severity
-Timing
-Setting
-Aggravating/Relieving factors
-Associated factors
-Client's perception

GENERAL SURVEY

Done when first entering room
-Physical Appearance
-Body Structure
-Mobility
-Behavior

MENTAL STATUS

Appearance (clean, shaved, groomed, posture, body movements)
-Behavior (LOC, Facial expression, speech)
-Cognition (orientation, attention span, new learning, recent memory)
Tool used to test cognition is the mini mental status
AAOx3 (awake, alert, oriented to person, place, time)

ASSESSMENT TECHNIQUES

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

INSPECTION

Concentrated watch
-close careful scrutiny first of the individual as a whole then of each body system
-always come first

PALPATION

-Follows and often confirms points noted on inspection
-with the sense of touch you assess: texture, temperature, moisture, organ location, swelling, vibration, pulsation

PERCUSSION

Done with plexor and plexometer
-avoid bone
-assess for sound and vibration

INSPECTION

Concentrated watch
-close careful scrutiny first of the individual as a whole then of each body system
-

AUSCULTATION

Listening to sounds a body produces such as: heart, blood vessels, lungs and abdomen
uses a stethoscope