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    Physical Assessment

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    Aira Catubay
    Physical assessment involves systematically collecting data about a client's health status through a health history and physical exam. This data includes physiological, psychological, sociocultural, and spiritual aspects to establish actual or potential health problems and develop the nurse-client relationship. The history is obtained first through interview and records, then the physical exam uses tools and techniques to collect data related to the history. A complete assessment is not always needed but may be part of an admission or health screening exam. Information is organized into subjective data from the client's perspective and objective data that can be observed or tested. Frameworks like head-to-toe or functional health patterns guide the assessment. The interview process establishes rapport, ensures privacy and cultural sensitivity, and obtain

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    Physical Assessment

    Uploaded by

    Aira Catubay
    23 views3 pages
    Physical assessment involves systematically collecting data about a client's health status through a health history and physical exam. This data includes physiological, psychological, sociocultural, and spiritual aspects to establish actual or potential health problems and develop the nurse-client relationship. The history is obtained first through interview and records, then the physical exam uses tools and techniques to collect data related to the history. A complete assessment is not always needed but may be part of an admission or health screening exam. Information is organized into subjective data from the client's perspective and objective data that can be observed or tested. Frameworks like head-to-toe or functional health patterns guide the assessment. The interview process establishes rapport, ensures privacy and cultural sensitivity, and obtain

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    Physical assessment involves systematically collecting data about a client's health status through a health history and physical exam. This data includes physiological, psychological, sociocultural, and spiritual aspects to establish actual or potential health problems and develop the nurse-client relationship. The history is obtained first through interview and records, then the physical exam uses tools and techniques to collect data related to the history. A complete assessment is not always needed but may be part of an admission or health screening exam. Information is organized into subjective data from the client's perspective and objective data that can be observed or tested. Frameworks like head-to-toe or functional health patterns guide the assessment. The interview process establishes rapport, ensures privacy and cultural sensitivity, and obtain

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    Download as docx, pdf, or txt
    23 views3 pages

    Physical Assessment

    Uploaded by

    Aira Catubay
    Physical assessment involves systematically collecting data about a client's health status through a health history and physical exam. This data includes physiological, psychological, sociocultural, and spiritual aspects to establish actual or potential health problems and develop the nurse-client relationship. The history is obtained first through interview and records, then the physical exam uses tools and techniques to collect data related to the history. A complete assessment is not always needed but may be part of an admission or health screening exam. Information is organized into subjective data from the client's perspective and objective data that can be observed or tested. Frameworks like head-to-toe or functional health patterns guide the assessment. The interview process establishes rapport, ensures privacy and cultural sensitivity, and obtain

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    of 3

    PHYSICAL ASSESSMENT

    Physical assessment is taking an educated, systematic look at all aspects of an individuals health status
    utilizing knowledge, skills and tools of health history and physical exam.
    o

    To collect data- information about the clients health, including physiological,


    psychological, sociocultural and spiritual aspects

    To establish actual and potential problems

    To establish the nurse-client relationship

    Method: The history is done first, then the physical examination focuses on finding data associated with
    the history.
    o

    Health History- obtained through interview and record review.

    Physical exam- accomplished by tools and techniques

    ** A complete assessment is not necessarily carried out each time. A comprehensive assessment is part
    of a health screening examination. On admission, you will do an admission assessment (not necessarily
    including everything presented here) and document it on the admission form. You will do a daily shift
    assessment (patient systems review). And, if client has a specific problem, you may assess only that
    part of the body (focused).
    Data Collection:
    Information is organized into objective and subjective data:
    o

    Subjective: Apparent only to person affected; includes clients perceptions, feelings,


    thoughts, and expectations. It cannot be directly observed and can be discovered only
    asking questions.

    Objective: Detectable by an observer or can be tested against an acceptable standard;


    tangible, observable facts; includes observation of client behavior, medical records, lab
    and diagnostic tests, data collected by physical exam.

    ** To obtain data for the nursing health history, you must utilize good interview techniques and
    communications skills. Record accurately. DO NOT ASSUME.
    D. Frameworks for Health Assessment
    There are two main frameworks utilized in health assessment:
    Head to Toe- systematic collection of data starting with the head and working downward.
    o

    Functional Health Assessment- Gordons 11 functional health patterns that address the
    behaviors a person uses to maintain health.

    PERSON is the ACC-ADN framework for assessment. It is similar to Gordon's functional

    health patterns.
    Interview Process:
    o

    If possible, review the chart before seeing the client. Review the medical history and
    progress notes; significant x-ray, imaging and lab findings.

    Secure the environment. It should be private, quiet and uninterrupted. The environment
    should be well lighted; have all the necessary equipment on hand.

    Greeting Client- Use appropriate title; introduce self (both names and explain role).
    Explain the purpose and nature of the assessment.

    Manner- Relaxed, not hurried; may sit or stand

    Comfort- Inquire how client is feeling; is it convenient; watch for signs of discomfort
    such as poor positioning; evidence of pain or anxiety.

    Opening- What brings you to the hospital? (Chief complaint). Then, tell me about it.
    Watch out for closed end questions.

    Follow client leads- Many will talk; others will not. Listen actively for important
    symptoms, emotions, events and relationships. Guide the client into telling more about
    these areas. Be empathetic and caring

    Be professional- nonjudgmental, concerned and informed. Reactions that betray distrust,


    disapproval, impatience (nonverbal behaviors) block communication.

    Confidentiality- Assure clients that the information you collect will be shared only with
    the health care team.

    Show Cultural sensitivity -Be aware of any preconceived biases. If language is a problem,
    try to get an official translator. Also, be aware that certain physical findings or conditions
    are associated with certain races or cultures.

    Health History Collection:


    o

    Biographical Data: Name, Age, Sex, etc.

    Chief Complaint: Answer to What brought you to the hospital? This should be told in
    the client s own words and establishes the purpose of the contact. Client should be
    encouraged to discuss symptoms specific to the complaint.

    History of the Present Illness (HPI): A clear, chronological account of the events

    that led the client to seek care (onset, s/s, occurrence of symptoms, and
    response to treatment).
    o

    Family History: Reveals risk factors for disease- focus on diabetes mellitus, heart
    disease, HTN; TB; cancer.

    Review of Systems: (subj. information) Purpose is to reveal data r/t present illness; to
    identify other problems that might be missed. Checklists are often used.

    Personal Profile: Personal habits (EOTH, drugs, tobacco); diet; ADLs (bathing, toileting,
    transfer, eating, dressing).

    Social History: Family members, occupation, spiritual beliefs, economic status.

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