Physical Assessment

Front 1

ASSESSMENT OVERVIEW

Back 1

-The first step of the nursing process
-Involves data collection
-Holistic assessment (head to toe)
-Data collection leads to Nursing diagnosis

Front 2

DATA COLLECTION

Back 2

Leads to nursing diagnosis
-interpret data
-identify related factors
-document diagnosis

Front 3

SUBEJECTIVE DATA

Back 3

What the person relates during history taking

Front 4

OBEJECTIVE DATA

Back 4

What the health professional observe
-inspecting
-palpating
-auscultation
-percussing
Lab results

Front 5

TYPES OF DATA BASE

Back 5

-Complete
-Episodic
-Follow up
-Emergency

Front 6

COMPLETE DATA BASE

Back 6

Head to toe
-Complete health history and full physical examination
-Describes the current and past health state and forms baseline
-yields the first diagnosis

Front 7

EPISODIC OR PROBLEM CENTERED DATA BASE

Back 7

-For a limited or short-term problem
-Collect a mini data base, smaller in scope
- more focused than complete data base
-concerns only one problem, one cue complex, one body system

Front 8

FOLLOW UP DATA BASE

Back 8

The status of any identified problem should be evaluated at regular and appropriate intervals
-what changes occured? did it get better or worse?
-Used in all settings to follow up short term or chronic health problems

Front 9

EMERGENCY DATA BASE

Back 9

-Rapid collection of data
-Complied with life-saving measures
-Diagnosis must be swift and sure

Front 10

LIFE CYCLE INFLUENCES

Back 10

-Transcultural
-Developmental
-Subjective/Objective data collection
-Risk factors
-Functional Assessment (ADL)
-Environmental
-Self-Care behavior

Front 11

HEALTH INTERVIEW

Back 11

Structured interaction between health care provider and client
-Collects subjective data

Front 12

COMPONENTS OF COMPLETE HEALTH HISTORY

Back 12

-Bio data and source of history
-Past, present and family history
-Review of Systems (ROS)
-Environmental Health
-Functional (ADL) what is impeding it?
-Self perception of health
-Reason for seeking care (CC)

Front 13

SYMPTOM CHARACTERISTIC

Back 13

-Location
-Quality
-Quantity and Severity
-Timing
-Setting
-Aggravating/Relieving factors
-Associated factors
-Client's perception

Front 14

GENERAL SURVEY

Back 14

Done when first entering room
-Physical Appearance
-Body Structure
-Mobility
-Behavior

Front 15

MENTAL STATUS

Back 15

Appearance (clean, shaved, groomed, posture, body movements)
-Behavior (LOC, Facial expression, speech)
-Cognition (orientation, attention span, new learning, recent memory)
Tool used to test cognition is the mini mental status
AAOx3 (awake, alert, oriented to person, place, time)

Front 16

ASSESSMENT TECHNIQUES

Back 16

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Front 17

INSPECTION

Back 17

Concentrated watch
-close careful scrutiny first of the individual as a whole then of each body system
-always come first

Front 18

PALPATION

Back 18

-Follows and often confirms points noted on inspection
-with the sense of touch you assess: texture, temperature, moisture, organ location, swelling, vibration, pulsation

Front 19

PERCUSSION

Back 19

Done with plexor and plexometer
-avoid bone
-assess for sound and vibration

Front 20

INSPECTION

Back 20

Concentrated watch
-close careful scrutiny first of the individual as a whole then of each body system
-

Front 21

AUSCULTATION

Back 21

Listening to sounds a body produces such as: heart, blood vessels, lungs and abdomen
uses a stethoscope