Physical Assessment

Systematic Approach

■ Always observe standard precautions.

■ Listen to your Pt.

■ Provide a comfortable environment and ensure privacy.

■ If there is an obvious problem, start at that point.

■ Work from head to toe and compare right to left.

■ Let your Pt know your findings and use this time to teach.

■ Leave sensitive or painful areas until the end of the exam.

■ Techniques used for physical assessment include (1) inspection,

(2) palpation, (3) percussion, and (4) auscultation and, except for the

abdomen, are carried out in this order.

■ Document assessments, interventions, and outcomes.

Assessing Vital Signs

■ Heart Rate: Using two to three fingers, palpate pulse over pulse point for 30 seconds and multiply by two. If pulse is irregular, count for an entire minute. Compare pulses right to left. Document: Rate, rhythm, strength, and any right-left differences.

■ Respirations: Ensure that Pt is resting comfortably and is unaware that respirations are being monitored. Count respirations for 30 seconds and multiply by two (count irregular or labored respirations for a full minute). Document: Rate, depth, effort, rhythm, and any sounds, noting whether heard on inspiration, expiration, or both.

■ Blood Pressure: Place Pt in comfortable position with arm slightly flexed and palm facing up, with forearm supported at heart level (Pt’s legs should not be crossed). Apply cuff snugly around upper arm and ensure proper size and fit. Place stethoscope over brachial artery and inflate cuff ~30 mm Hg over expected systolic pressure. Slowly release cuff pressure. NEVER measure BP on arm with dialysis shunt, injury, intra-arterial line, or same side mastectomy or axilla surgery! Avoid arms with IV/VAD if possible. Document: Point at which sound is first heard (systolic) over point at which sound completely ceases (diastolic).

■ Temperature: Oral—electronic: Reading obtained in ~1 minute; Oral— glass: Reading obtained in ~2–3 minutes; Oral—chemical (Temp-a-dot): Reading obtained in ~45 seconds; Tympanic—electronic: Reading obtained in ~2 seconds. Document:Temperature reading and route.