physical assessment Flashcards
head-to-toe assessment is done on patient admission
physical assessment
The systematic collection of objective information that is directly observed or is elicited to examination techniques
physical assessment
• To obtain baseline data about the client’s functional abilities.
• To supplement, confirm, or refute data obtained in the nursing history.
• To obtain data that will help establish nursing diagnoses and plans of care.
• To evaluate physiological outcomes of health care and thus the progress of a client’s health problem.
• To make clinical judgments about a client’s health status.
• To identify areas for health promotion and disease prevention.
Purpose of Physical Assessment
Types of physical assessment
● Complete Physical Assessment
● Examination of Body System
● Examination of Body Area
Draping
• Draping should be arranged so that the area to be
assessed is exposed and other body areas are covered.
• Exposure of the body is frequently embarrassing to clients.
• Drapes provide not only a degree of privacy but also
warmth
what are the four methods?
Inspection
Palpation
Percussion
Auscultation
• Visual examination of the body
• It is the observation of the naked eye to determine the structure and
functions of the body.
• Observe the client while facing him or her in the bed or chair.
• Observe the client’s skin color and texture.
• Look at overall body structure.
• Note all parts of the body as the examination proceeds.
• Inspection also evaluates verbal and behavioral responses and mental
status.
• In addition to visual observations, olfactory (smell) and auditory
(hearing) are also noted
inspection
It is the examination of the body using the sense of touch.
• It is the feeling of the body with the hands, to note the size and positions of the organs.
(e.g. texture,temperature, vibration, position, size, consistency and
mobility of organs or masses;distension, pulsation and tenderness or
pain)
palpation
with light palpation extend the dominant hands fingers parallel to the skin surface & presses gently while in a circle.
light palpation (superficial)
done with 2 hands
deep/bimanual palpation
Characteristic of Masses
Location: Site on the body, dorsal/ventral surface
Size: Length and width in centimeters
Shape: Oval, round, elongated, irregular
Consistency: Soft, firm, hard
Surface: Smooth, nodular
Mobility: Fixed /mobile
Pulsatility: Present/absent
Tenderness: Degree of tenderness to palpation
Remember!
• Deep palpation is usually not done in a routine examination and requires significant practitioner skill.
• It is usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed
It is the examination, by tapping with the fingers on the body to
determine the condition of the internal organs, by the sounds
that are produced or vibrations that can be felt.
percussion
tapping by sound
percussion
Striking the area to be percussed directly.
direct percussion
Striking of an object that held against the body area to be examined.
(finger over finger)
indirect percussion
• It is the listening to sound within the body with aid of a stethoscope,
fetoscope or directly with the ear placed on the body
auscultation
what type of auscultation?
• Performed using unaided ear.
(e.g. respiratory wheeze or the grating of a moving joint).
direct auscultation
what type of auscultation?
• Performed using a stethoscope, which transmits sounds to the healthcare provider’s ears.
(e.g. bowel sounds, valve sounds of the heart and Blood Pressure)
Indirect auscultation
