PUTTING IT ALL TOGETHER

Outcomes Identify pertinent history data included in a complete history. Obtain a complete history. Differentiate a regional versus a system approach in performing a complete physical assessment (Continued)

Outcomes Perform a complete physical assessment. Document complete assessment findings. Identify actual/potential health problems stated as nursing diagnosis with supporting data

History Biographical Current health status Past health history Family history Review of systems Psychosocial

Case Study Marcia Malone, age 40, married, mother of three, accountant Requesting health screening Concerned about osteoporosis

Pertinent History Findings Biographical: 40-year-old, white, married, mother of 3, accountant, Protestant No current health problems Past Health History: appendectomy, tubal ligation; frequent strep throats; NKDA (Continued)

Pertinent History Findings ROS: 15# weight gain over past year; menarche at age 14; irregular menses 23-45 days; LMP 21 days ago for 5 days with moderate to heavy flow; Gravida 3 Para 3; occasional BSE (Continued)

Pertinent History Findings Psychosocial: doesn’t have routine health care; doesn’t know cholesterol level; never had a mammogram; no PAP for 3 years; no routine exercise program; + night sweats; prayer, friends, and family are supports

Physical Assessment Anatomical landmarks: use appropriate landmarks for area being assessed Approach: inspection, auscultation, percussion, palpation by system or region Position: dependent on region being assessed Tools: all tools of assessment needed for complete exam

Focused Physical Exam General survey with VS, height, and weight Level of consciousness Skin color, temperature, and texture Gross balance and coordination EOM, pupils, gross vision and hearing (Continued)

Focused Physical Exam Oral mucosa and say “Ah” Palpate apical, PMI, auscultate heart sounds Auscultate bowel sounds; percuss and palpate abdomen Palpate pulses Test sensation and strength on upper and lower extremities

Physical Assessment by Region General survey: vital signs, height, weight Skin, hair, & nails Head, face, & neck Anterior chest  Posterior chest Upper extremities  Abdomen Lower extremities  Pelvic exam

Documentation Document by systems and, to small extent, by region Document + findings Document pertinent negatives

Pertinent Physical Findings General Survey: well-developed, 5’3”, 165# VS WNL, AAO x 3 Hair gray; skin pink, dry, and warm Far Vision 20/20, near vision intact, EOM intact, PERRLA direct and consensual (Continued)

Pertinent Physical Findings Lungs clear, HRRR no extra sounds Abdomen soft nontender + BS MS: + 5 muscle strength of upper and lower extremities; normal spinal curves, joints FROM without pain or deformity (Continued)

Pertinent Physical Findings Neurological: upper and lower extremities sensations intact; CN I through XII intact Gait balanced and coordinated, DTR +2 Pelvic exam negative; mucous membranes pale, pink

Nursing Diagnosis What actual or potential problems can you identify for Mrs. Malone?