BarCharts, Inc WORLD'S #1 ACADEMIC OUTLINE b= Nursing-Assessmen AV - a ‘Patent intro, physical, cardiovascular, HEENT, integumentary, espiratary, breasts, GI, GU, musculoskeletal & neurologic systems including post assessment INTRODUCTION Perlorming an accurate physical assesiment arc boing abe to cifrenite hormal rom abnormal ndings se of the most important rles fo toys Team carepracttoner, Fan accurate phic’ szeremert cannot be performed vihethor fo baseline data or when ihe clents condition changes, hen te hents NOT receiving fe level of competent care he/she deseres ‘Assessment “hss the process by whidh a nurse voaignn Te body ofa ent Tor dane of csenoe or dorelare: germaby takes tre bia) of Un katary on Sichunt of she symptoms se experencod by the clone. Using etal inking Shu professional Lowledge, te nurse rales the parson-spacic history and ‘Physical assessment inorder to otormine the cionts nureng care needk and fo design appropriate nursing responses This data then becomes part of the Clents health record Nuts sesessment isthe fist stage of he nursing process ‘indies the gathering of Information abouts clients. physiological, paycholgyeal sekslogen and spre satis +The purpaee of ssostment i 0 identify the cients nursing problems and Tura eare needs Collection of Symptoms & Signs Symptom: A sibjctve experince by the cent 2 Slgn ar objective hnding by the examinerraciioner Nurses use assessment to: 1 Obtain baetine data and expand the database rom which subsequent phases of the nursing process can ewowe + antiy snd manage a variety of cant problems Evaliste the afecivoness of rursing cae Proud data for planning interventions Enhance the nurte/elent reltonship {Make nial jodgnants Assessment Before you begin: Dong propared ond hopag te Sem enable fMistng felatontnp ss mmporant to conducting a comprehensive sod Ne Review the Chart “Riot the cents name, age, addres, race, occupation and religion 1 The chart proves a starting point for coming te know the chent 8 8 person {information onthe chart gies you anion ofthe chen eso 1 Char date may enti ak factors Establish Ropport + Graet the chent in a fendy, non threatening manner {Explain your role in client care~your frst mpression cen earn the client's rust, andeanfidence ‘Share withthe clent the purpose of the assessment “the assessment will provide a bassline picture of your health status Control Environment 4 * Give peuney by drawing the curtain, closing the door 1 Excute larly members so the cient can tak candialy with you PHYSICAL EXAMINATION ‘This isthe process by which a health-care provider investigates the body of » lent for signs of disease. ae ee gp palpation, percussion and auscultation. Inspection [Thief the close, careful and unhurried visualization ofthe client asa whole and seh ba ayer Sime ica aouavation hat * eur good tag, ua inspect the body wtheu dstorion or + Bolsa he coor shape, symmetry and potion of body pars Palpat “his the {and cael feeng with the hends during a physical tran fe heanere proer aches oe leas the lat cy {o enamine the sae, consibtency, texture, location ard tenderness ofa Ne organ or body part ro hack or bporipe ese: consistency of sue sigan tang of ces ‘oon ure cvernants 1 fiumon of sun and ne vibstone = Bac ote ard neween sn tepertie Peston Chore Paha teers ps ring an sent co oe sion ay ere oie eer fre ea on sae aeimatn ee ee eee ie een cee ees ee ei pereieeseeoeeeet sage ar Slt yepcnor epetak; pranier niaes ae aietoay Sechniaers of Acsenanent. Observation Che tee og th sae cal sear - fac x Sects Pee sesame aie + color of shin, nals and har + Sel caterer evo fase ade sls sets Wt pa ae ei s Respears chose entrance ess naling = see Ste tao fy pec eo hm heb > Bapron Aa coc tt br op tender ‘Rete of therapeutic communication o obtain subjected is aed on "iin uni acta or pci helt plea, apt sea ‘eran nelle nee rom he chants perspec Nursing History A coschred ord pir to the psc seer cleomat ere te TReerecheweroarg tony ete ateisaver «fit pte ws te 1 Toason lo seeing coreshealth stats = Lamaret peer ieee eanlog peer i Geon nee ener + poe medicl tery + Bi Brey ey etd Analysis of» Symptom Provoke Wie taker Syrnptoms beter or worse? Quality: What doos it foo ik? Radiation: Wheres the Symptom and where does i go? Severity: How bad does fel Erased of tte 1? Time: When dows t occur Row often and ow ong does Bid erception of illness vst of systems ‘series of questions about current dnd past health, neluding heath ask about signs. and symptoms, fe wall 28 diseases rolateo''o 00ch Body system + functional assessment (activities of daly ving) + perception of heath + Unarauace of ingers assesses texture, moisture, masses, organ position and py rae Percussion ‘This a method of tapping on a surface to assess the Indetbing’scre® cation, size or densi. The ‘ind! drgee atthe practioner ves fom one Seow *'Bone wth tho mide fingar ef the righthand the metln finger of ook hat whe ek 1 A flat/dull sound indicates the ‘of solid mass under the surface “A tympanic/resonant sound hollow, si-containing sructures