physical assessment objectives

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Author:
athors766ns
ID:
282033
Filename:
physical assessment objectives
Updated:
2014-09-03 20:15:13
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test1
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Description:
Physical assesment
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  1. Types of nursing assesments
    initial, focused, shift, emergency, ongoing
  2. Initial assessment
    • comprehensive assessment
    • done with the first/initial contact with pt to rule out and identify problems
  3. focused assessment
    • detailed exam of the identified problem areas.
    • done with new complaints and problems identified
  4. shift assessment
    • combo of initial and focused exam.
    • done at the start of a shift or change of care providers.
  5. emergency assessment
    • life threatening or time sensitive.
    • prioritized based upon ABC
  6. Ongoing assesment
    • throughout pt stay
    • before and after interventions
  7. normal temperature
    • 36-38 deg C
    • 96.8-100.4 deg F
  8. normal pulse
    60-100 beats per min
  9. Respiratory rate
    12-20 breaths per min
  10. Blood pressure
    100/60-120/80
  11. O2 Saturation SpO2
    90% (really want it to be 95%)
  12. Pain PQRST
    • Pain rating scale: Faces and number rating scale
    • P: provoke- what makes it better/worse
    • Q: quality
    • R: radiation
    • S: severity
    • T: temporal factors
  13. inspection
    Visual exam. symmetry is key
  14. palpation
    • Touch to examine body
    • back of hand: temp
    • fingertips: texture, shape, size, consistency, position and tugor.
    • Palm: vibration
  15. Percussion
    • short, sharp strikes or tapping on body to produce vibrations and sounds to evaluate size, borders, and consistency of body organs.
    • Fluid filled: melon
    • air filled: drum
    • solid: wood
  16. auscultation
    • listen to sounds made by the lungs heart and intestines.
    • intensity(loudness), frequency, quality(gurgling), duration(length)
  17. abdominal physical assessment
    • inspect, auscultation, palpate, percussion
    • This is because if you tap before listening, you can hear can air bubbles in the intestines not bowel sounds.

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