PUTTING IT ALL TOGETHERNUR211

Kathleen Hancock

Nurse’s SkillsCritical thinkingInterpersonalProficient examination skillsProper equipmentUse appropriate barriers – glovesSystematic method of organization

OutcomesObtain complete health historyPerform physical examAssess mental statusDocument findingsDevelop problem listIdentify nursing diagnoses

History Biographical Current health status Past health history Family history Review of systems Psychosocial

Organization of PE

Head to toe

Body Systems

Body Regions

Helpful HintsWarm hands & equipmentShort fingernailsPrivacy, gown drapes, quietExplainObserve client, especially face

Physical Assessment

Anatomical landmarks: use appropriate landmarks for area being assessed

Approach: inspection, auscultation, percussion, palpation by system or region

Position: dependent on region being assessed

Tools: all tools of assessment needed for complete exam

Focused Physical Exam General survey with VS, height,

and weight Level of consciousness Skin color, temperature, and texture Gross balance and coordination EOM, pupils, gross vision and

hearing (Continued)

Focused Physical Exam Oral mucosa and say “Ah” Palpate apical, PMI, auscultate

heart sounds Auscultate bowel sounds; percuss

and palpate abdomen Palpate pulses Test sensation and strength on

upper and lower extremities

Physical Assessment by Region General survey: vital signs, height,

weight Skin, hair, & nails Head, face, & neck Anterior chest Posterior

chest Upper extremities Abdomen Lower extremities Pelvic exam

Documentation Document by systems and, to small

extent, by region Document + findings Document pertinent negatives