How to Conduct a Physical Assessment Cindy Fichera RN MSN

The Purpose of this Lecture Introduction The Goal: Avoid the “deer in the head lights” Physical Assessment folded sheet method Overview

Where do I go from here? ABC’s Subjective vs. Objective Data The Nursing Process Your Nursing Note

Neurological Assessment A & O X3 MAEW Pupils/ PERRLA numbness/dizziness R/L sided weakness UE/LE weakness follows command responds to stimuli facial droop speech clear

Cardiac Assessment Any chest pain/denies? Skin= P/W/D Pulses -radial, pedal, post tibial Peripheral Edema -where, how much, pitting? AP= reg/irreg? Unusual Sounds? IV site -where, size, patent & intact? IV fluids -what is running and rate?

Respiratory Assessment Any SOB/denies? Cyanosis? Where? Breathing - labored or non- labored? RR ( respiration rate) Lung Sounds? Cough? Expectorations? -describe secretions O2 Saturation? O2 delivery system -how many liters via R/A, N/C, VM, NRB?

Gastrointestinal Assessment Any Pain, where? Any N/V/D? Look, Listen, Feel Bowel Sounds? -positive/absent -hyper/hypo active -where? RLQ, RUQ, LUQ or LLQ Flat/Distended? Tender/non-tender? PO intake, how much? N/G tube, which nare & placement? Bowels habits? Tube feed what, how much per hour?

Genitourinary Assessment Symptoms? F requency, burning, flank pain Urine, color, consistency? Foley, size? Total UO (urine output) Using urinal or bedpan? Dialysis? CAPD? (continuous ambulatory peritoneal dialysis) Urine Dip?

Musculoskeletal Assessment Related to orthopedic not neurological problems OOB to chair, 1 or 2 assist? MAEW ROM Visit by PT Gait, steady/unsteady any assistive devices Activity Level? Site of surgical site? Staples intact, pulses ( skin or cardiovascular)

Integumentary System Describe what you see? 1 inch area, 1cm area Ecchymotic, Red, Black, odor? Intact or draining? If draining consistency of exudate, scant, moderate or copious drainage? Surgical Site, Wound Site or Ulcer Site? Staples or sutures intact. -Edges of site “approximate”; drainage? -Dressing intact? -Dressing change?

Psycho-Socio Assessment Pleasant Cooperative Sad Tearful Flat Poor eye contact Talkative Withdrawn

Conclusion and Re-cap Your Nursing Process! Assessment: What are your problems? Diagnosis: Based on NANDA Plan: What will you do and continue to do about your problems? Interventions: Your actual actions carried out to fix problem. Any action you do to comfort your patient. Evaluate: How did your interventions work?