Purpose of physical examination

Purpose of physical examination

1. PURPOSES OF PHYSICAL EXAMINATION

2. A PHYSICAL EXAMINATION IS PERFORMED FOR ANY OF SEVERAL REASONS: To obtain baseline data.

3. Data about the patient’s physical status and functional abilities serve as a baseline for comparison as the patient’s health status changes.

4. To identify nursing diagnoses, collaborative problems, and wellness diagnoses.

5. Problem statements form the basis for the plan of care and help to address the patient’s nursing care needs.

6. To monitor the status of a previously identified problem.

7. To screen for health problems. Regular checkups can help to identify health problems at early stages.

8. The type of physical examination perform will depend on The client’s health status, The nature of the client , and the setting.

9. A comprehensive physical assessment, which includes a health history interview and a complete head-to-toe examination of every body system.

10. A focused physical assessment pertains to a particular topic, problem, body part, or functional ability of the patient.

11. A system-specific assessment is a focused assessment limited to one body system. (e.g., the lungs, the peripheral circulation).

12. The following are examples of focused and system-specific physical assessments, respectively: Assessing bowel sounds when a client has abdominal pain.

13. Listening to breath sounds, counting respirations, and obtaining pulse oximetry readings to assess a patient’s respiratory status.

14. ONGOING ASSESSMENT Ongoing assessment is performed as needed, after the initial database is completed, and, ideally, at every interaction with the patient.

15. For example, on a medical–surgical unit, each nurse who provides care to a client conducts a brief ongoing assessment to determine changes in the client’s status and evaluate client outcomes.

16. Develop a systematic approach and follow the same order each time to perform a physical exam.

17. A HEAD-TO-TOE APPROACH A head-to-toe approach starts at the head and neck and progresses down the body, examining the feet last.

18. BODY SYSTEMS APPROACH A body systems approach examines each system in a predetermined order. (e.g., Musculoskeletal, cardiovascular, neurological).

19. Whatever the approach, prepare the environment, and the client before procedure begins.

20. Preparing for a physical examination requires theoretical knowledge of anatomy and physiology,

21. Examination equipment and techniques, therapeutic communication, and documentation. Self-knowledge is also important.

22. PREPARE THE ENVIRONMENT : Physical examination requires you to observe and touch the client’s body, so privacy is essential.

23. It needs a room with curtains or a door to shield the client from view.

24. For additional privacy, drape your client and uncover only the area you are examining.

25. For convenience you may use bed linens and/or a gown to drape.

26. Determine the instruments and equipment you will need.

27. Take the time to establish rapport with the client, to help him relax and cooperate fully in the assessment.

28. Introduce yourself, ask the client how he wishes to be addressed, and explain what will be doing.

29. -Ask the client to void before the examination; -this promotes relaxation and also makes it easier to palpate the abdomen.

30. -Always alert the client before touching him.

31. The client will need to assume a variety of positions during a comprehensive physical examination.

32. -To begin the examination, seat the client on the side of the bed or examination table. -Face the client, and establish eye contact.

33. -An upright position allows the client to expand his lungs fully and is useful for assessing vital signs, the head and neck, the heart and lungs, the back, and the upper extremities.

34. -As you place your client in positions that allow to best observe the body system you are examining, be alert to special needs that call for you to modify the position.

35. THANKING YOU