Exam (elaborations)
NUR 3010 Physical Assessment (1)
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NUR 3010 Physical Assessment (1)
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NUR 3010 Physical AssessmentIntroduction & Chief Complaint - ANS--Introduce self
-identify pt (full name, DOB, wristband)
-Ask open ended question & identify chief complaint (what brought you in to the hospital?)
Gather Subjective Data - ANS--COLDSPA & patient perception. (Have you experienced/felt this
before? OR what do you think is going on?)
General Systems - ANS--Appearance (anything stand out)
-Vitals & Pain
Neurological System - ANS--A&O status
-Follows commands (wiggle toes)
-PERRLA
Cardiovascular System - ANS--Inspect Precordium (symmetry, apical impulse)
-Palpate chest tenderness and/or heaves/thrills
-Auscultate APETM (bell & diaphragm)
-Assess grade all pulse points & cap refill
-Assess edema in all extremities
Cardiovascular Pulse Points - ANS--Carotid
-Femoral
-Radial
-PT pulse
-DP pulse
Respiratory System - ANS--Inspect chest shape & A/P diameter
-Auscultate posterior & anterior lung fields (diaphragm, NOT over clothes)
Gastrointestinal System - ANS--Inspect shape and any scars, assess last BM
-Auscultate bowl sounds (all quadrants)
-Percuss abdomen (all quadrants)
-Palpate abdomen (LAST, ask about RUQ pain BEFORE)
Genitourinary System - ANS--Assess voiding (last void, how often)
-Inspect catheter & note urine color (if present)
Integumentary System - ANS--Assess skin; color, temp., moist., CHECK scalp.
-Assess for open wounds, drainage, rashes, abnormalities.
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