![]() ![]() ![]() Physical assessment is a fundamental part of a nurse’s skill set and a technique that promotes patient safety. Advanced practice nurses also carry out this exam when admitting patients and in office settings. ![]() The exam length varies depending on how complex the patient is and the indication for the exam. Assess for changes such as jaundice, cyanosis (bluish tint), flushing, diaphoresis (sweating), and paleness.Īs a nurse, you typically perform an assessment each shift. Integument: Assess for skin breakdown or wounds.Assess for slurred speech, extremity movement, gait, and difficulty swallowing. Neuromuscular: Evaluate the level of consciousness.Genitourinary: Assess voiding, discharge, vaginal bleeding, rashes, pain, urinary frequency, and catheter presence.Ask about the character of bowel movements, appetite, weight loss or gain, nausea or vomiting, and pain. Gastrointestinal: Auscultate for bowel sounds.Assess for cough, labored breathing, gasps, or any difficulty with breathing. Respiratory: Evaluate breath sounds for rate and rhythm.Inspect extremities for edema, coolness, or cyanosis. Cardiovascular: Auscultate heart sounds.General: Complete an overall survey of the patient, including body habitus, hygiene, body odor, mood, and vital signs.And the following critical components are assessed: When conducting an assessment, nurses take a comprehensive look at all areas of the body. The physical exam portion provides a nursing diagnosis 15% to 20% of the time. Additional components are added based on these factors.įor example, an obstetric patient may have additional areas to assess, including fetal well-being, contractions, and cervical dilation. Once everything is ready, the exam can start.Ī head-to-toe assessment varies depending on the purpose of the exam and the patient’s condition. You must be knowledgeable in the use of various equipment, and prepare the patient, setting, and yourself. Information provided by other health professionalsĬonduct the head-to-toe assessment systematically to ensure you include all necessary components.Observations from family or significant others.Physical exam techniques, which involve inspection (use of vision, smell, and hearing to observe and detect normal and abnormal findings), palpation (use of your hands to feel for temperature, consistency, size, shape, strength, moisture, and texture), percussion (use of your hands to tap and hear different tones), auscultation (listening to body sounds using a stethoscope).You analyze and use the data to form nursing diagnoses and interventions.ĭata collection occurs in different ways, including: An assessment is not a one-time event but rather an ongoing process. You consider the patient’s mind, body, and spirit through a comprehensive assessment. Features of an assessment consist of objective and subjective data, which can include: One central component of a holistic health assessment is a head-to-toe physical exam. By practicing comprehensive health assessments and understanding what is involved and steps you should take, you contribute to higher quality care and give patients better and safer outcomes. Head-to-toe assessments are an invaluable component to patient care. Exam findings are then communicated to other clinicians and interdisciplinary teams to help facilitate solutions. Early warning signs noted by changes in your patient’s condition can be discovered, which can then lead to appropriate interventions. Heath assessments also provide vital information that can identify life-threatening conditions. You collect subjective and objective data that helps to identify a patient’s needs and problems which lead to the formation of nursing diagnoses. This evaluation includes many factors, including a head-to-toe exam.Ī head-to-toe assessment is a comprehensive patient health evaluation. The first step of the nursing process involves collecting data with a thorough assessment. ![]()
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