Summary Physical Assessment Wk 1 to Wk 4

Week One: Skin, Hair, Nails, Head, Neck and Related Lymphatic • Subjective Data (always collected first) o Info that the client experiences ▪ Example: What they report that they ate for breakfast o Pain o Symptoms o Emotional Status o Biographical Data ▪ Health History: info based on the client’s own perception ▪ History of illness and injury: past and present ▪ Family history (3 generations) ▪ Review of Systems • Example: If you ask the pt how tall they are ▪ Social History: alcohol, smoking, drugs, caffeine ▪ Practices: Western Medicine, etc. ▪ Health Patterns: exercise, diet, sleep, level of stress (what, how often, specifics) o Note: accuracy of subjective date depends on the nurse’s ability to clarify the info o OLDCART & ICE: used to clarify subjective data ▪ Onset ▪ Location ▪ Duration ▪ Characteristics ▪ Aggravating factors ▪ Relieving Factors ▪ Impact on ADL’s ▪ Coping Strategies ▪ Emotional Response • Objective Data o What you observe by examination; measurable o Focus on areas of interest such as chief complaint o Done in a systematic fashion o Examples: checking vital signs, measuring weight, auscultating the lungs • General Survey: First part of inspection; similar to head to toe assessment o Physical Appearance ▪ Nourishment ▪ Color of skin (cyanotic, etc.) ▪ Older for age ▪ Body shape (banana, pear, hourglass, etc.) o Mental Status ▪ Orientation (A&Ox?) ▪ Affect and general mood ▪ Level of anxiety ▪ Speech o Mobility/Neuro ▪ Gait (stumbling, limping, etc.)