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Physiacl Assessment

Essay by   •  December 16, 2010  •  Essay  •  318 Words (2 Pages)  •  1,047 Views

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1. Wash your hands and assemble equipment. Greet the patient and explain what you need to do. Provide for privacy.

2. Begin with the 5 vital signs: Temperature, Pulse, Respirations, BP and Pain. Ask the patient how he feels and observe the environment. As you assess the body by systems observe for mobility and ROM.

3. HEENT

* head: shape and symmetry; condition of the hair and scalp

* eyes: conjunctiva and sclera, pupils; reactivity to light and able to follow a finger or light

* ears: hearing aids, pain, hears whispers, comprehension

* nose: drainage, congestion, difficulty breathing or with sense of smell

* throat and mouth: mucous membranes, any lesions, teeth or dentures, odor, swallowing, trachea, lymph nodes

4. As you examine all body systems observe the integumentary system for any breaks in the skin, scars, lesions, wounds, redness or irritation. Also note turgor, the color, temperature, and moisture of the skin.

5. Thoracic region. Assess lung sounds and cardiac sounds. Front and back: assess for character and quality as well as the presence or absence of appropriate sounds Palpate the chest wall and breasts for any tenderness, lumps.

.6. Abdomen: Listen to bowel sounds throughout the four quadrants. Palpate for tenderness or lumps Palpate the bladder Ask about Intake and appetite, and output both urinary and bowels Genetalia: assess for tenderness, lumps or lesions

7. Extremities: Assess for temperature, capilary fill and ROM. Palpate pulses. Note any edema, lesions, lumps, pain.

8. Ask the patient how he feels. Has anything changed recently? Any pain, burning, SOB, chest pains, change in bowel or bladder habits, change in sleep habits, cough, discharge from any orafice,depression, sadness, change in appetite.

9. Wash your hands. Document your findings. Report any significant changes or findings to the MD.

What You Need:

* Pen

* Assessment forms or note paper

* Thermometer

* Watch

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