1. Physical Assessment

2. Indications for the Physical Exam
1. Routine screening
2. Eligibility prerequisite for health insurance, military service, job, sports, school
3. Admission to a hospital or long term care facility

3. Physical Exam and Health Assessment
A complete health assessment includes both nursing history and physical exam
Information gathered in both the health history and physical exam serves provides a baseline of the client’s functional abilities

4. Skills of Physical Assessment
Inspection
Palpation
Percussion
Auscultation
Olfaction

5. Utilization of Assessment Skills
We utilize our assessment skills to:
Gather a database (baseline)
Confirm and identify nursing diagnoses
Make clinical judgments about a client’s changing health status
Evaluate the effectiveness of nursing care

6. Preparation of Client and Environment
Exam room needs to be well lit and and noises limited or eliminated
Equipment should be within reach and working properly
Client should be prepared with appropriate draping
Client’s dignity, privacy, and comfort should be maintained
Client should be given appropriate explanations and directions before and during exam

7. Organization of Exam
Exam should follow organized and systematic format
Why?
All physical and emotional findings should be recorded as soon as possible

8. Helpful Guidelines for Examination
Compare both sides for symmetry
If client is seriously ill, first assess systems of the body more at risk for being abnormal
If client becomes fatigued, offer rest periods of rest
Record results of exam in specific anatomical and scientific terms
Use common, accepted abbreviations, keep notes brief and concise
Record quickly to avoid keeping client waiting
May use standardized form to record findings in the same sequence that it was gathered

9. Types of Examinations Head to Toe exam Systems assessment
A complete physical
Often done on an initial visit to hospital or doctor’s office- serves as a baseline
Head to toe exam includes an assessment of systems
Systems assessment
Used more on a day to day basis w/ hospital clients
Focus is on a particular system that may be affected by pathology
Guides questioning
Provides clues of related pathology
Example: Pneumonia- exam lungs, breath sounds and any other system affected by poor oxygenation