1. PUTTING IT ALL TOGETHER NUR211 Kathleen Hancock

2. Nurse’s Skills 4Critical thinking 4Interpersonal 4Proficient examination skills 4Proper equipment 4Use appropriate barriers – gloves 4Systematic method of organization

3. Outcomes 4Obtain complete health history 4Perform physical exam 4Assess mental status 4Document findings 4Develop problem list 4Identify nursing diagnoses

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

5. 4Organization of PE 4Head to toe 4Body Systems 4Body Regions

6. Helpful Hints 4Warm hands & equipment 4Short fingernails 4Privacy, gown drapes, quiet 4Explain 4Observe client, especially face

7. 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

8. Focused Physical Exam 4 General survey with VS, height, and weight 4 Level of consciousness 4 Skin color, temperature, and texture 4 Gross balance and coordination 4 EOM, pupils, gross vision and hearing (Continued)

9. Focused Physical Exam 4 Oral mucosa and say “Ah” 4 Palpate apical, PMI, auscultate heart sounds 4 Auscultate bowel sounds; percuss and palpate abdomen 4 Palpate pulses 4 Test sensation and strength on upper and lower extremities

10. Physical Assessment by Region 4 General survey: vital signs, height, weight 4 Skin, hair, & nails 4 Head, face, & neck 4 Anterior chest  Posterior chest 4 Upper extremities  Abdomen 4 Lower extremities  Pelvic exam

11. Documentation 4 Document by systems and, to small extent, by region 4 Document + findings 4 Document pertinent negatives