1. PUTTING IT ALL TOGETHER

2. 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)

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

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

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

6. 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)

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

8. 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

9. 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

10. 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)

11. 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

12. 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

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

14. 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)

15. 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)

16. 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

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