Objectives:
Obtain physical data about the client’s functional
abilities
Supplement, confirm, or refuse data obtained in the nursing history
Obtain
... [Show More] data that will help the nurse data establish
nursing diagnoses and plan the client’s care.
Evaluate the physiologic outcomes of health care and
thus the progress of a patient’s health problem
Screen presence of cancer
CEPHALOCAUDAL ORDER OF EXAMINATION AREAS
HEENT
NECK
UPPER EXTREMITIES
CHEST AND BACK
BREAST AND AXILLAE
ABDOMEN
GENITALS
ANUS AND RECTUM
LOWER EXTREMITIES
Note: SKIN IS CHECK THROUGHTOUT THE ASSESSMENT
General Concepts:
Approach the client calmly and confidently. Provide privacy.
Make sure that all needed instruments are available before starting the physical assessment
Several positions are frequently required during the
assessment. Consider the client’s ability to assume a
position.
Be systematic and organized when assessing the client. (Inspection, Palpation, Percussion, Auscultation
If a client is seriously ill, assess the systems of the body that are more at risk
Perform painful procedures at the end of the examination
METHODS OF EXAMINING
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
INSPECTION
Visual examination of the patient done in a methodical and deliberate manner.
PALPATION
To check muscle tone and assess for tenderness
Techniques:
Place the hand with fingers together parallel to the area being palpated. Press down 1 to 2 cm. Repeat in ever-widening circles until the area to be examined is covered.
Deep Palpation
To identify abdominal organs and abdominal masses.
Techniques:
With fingers together, approach the area to be examined at a 60 degree angle and use the pads and
tips of the fingers of one hand to press in 4 cm.
Two – handed Deep Palpation place the fingers of one hand on top of those of the other.
PERCUSSION
Striking of the body surface with short, sharp strokes
in order to produce palpable vibrations and characteristic sound.
It is used to determine the location, size, shape, and density of underlying structures; to detect the presence
of air or fluid in a body space; and to elicit tenderness.
TYPES OF PERCUSSION Direct Percussion
Percussion in which one hand is used and the striking
finger (plexor) of the examiner touches the surface being percussed.
Techniques:
Using sharp rapid movements from the wrist, strike the body surface to be percussed with the pads of two, three, or four fingers or with the pad of the middle finger alone. Primarily used to assess sinuses in the adult. [Show Less]