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Why do we assess the pt?
· To evaluate the client’s current physical condition
· To detect early signs of developing health problems

Gather General Data information….The Data Base 1. Personal Data 2. Chief Complaint =

3. Past Health History = the past health problems, treatments, & outcomes. A. Surgical history…..type & date of surgery. B. Medical Illnesses 4. Family History= 5. Allergies = 6. Current Meds 7. Prosthesis= Pacemaker, Hearing Aid, Dentures, False Eye, False Limb 8. ADL’S @ home….hygiene, bladder & bowel elimination, hygiene, activity level, diet habits. 9. Health Practices 10. Lifestyle Habits

Vital Signs: Must be taken

Height/Weight: Always take the pt’s weight on the hospital scale

1. Compare the weight with

2. Determine if

See Guidelines of Wgt/Height measurement pg. 188.

Before you begin your assessment, ask the pt how he/she feels?
· Note any Signs & Symptoms = warning that something is wrong. A. sign= B. symptom = C. local sign= D. systemic sign = one that’s produced by the effect of disease on the whole body
· Does the pt c/o any pain or discomfort? Where?
· How much pain?
· use

Make your assessment give a mental picture of the patient:
· don’t use critical or judgmental words
· don’t use the words: Good or Bad, Well, or Normal
· Instead describe why you think it’s normal, good, or bad!

4 Methods (Techniques) of Physical Assessment

1. Inspection = Purposeful Observation
“Looking” for See Figure 12.1A; pg.186 Inspect from

2. Percussion = “striking” or tapping a part of the body & listening for the sound it makes.
Mostly done
See Table 12.1B; pg. 186

3. Palpation = lightly “touching” or applying pressure
· See Figure 12-2
Noting the size, shape, mobility, pain of masses &/or normal tissue

4. Auscultation = “listening” to body sounds with or without a stethoscope. What type of sounds would you auscultate?

1. Head – to – Toe Approach
*2. Body Systems Approach

I. Mental Status
Pt’s Mood

Pt’s Facial Expression

Pt’s Ability to Verbally Communicate
Pt’s Intellectual Ability 1. 2. 3.
Note pt’s Appearance, Hygiene, Speech, & Behavior

II. Neurological System

Level of Consciousness

Level of Orientation (oriented X 3)
Oriented to person
Time/date Pupillary Reaction 1. Consensual Response = both pupils respond to light (when shining light in 1 eye) 2. Accommodation = pupils constrict with near objects pupils dilate with far objects

Pupils should be equal. Note size & Shape of Pupils!
Size of Pupil? [Figure 12-9…3mm, 4mm, etc]

PERRLA =Pupil’s Equally Round & Reactive to Light & Accommodation
If ≠, report to nurse.

Strength of Hand Grasp:
Ask pt to squeeze hands
Note if

III. Sensory – Perceptual
Functional Ability of the Sense Organs: (eyes, ears)
Appearance of the Sense Organs Eyes:
Functional Ability = Visual acuity, is he blind in either eye? Does pt wear glasses,

Appearance of the Eye: Ears:
Functional Ability: How is his hearing in each ear? …any use of hearing aids??

Appearance of the Ear:
Any ear pain?

IV. Integumentary Assessment

Color of Skin or Mucous Membranes Uniform Color/ Ethnic Race
(pink) skin or mucous membranes Diagnostic Skin Color Variations Flushed = = superficial burns Ecchymosis(purple) = trauma to soft tissue (bruise) = bluish, low tissue oxygenation = ↓ RBC’s , blood loss, anemia Jaundice (yellow) = liver problems (seen also in eyes, & urine) Tan (brown) = ethnic race, sun exposure Skin Temp (Warmth)
Warm, cool, or cold- to –touch. Wet or Dry
Skin should be
Check if skin is slightly moist?
Does pt have excessive perspiration = Any Lesions = change in the integrity of the skin. 1. Wound 2. Ulcer
3. Abrasion 4. Laceration
5. Fissure 6. Scar

Note the LOCATION--SIZE—SHAPE—DRAINAGE of ALL WOUNDS Location: · Left upper arm · Right lower leg Size: 1 in.; 2in, etc 1cm, 2cm, etc Dime-size; Quarter-size; Half-dollar size Shape: Round, crescent or quarter-moon shaped; rectangular; Drainage: 1. Amount Scant Moderate Profuse 2. Appearance of Drainage Serous = clear = bloody = blood + serous Mucoid = Mucous Purulent = Contains Pus Skin Turgor = the elasticity of the skin ..Pinch the skin & see how quickly it returns. 1. immediate return = good hydration 2. (slow) return = dehydration · example = “tented for 8 seconds” Edema = excessive amt of fluid trapped within tissue 1. Location: Pretibial (lower leg), ankle, or foot a. press area for 5 secs b. grade 1+ = 2 mm 2+ = 4 mm 3+ = 6 mm (size of common pencil eraser) 4+ = 8 mm ---------------------------------------------- non-pitting > 4+ = Brawny Edema

V. Respiratory System Respiratory Rate & Effort?

Lung Sounds
1. Normal Lung Sounds area of the lung, type of sound, length of sound Insp. Expir. a. Tracheal _____ _____ b. Bronchial __ _______ c. Bronchovesicular _____ _____ *d. Vesicular ________ __ * Listen over the anterior and posterior chest of the patient. *For most of the chest area, you will hear Vesicular sounds (long inspirations---short expirations) * Document if lung sounds are clear anteriorly, posteriorly, and bilaterally 2. Abnormal Lung Sounds = Adventitious Sounds
· Caused by air moving thru secretions or narrowed airways a. Crackles = rales (in periphery on inspiration) b. c. d. Rubs = Loud grating sound (over inflamed areas)

Cough (productive or nonproductive) If productive…note the following:

a. color =
b. amount =
c. consistency =


Auscultate the Apical Heart Sounds = caused by closure of the 4 heart valves.

The A-V Valves The Semilunar Valves 1 1. Aortic 2. 2. Pulmonic

Normal Heart Sounds: S1* S2 Lub Dub

*S1 = closure of the A – V valves S2= closure of the Aortic & Pulmonic Valves Abnormal Heart Sounds = galloping sounds S3= indicates ↑ heart failure in adults Is S1 S2 S3 Lub-dub-dub S4 = means coronary artery disease, hypertension, etc. S4 S1 S2 Lub-lub-dub Murmur =

Palpate the Peripheral Pulses
Is pulse present?
Start at most
What is quality of pulse?

Check Capillary Refill Time color should return in < 3 seconds if > 3 secs. = circulation problems

Does pt c/o chest pain?



Auscultate bowel sounds
Divide abdomen in
Best heard in RLQ
Describe bowel sounds as: 1. 2. 3.

Palpate abdomen & note: 1. soft & flat 2. hard & distended
Describe any Stools during your shift. Is pt continent or incontinent? If no stools on your shift, when was last BM? What is pt’s usual bowel pattern? Does pt have a colostomy/ileostomy? Describe stool.


Does pt have a Foley Cath? or

Is pt urinating continently? 1. Describe urine a. b. c. 2. Note any difficulty with urination a. burning b. frequency If incontinent? many times were attends checked & changed? Any perineal lesions? Palpate the lower abdomen
· the
· if bladder is palpable IX. MUSCULOSKELETAL SYSTEM

Muscle Strength? = power to perform
· Push against the pt’s foot or hand while he resists. (figure 12.23; pg 200) · Any atrophy? = wasting away of muscle

Walking Ability or transfer ability?

Joint Mobility …Range of Motion of the Joint?
Full Range of Motion = Limited Range of Motion =
Muscle or Joint pain?

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