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    Approach To The Physical Assessment

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    Aileen A. Monares
    This document outlines the key components and processes involved in performing a nursing physical assessment according to the Nursing Health Assessment, 2nd Edition textbook. It discusses the purpose of assessments, differentiating between complete and focused assessments. The major sections include an overview of assessment tools, techniques like inspection, palpation, percussion and auscultation, approaching the assessment, recording vital signs, performing a head-to-toe assessment, and documenting findings. The goal is to collect objective health data to identify problems and strengths while validating the patient's history.

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    Approach To The Physical Assessment

    Uploaded by

    Aileen A. Monares
    205 views24 pages
    This document outlines the key components and processes involved in performing a nursing physical assessment according to the Nursing Health Assessment, 2nd Edition textbook. It discusses the purpose of assessments, differentiating between complete and focused assessments. The major sections include an overview of assessment tools, techniques like inspection, palpation, percussion and auscultation, approaching the assessment, recording vital signs, performing a head-to-toe assessment, and documenting findings. The goal is to collect objective health data to identify problems and strengths while validating the patient's history.

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    Approach to the Physical Assessment

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    This document outlines the key components and processes involved in performing a nursing physical assessment according to the Nursing Health Assessment, 2nd Edition textbook. It discusses the purpose of assessments, differentiating between complete and focused assessments. The major sections include an overview of assessment tools, techniques like inspection, palpation, percussion and auscultation, approaching the assessment, recording vital signs, performing a head-to-toe assessment, and documenting findings. The goal is to collect objective health data to identify problems and strengths while validating the patient's history.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    205 views24 pages

    Approach To The Physical Assessment

    Uploaded by

    Aileen A. Monares
    This document outlines the key components and processes involved in performing a nursing physical assessment according to the Nursing Health Assessment, 2nd Edition textbook. It discusses the purpose of assessments, differentiating between complete and focused assessments. The major sections include an overview of assessment tools, techniques like inspection, palpation, percussion and auscultation, approaching the assessment, recording vital signs, performing a head-to-toe assessment, and documenting findings. The goal is to collect objective health data to identify problems and strengths while validating the patient's history.

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    Nursing Health Assessment, 2nd Edition

    Approach to the Physical Assessment

    Nursing Health Assessment, 2nd Edition

    Outcomes
    Discuss the purpose of the physical assessment. Differentiate a complete from a focused physical assessment. Differentiate nursing physical assessment from medical physical assessment. Identify the tools used during a physical assessment.

    Nursing Health Assessment, 2nd Edition

    Outcomes
    Define physical assessment techniques. Demonstrate physical assessment techniques. Discuss variations in approaches for different age groups. Define the components of the physical assessment.

    Nursing Health Assessment, 2nd Edition

    Purpose
    Provides an objective data base Identifies actual/potential health problems Identifies patients strengths Validates history data

    Nursing Health Assessment, 2nd Edition

    Types of Physical Assessment


    Complete Focused Which type do you do? Reason for performing examination Patients condition Amount of time

    Nursing Health Assessment, 2nd Edition

    Components
    General survey Measurements
    Vital signs Height Weight

    Head-to-toe, including all systems

    Nursing Health Assessment, 2nd Edition

    Assessment Tools
    Thermometer Doppler Pen light Otoscope Stethoscope Visual acuity charts Ophthalmoscope Nasoscope

    Nursing Health Assessment, 2nd Edition

    Assessment Tools
    Transilluminator Tape measure Goniometer Triceps skinfold calipers Ruler Scale Tongue depressor

    Nursing Health Assessment, 2nd Edition

    Assessment Tools
    Cotton balls Cup of water Safety pins or toothpicks Substances for smell and taste Test tubes Coin Gloves

    Nursing Health Assessment, 2nd Edition

    Assessment Tools
    Lubricant Specula Cytology brush and scraper Slides Hemoccult test

    Nursing Health Assessment, 2nd Edition

    Physical Assessment Techniques


    Inspection Palpation Percussion Auscultation

    Nursing Health Assessment, 2nd Edition

    Inspection
    Types Direct, indirect Senses Sight, smell What can inspection tell you?
    Surface characteristics Symmetry Gross abnormalities or signs of distress Unusual odors

    Nursing Health Assessment, 2nd Edition

    Palpation
    Types Senses Single-handed, bimanual Touch
    Light: < 1/2 inch Deep: > 1/2 inch Ballottement: used to assess partially free-floating objects

    Nursing Health Assessment, 2nd Edition

    Parts of Hand Used for Palpation


    Dorsal aspect
    Best for temperature

    Balls & ulnar surface of hand


    Best for vibrations

    Fingertips
    Best for fine sensations

    Nursing Health Assessment, 2nd Edition

    Palpation
    What can palpation tell you? Light
    Surface characteristics

    Deep
    Organs, masses, tenderness

    Ballottement
    Size, shape of free-floating objects

    Nursing Health Assessment, 2nd Edition

    Percussion
    Types
    Direct (immediate) Indirect (mediate) Fist or blunt

    Senses
    Touch Hearing

    Nursing Health Assessment, 2nd Edition

    Percussion
    What can percussion tell you? Direct or indirect
    Density (air, fluid, solid) Size and shape Tenderness Deep tendon reflexes

    Fist or blunt
    Tenderness

    Nursing Health Assessment, 2nd Edition

    Auscultation
    Types Direct, indirect: stethoscope Senses Hearing What can auscultation tell you?
    Heart sounds Lung sounds Bowel sounds Vascular sounds

    Nursing Health Assessment, 2nd Edition

    Approach to Assessment
    System or region Be systematic. Minimize position change. Expose only the area being assessed.

    Nursing Health Assessment, 2nd Edition

    Approach to Assessment
    Explain as you go. Share findings with patient and teach. Ensure privacy and confidentiality. Consider developmental level of patient. Consider cultural background of patient.

    Nursing Health Assessment, 2nd Edition

    General Survey
    Age: actual and apparent Race Level of consciousness Obvious abnormalities or signs of distress Gender Affect Dress Speech Posture

    Nursing Health Assessment, 2nd Edition

    Vital Signs and Anthropometric Measurements


    Temperature Respirations Height Pulse Blood pressure Weight

    Nursing Health Assessment, 2nd Edition

    Head-to-Toe Physical Assessment


    Integumentary Breast Cardiovascular Musculoskeletal Genitourinary/reprodu ctive HEENT Respiratory Gastrointestinal Neurological

    Nursing Health Assessment, 2nd Edition

    Documentation
    Accurately Concisely Objectively Record by systems Chart pertinent negatives

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