| A | B |
|---|
| Parts of the Nursing Health Assessment | General Survey, Nursing History, Physical Assessment |
| Purpose of Physical Assessment | Obtain data re: client's ability to function |
| Purpose of Physical Assessment | Confirm or refute data from Nursing History |
| Purpose of Physical Assessment | Obtain data to establish a nursing diagnosis and plan of care |
| Purpose of Physical Assessment | Evaluate progress of the client in meeting health care needs |
| Purpose of Physical Assessment | Screen for cancer |
| Physical assessment techniques | Inspection, palpation, percussion & auscultation |
| Inspection | Visual technique, active process of knowing what to look for. Assess moisture, color and texture of body surfaces as well as size, shape, position and symmetry of the body |
| Palpation | Light and deep palpations-exam of the body through the sense of touch: temperature, texture, tenderness and pulsation. |
| Percussion | Direct vs indirect percussion. Tapping the body to produce sounds or vibration. Helps to determine the make-up of underlying tissues or organs. |
| Percussed sounds-Flatness | dull sound over bone or muscle |
| Percussed sounds-Dullness | "thud like" sound over organs |
| Percussed sounds-Tympany | drum like sound over air filled spaces like an empty stomach |
| Percussed sounds-Resonance | hollow sound produced over lungs |
| Auscultation | Listening to sounds produced within the body with a stethoscope |
| Auscultation-stethoscope diaphragm | High pitched sounds |
| Auscultation-stethoscope bell | Low pitched sounds |
| Preparation of the Physical exam environment | Privacy, lighting, physical & psychological preparation |
| General Survey assessment | Height, weight and VS, general appearance & impressions, abnormalities for focus assessment |
| General appearance | Gender, race, age, posture, hygiene, grooming, mood, speech, emotions, body movements |
| Abnormalities for focus assessment | Assess behavior of an individual in relationship to culture, educational level, socioeconomic status and current circumstances |
