Health Assessment and Physical Examination
List the five nursing purposes for performing a physical
assessment. (5) –
a. Gather baseline data about the patient's health status
b. Support or refute subjective data obtained in the nursing
history
c. Confirm and identify nursing diagnoses
d. Make clinical judgments about a patient's changing
health status and management
e. Evaluate the outcomes of care
List the principles related to the nurse performing daily
physical examinations. (4) –
a. A head-to-toe assessment is required daily
b. Reassessment is performed when the patient's condition
changes as it improves or worsens
c. The environment, equipment, and patient are properly
prepared
d. Safety for confused patients should be a priority
Proper preparation for examination should include: (5) –
a. Infection control
b. Environment
c. Equipment
d. Physical preparation of the patient
e. Psychological preparation of the patient
List seven variations in the nurse's individual style that are
appropriate when examining children. (7) –
, a. Gather all or part of the histories of infants and children
from parents
b. Perform the examination in a nonthreatening are and
provide time for play
c. Offer support to the parents during the examination and
do not pass judgment
d. Call children by their first names and address their
parents as Mr. and Mrs.
e. Use open-ended questions to allow parents to share
more information
f. Treat adolescents as adults
g. Provide confidentiality for adolescents; speak alone with
them
List seven variations in the nurse's individual style that are
appropriate wen examining older adults. (7)
a. Do not stereotype about aging patients's level of
cognition
b. Be sensitive to sensory or physical limitations (more time)
c. Adequate space is needed
d. use patience, allow for pauses, and observe for details
e. Certain types of information may be stressful to give
f. Perform the examination near bathroom facilities
g. Be alert for signs of increasing fatigue
Identify the principles to follow to keep an examination well
organized. (7) –
a. Compare both sides for symmetry
b. If a patient is ill, first assess the systems of the body part
most at risk
c. Offer rest periods if the patient becomes fatigued
, d. Perform painful procedures near the end of the
examination
e. Record assessments in specific terms in the record
f. Use common and accepted medical terms and
abbreviations
g. Record quick notes during the examination to avoid
delays
Define inspection. - Looking, listening, and smelling to
distinguish normal from abnormal findings
Identify the guidelines to achieve the best results during
inspection. (6)
a. Adequate lighting is available
b. Use direct light source
c. Inspect each area for size, shape, color, symmetry,
position, and abnormality
d. Position and expose body parts as needed, maintaining
privacy
e. Check for side-to-side symmetry
f. Validate findings with the patient
Define
palpation - Using the hands to touch body parts.
Light palpation - Pressing inward 1 cm (superficial)
Deep palpation - Depressing the area 4 cm to assess the
conditions of organs.
List the five nursing purposes for performing a physical
assessment. (5) –
a. Gather baseline data about the patient's health status
b. Support or refute subjective data obtained in the nursing
history
c. Confirm and identify nursing diagnoses
d. Make clinical judgments about a patient's changing
health status and management
e. Evaluate the outcomes of care
List the principles related to the nurse performing daily
physical examinations. (4) –
a. A head-to-toe assessment is required daily
b. Reassessment is performed when the patient's condition
changes as it improves or worsens
c. The environment, equipment, and patient are properly
prepared
d. Safety for confused patients should be a priority
Proper preparation for examination should include: (5) –
a. Infection control
b. Environment
c. Equipment
d. Physical preparation of the patient
e. Psychological preparation of the patient
List seven variations in the nurse's individual style that are
appropriate when examining children. (7) –
, a. Gather all or part of the histories of infants and children
from parents
b. Perform the examination in a nonthreatening are and
provide time for play
c. Offer support to the parents during the examination and
do not pass judgment
d. Call children by their first names and address their
parents as Mr. and Mrs.
e. Use open-ended questions to allow parents to share
more information
f. Treat adolescents as adults
g. Provide confidentiality for adolescents; speak alone with
them
List seven variations in the nurse's individual style that are
appropriate wen examining older adults. (7)
a. Do not stereotype about aging patients's level of
cognition
b. Be sensitive to sensory or physical limitations (more time)
c. Adequate space is needed
d. use patience, allow for pauses, and observe for details
e. Certain types of information may be stressful to give
f. Perform the examination near bathroom facilities
g. Be alert for signs of increasing fatigue
Identify the principles to follow to keep an examination well
organized. (7) –
a. Compare both sides for symmetry
b. If a patient is ill, first assess the systems of the body part
most at risk
c. Offer rest periods if the patient becomes fatigued
, d. Perform painful procedures near the end of the
examination
e. Record assessments in specific terms in the record
f. Use common and accepted medical terms and
abbreviations
g. Record quick notes during the examination to avoid
delays
Define inspection. - Looking, listening, and smelling to
distinguish normal from abnormal findings
Identify the guidelines to achieve the best results during
inspection. (6)
a. Adequate lighting is available
b. Use direct light source
c. Inspect each area for size, shape, color, symmetry,
position, and abnormality
d. Position and expose body parts as needed, maintaining
privacy
e. Check for side-to-side symmetry
f. Validate findings with the patient
Define
palpation - Using the hands to touch body parts.
Light palpation - Pressing inward 1 cm (superficial)
Deep palpation - Depressing the area 4 cm to assess the
conditions of organs.
