Nursing 110 Physical Assessment
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Steps in an assessment-Use the nursing process to identify patient needs-Gathering data
-Obtain a history:
-Sources of information
-Essential elements
-Establish a baseline
-Provides direction for care
Obtaining a history-Reason for accessing health care-Past Medical problems-
PMH-Past Surgeries- PSH
-Medications
-Prescription
-OTC
-Supplements
Health history-Family History- diseases - especially heart disease, cancer, diabetes-Mother, father, siblings
-Social History- living arrangements, smoke, drink alcohol, occupation-Activities of daily living. How does the client
usually care for themselves?-How do they perceive their health? Changes?
-Type of diet usually consumed
Physical assessment-Head to Toe approach vs. system approach
-Positioning/draping
-Minimize patient movement
-Compare one side to the other
-Remember developmental issues, children will be approached differently than adults
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, 4/26/26, 2:57 PM Nursing 110 Physical Assessment Flashcards |
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Physical assessment techniques-Inspection-Auscultation-Percussion-
Palpation
Physical assessment instruments-Inspection
-Otoscope
-Ophthalmoscope
-Penlight
-Snellen Chart
-Auscultation
-Stethoscope
-Miscellaneous:
-Tongue blade, Reflex hammer, Tuning fork, Sharp/dull objects
Overall assessment-Observe patient
-General looks
-Gait
-Hygiene
-Manner, affect
-Odors
-General state of health
-Vital Signs, height and weight
-Posture, physical mobility
-How do they talk? Make sense, confused, disjointed?
-Awake and alert
-Oriented to person, place and time?
-Memory intact?
-Is their speech appropriate for their age?
-Language skills intact?
Skin assessment-Using inspection and palpation check for:
-Color, Moisture, Temperature
-Pallor, assess conjunctiva of eye, palms, soles of feet and "acral" areas-elbows, knees for underlying "pink or red" color.
-Inspect for wounds, lesions, discolorations
-Turgor
Assessing hair and nails-Look at hair on scalp and overall body hair. Note presence of infections, inflammation
-Nails - Inspect shape of nail plate, texture, surrounding nail tissue, nail bed color, perform capillary blanch test
Assessing skull and face-Size, shape and symmetry, palpate skull for nodules, masses or depressions.-Inspect facial features -
eyes for hollowness or edema.
-Note facial movements
-Elevate/lower eyebrows
-Close eyes
-Smile/frown, show teeth
Eye assessment- Pupil Response-Direct
-Consensual
-Extra-ocular movements-Red Reflex
-General vision
-Peripheral vision
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