Physical Assessment Handout

CHAPTER 4
Physical Assessment
1
Slide 1
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
OBJECTIVE DATA DEFINED
Objective data as OBSERVED by

the PT
– Can be seen, heard, & measured
– Examples: rashes, altered vital signs,
visible drainage or SWELLING/EDEMA
– Lab results, diagnostic imaging, and
other studies
Slide 2
WHAT DO YOU OBSERVE?
Slide 3
1
OBJECTIVE VERSES
SUBJECTIVE
– Subjective data
– Perceived by the patient
– Examples: pain, nausea, vertigo, and
anxiety
– Pt may be unaware of symptoms unless
the patient describes the sensation
Slide 4
Signs and Symptoms
Disease and Diagnosis

– Disease
It is any disturbance of a structure or
function of the body.
It is recognized by a set of signs and
symptoms.
Signs and symptoms are clustered in groups
to help the physician to make a medical
diagnosis.
The PT also relies on collaboration of the
team evaluations and assessments to collect
both subjective and objective data
Slide 5
Signs and Symptoms
Disease
– Disease or illness may be : hereditary,
congenital, inflammatory, degenerative,
infectious, deficiency, metabolic,
neoplastic,
neoplastic, traumatic, and
environmental.
– Unknown etiology
Diseases that have no apparent cause.
Slide 6
2
Signs and Symptoms
Risk
Factors for Development of
Disease
– A risk factor is any situation, habit,
environmental condition, genetic
predisposition, physiologic condition,
and other that increases the
vulnerability of an individual or a group
to illness or accident.
– Categories of risk factors
Genetic and physiologic, age, environment,
and lifestyle
Slide 7
Slide 8
Slide 9
3
Signs and Symptoms
Terms Used to Describe Disease

– Chronic
– Develops slowly and persists over a long period,
often for a person’
person’s lifetime
– Remission
Partial or complete disappearance of clinical
and subjective characteristics of a disease
– Acute
Begins abruptly with marked intensity of
severe signs and symptoms and then often
subsides after a period of treatment
Slide 10
Signs and Symptoms
– Infection
Caused by an invasion of microorganisms,
such as bacteria, viruses, fungi, or parasites
that produce tissue damage
– Inflammation
Protective response of the body tissues
to irritation, injury, or invasion by disease-
disease-
producing organisms
Slide 11
Signs and Symptoms
Frequently Noted Signs and

Symptoms
– Signs of Infection and Inflammation
Erythema
Edema
Heat
Pain
Purulent drainage
Loss of function
Slide 12
4
Assessment
Process of making an evaluation or

appraisal of the patient’
patient’s condition
Collection of subjective and objective
data
Slide 13
Assessment
Medical Assessment
– Functions That May Be Expected of the
PT
– Preparing the exam room
Assisting with equipment
Preparing the patient
Collecting specimens
Slide 14
Slide 15
5
Assessment
Initiating
the Nurse-
Nurse-Patient
Relationship
Introduce yourself and state name, position,
and purpose of the interview.
Give an estimate of time.
Ask if the patient has any questions and

answer them appropriately.
Communicate trust and confidentiality.
Convey competence and professionalism.
Slide 16
Assessment
Nursing Assessment
– The Interview
Provide relaxed, unhurried manner.
Conduct in a quiet, private, well-
well-lighted
setting.
Convey feelings of compassion and concern.
Determine by what name the patient wishes
to be addressed.
PT should have an accepting posture,
relaxed, eye level, and pleasant facial
expression.
Slide 17
Slide 18
6
Guess what ? Time to put you in
the driver seat.
Break into two’
two’s
Grab your mind
Shy ones are going to have an anxiety
attack!
Practice makes perfect
Perform a nursing introduction to your

partner
We will discuss the process after the
exercise
Slide 19
Assessment
Nursing Health History

– Reasons for Seeking Health Care
Chief complaint
– Document information in patient’
patient’s own words.
Slide 20
SOAP:
Subjective data
Objective data,
Assessment,
Plan.
Slide 21
7
Assessment
Present Illness health history
The data collected from both subjective and
objective data can found in the chart. IDN’
IDN’s
and Doctors progress notes will describe the
time of onset of the current signs and
symptoms.
– Past Health History
Previous hospitalizations
Allergies
Habits and lifestyle patterns

Abilityto perform ADLs
Patterns of sleep, exercise, and nutrition
Slide 22
Assessment

– Family History
Includes health or cause of death, as well as
history of illness
Objective is to determine patient’
patient’s risk for
illnesses of a genetic or familial nature
Slide 23
Assessment
– Environmental History
Provides data about patient’
patient’s home
environment
– Psychosocial and Cultural History
Data about primary language, cultural
groups, educational background, attention
span, and developmental stage
Coping skills and family support
Identify major beliefs, values, and behaviors

when treating them
Slide 24
8
Assessment

– Review of Systems
Systematic method for collecting data on all
body systems.
Record in clear and concise manner with
appropriate terminology.
Ask specific questions relating to functioning
of each system.
Slide 25
Slide 26
Assessment
– Methods of Nursing Physical Assessment

Head-
Head-to-
to-toe
System-
System-by-
by-system
Focused
Slide 27
9
Assessment
Nursing Physical Assessment

– Performing the Nursing Physical
Assessment
Items needed: penlight, stethoscope, blood
pressure cuff, thermometer, gloves, and a
tongue blade
PT also makes use of the senses; touch,
smell, sight, and hearing.
Slide 28
Slide 29
Figure 4-1
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
Equipment used during a physical examination.

Slide 30
10
Assessment
– Head-
Head-to-
to-Toe Assessment
Neurologic
– Level of consciousness
– Level of orientation
– Hand grips
Slide 31
Figure 4-3
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
Assess skin turgor by grasping fold of skin on back of patient’s hand,

sternum, forearm, or abdomen.
Slide 32
Assessment
– Head-
Head-to-
to-Toe Assessment (continued)
Head and neck
– Note facial expression.
– Note symmetry of features.
Slide 33
11
Slide 34
Figure 4-9
(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical
examination. [5th ed.]. St. Louis: Mosby.)
Palpation of arterial pulses.

Slide 35
TIME FOR YOUR PHYSICAL

“Myname is wee-
wee-wee and I will be
doing your head to toe assessment
today”
today”
Slide 36
12

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CHAPTER 4

OBJECTIVE DATA DEFINED

 Objective data as OBSERVED by

WHAT DO YOU OBSERVE?

Signs and Symptoms

 Disease and Diagnosis

Signs and Symptoms

 Terms Used to Describe Disease

Signs and Symptoms

Signs and Symptoms

 Frequently Noted Signs and

 Process of making an evaluation or

 Preparing the patient

 Ask if the patient has any questions and

 Convey competence and professionalism.

 Perform a nursing introduction to your

 Nursing Health History

 Habits and lifestyle patterns

 Nursing Health History

 Identify major beliefs, values, and behaviors

 Nursing Health History

– Methods of Nursing Physical Assessment

 Nursing Physical Assessment

Equipment used during a physical examination.

Assess skin turgor by grasping fold of skin on back of patient’s hand,

Palpation of arterial pulses.

TIME FOR YOUR PHYSICAL

S-ar putea să vă placă și

Objective data as OBSERVED by

Disease and Diagnosis

Terms Used to Describe Disease

Frequently Noted Signs and

Process of making an evaluation or

Preparing the patient

Ask if the patient has any questions and

Convey competence and professionalism.

Perform a nursing introduction to your

Nursing Health History

Habits and lifestyle patterns

Nursing Health History

Identify major beliefs, values, and behaviors

Nursing Health History

Nursing Physical Assessment