Physical Assessment Final Notes Wk 1 to Wk 8

1 PHYSICAL ASSESSMENT MIDTERM STUDY GUIDE Week 1 Skin, Hair, and Nails, Head, Neck, and Related Lymphatic ● Subjective (subjective data always collected first) ○ Info that the client experience ○ Pain ○ Symptoms ○ Emotion ○ Health history (in the order) ○ History of illness and injury ○ Family history ○ Review of system ○ Social history ○ Patient has a new diagnose with Hepatitis C. Ask patient about history of piercing and tattoos (because Hepatitis C is transmitted through blood). ● Objective data ○ What you observe by examining ○ Focus on areas of interest - such as chief complaint ○ ex. checking vitals ● General Survey (1st part of inspection) similar to head to toe assessment ○ Physical appearance ■ Nourishment ■ Color of skin - cyanotic etc. ■ Older for age ○ Mental status ■ Orientation (A&O x 4) ■ Affect and mood ■ Level of anxiety ■ Speech ○ Mobility ■ Gait ■ Range of motions ○ Behavior (How are they acting?) ■ Body odor ■ Facial expression ■ Anxiety ● Focused Assessment ○ After family history, nurse begins to ask specific questions about a problem ● Palpation: ○ Light Palpation = 2 fingertips in circular motion, 1 cm deep (0.39in) ○ Moderate Palpation = palmer surface of fingers of the dominant hand over the structure ■ 2 cm deep (0.4-0.75 in) ○ Deep Palpation = extended fingers of the nondominant hand placed over the fingers of the dominant hand ■ 2-4 cm (0.75 to 1.5in) ○ Fremitus (palpable vibration) and Crepitus – use palpation technique ○ Fremitus - palpation