Baseline data that is collected after the health history and before the complete head to toe examination includes a general survey of the client. The general survey includes the patient’s weight, height, body build, posture, gait, obvious signs of distress, level of hygiene and grooming, skin integrity, vital signs, oxygen saturation, and the patient’s actual age compared and contrasted to the age that the patient actually appears like. For example, does the patient appear to be older than their actual age? Does the patient appear to be younger than their actual age?Physical Health Assessment Essay.
Nurses prepare and position clients for physical examinations. Nurses provide privacy, explain and reinforce the procedures to the client and insure that the client is as comfortable as possible during the physical examination.
As with all other aspects of nursing care, all data and information that is collected with the health history and the physical examination are documented according to the particular facility’s policies and procedures. Some facilities use special forms for this data and information.Physical Health Assessment Essay.
Registered nurses, advanced practice nurses such as nurse practitioners, and doctors typically do the complete head to toe physical assessment and examination and document all of these details in the patient’s medical record; however, licensed practical nurses review these details and compare this baseline physical examination data and information to the current patient status as they are providing ongoing care. They also report and document all their significant physical examination results to the supervising registered nurse and/or the patient’s health care provider.Physical Health Assessment Essay.
The four basic methods or techniques that are used for physical assessment are inspection, palpation, percussion and auscultation. Inspection is a visual examination of the patient; palpation is done when the person doing the assessment places their fingers on the body to determine things like swelling, masses, and areas of pain. Palpation can include light and deep palpation. Deep palpation is cautiously done after light palpation when necessary because the client’s responses to deep palpation may include their tightening of the abdominal muscles, for example, which will make the light palpation less effective for this assessment, particularly if an area of pain or tenderness has been palpated.Physical Health Assessment Essay.
Percussion is tapping the patient’s bodily surfaces and hearing the resulting sounds to determine the presence of things like air and solid masses affecting internal organs. The sounds that are heard with percussion are resonance which is a hollow sound, flatness which is typically hear over solid things like bone, hyper resonance which is a loud booming sound, and tympany which is a drum type sound.
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