Head to Toe Physical Assessment – Nursing is a profession within the healthcare sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other healthcare providers by their approach to patient care, training, and scope of practice. Nurses practice in many specialisms with differing levels of prescriber authority.
Many nurses provide care within the ordering scope of physicians, and this traditional role has shaped the public image of nurses as care providers. However, nurses are permitted by most jurisdictions to practice independently in a variety of settings depending on training level. In the postwar period, nurse education has undergone a process of diversification towards advanced and specialized credentials, and many of the traditional regulations and provider roles are changing.
Nurses develop a plan of care, working collaboratively with physicians, therapists, the patient, the patient’s family, and other team members, that focus on treating illness to improve quality of life. Nurses may help coordinate the patient care performed by other members of an interdisciplinary healthcare team such as therapists, medical practitioners, and dietitians. Nurses provide care both interdependently, for example, with physicians, and independently as nursing professionals.
Head to Toe Physical Assessment
Definition of Physical Assessment:
Physical assessment is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination. A physical assessment should be adjusted to the patient, based on his needs. It can be a complete physical assessment, an assessment of a body system, or an assessment of a body part.
Or,
Physical assessment or examination is a thorough investigation of the entire body or some parts of the body to determine the general physical or mental condition of the body (client).
Types of Nursing/Physical Assessment:
There are several types of nursing assessment, each conducted at different times and for different purposes.
A. Initial assessment: This is aimed at providing a complete data base for identifying problems and planning care. It also provides the baseline data for comparison when evaluating the effectiveness of care. It is therefore performed as close to the time of admission when evaluating the effectiveness of care. It therefore performed as close to the time of admission as possible. It includes taking a comprehensive nursing history and performing a physical examination.
Techniques/methods of physical examination
Technique of Health Assessment
The nurse mainly uses four technique during performing physical assessment. The following techniques are given below-
5. Inspection
6. Palpation
7. Percussion
8. Auscultation
E. Inspection-critical observation #always first –
- Take time to “observe” with eyes, ears, nose (all senses)
- Use good lighting
- Look at color, shape, symmetry, position
- Observe for odors from skin, breath, wound
- Develop and use nursing instincts
- Inspection is done alone and in combination with other assessment techniques
F. Palpationlight and deep touch –
- Back of hand (dorsal aspect) to assess skin temperature
- Fingers to assess texture, moisture, areas of tenderness
- Assess size, shape, and consistency of lesions and organs
- Deep = 5-8 cm (2-3″) deep; Light = 1 cm deep
G. Percussion-sounds produced by striking body surface –
- Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)
- Used to determine size and shape of underlying structures by establishing their borders and indicates if tissue is air-filled, fluid-filled, or solid
- Action is performed in the wrist.
H. Auscultation- listening to sounds produced by the body –
- Direct auscultation – sounds are audible without stethoscope
- Indirect auscultation – uses stethoscope
- Know how to use stethoscope properly [practice skill]
- Fine-tune your ears to pick up subtle changes [practice skill]
- Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill]
- Flat diaphragm picks up high-pitched respiratory sounds best.
- Bell picks up low pitched sounds such as heart murmurs.
- Practice using BOTH diaphragms
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