Basic Physical Assessment Notes (Nursing)

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Topics: Heart
Physical Assessment Reading notes
Monday, August 26, 2013

TCNS:
Physical assessment is the systematic collection of objective data that are directly observed or are elicited through examination techniques, such as inspection, palpation, percussion, and auscultation.
Subjective & Objective data
Subjective data is the data the patient tells you
Objective data is the data you collect during the assessment
Inspection
Performing deliberate, purposeful observations in a systematic manner
Uses senses of smell, hearing, and sight
Looking for symmetry on both sides of body, lesions (tattoos, moles, pimples, and anything else not meant to be on skin), abnormalities, color, shape, moisture (diaphoresis, or lack of)
Make sure you’re talking to the pt, letting them know what you’re looking at/for (not just blankly staring at them)
Palpation
Uses sense of touch
Assesses temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs
Temperature is assessed with the dorsal (back) side of your hand
The palms of your hand are used to feel vibrations
Tips of your fingers are used to feel organs and other underlying structures
Light palpation: apply light pressure with dominant hand, using circular motions to feel surface structure (only press ½in.)
Deep palpation: place non-dominant hand on top of dominant hand and apply pressure to feel deeper structures, like organs or masses (about 1-2in)
Palmar surfaces of the examiner’s fingertips and finger pads are used for discriminatory sensation such as texture, vibration, presence of fluid, or size and consistency of a mass
The dorsum (back of hand) is used to assess surface temp.
Percussion
Act of striking one object against another to produce sound
Assess location, shape, size, and density of organs and other underlying structures or tissues
Tones (from softest to loud intensity):
Flat: over bony prominences (thigh)
Dull: over organs (liver)
Resonance: normal lung

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