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Physical Assessment Skills - H&P, General Survey, Psychosocial Observations, Pain Evaluation, ADL Evaluation, Vital Sign

Learn about the key components of a physical assessment, including history and physical (H&P), general survey, psychosocial observations, pain evaluation, ADL evaluation, and vital signs (VS) such as pulse, respiration, and blood pressure.

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Physical Assessment Skills - H&P, General Survey, Psychosocial Observations, Pain Evaluation, ADL Evaluation, Vital Sign

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  1. Unit 7 Health Care Skills

  2. Chapter 20 Physical Assessment

  3. H&P • Date • Demographic data • Source of referral • Chief complaint(s) • History of present illness • Past history (continued)

  4. H&P • Current health status • Family history of illness • Psychosocial history • Review of all systems • Information called baseline

  5. Variances from Normal • Discriminate normal from abnormal • Use observation skills • Ask questions • Note changes in condition • Employ strong assessment skills • Report variances to supervisor

  6. General Survey • Look at patient as whole • Overall impression valuable • Determines where to focus if time limited • What to look for in general survey

  7. Psychosocial Observations • Part of general survey • Emotional status • Mental status • Appearance

  8. Question • True or False: • A critical function of the health care worker is to be able to discriminate between normal and abnormal conditions and situations.

  9. Answer • True • Critical function of health care worker: • Discriminate between normal and abnormal conditions and situations

  10. Physical Assessment Skills • Inspection • Auscultation • Palpation • Percussion

  11. Assess Systems • Musculoskeletal • Integumentary • Circulatory • Respiratory • Digestive • Urinary (continued)

  12. Assess Systems • Eyes • Ears • Nervous • Endocrine • Female reproductive • Male reproductive

  13. Question • Which of the following is using the senses of vision, hearing, and smell for observation of patient condition? • Auscultation • Palpation • Inspection

  14. Answer • C. Inspection • Inspection • Using senses of vision, hearing, and smell for observation of patient condition • Auscultation • Listening to sounds inside body with aid of stethoscope

  15. Answer • C. Inspection • Palpation • Using hands and fingers on exterior of body to detect evidence of abnormalities in various internal body organs

  16. Pain Evaluation • Subjective information • Use pain rating scale • 0 to 10 • 0 = no pain • 10 = worst pain imaginable • Wong-Baker FACES Pain Rating Scale • Oucher Scale (continued)

  17. Pain Scale Rating

  18. Pain Evaluation • Compare levels before and after pain medications • Note nonverbal cues

  19. Activities of Daily Living (ADL) Evaluation • Actions done on regular basis to meet physical needs • Inability to perform ADLs • Assistance needed as long as unable to do so

  20. Vital Signs (VS) • Temperature • Pulse • Respiration • Blood pressure

  21. Temperature • Normal range essential to homeostasis • Afebrile and febrile • Intermittent fever • Continuous fever • Night sweats

  22. Thermometer Routes • Oral • Axillary • Rectal • Aural • Temporal artery

  23. Question • Which of the following would be an ADL (activity of daily living)? • Doing laundry • Gardening • Playing piano

  24. Answer • A. Doing laundry • Doing laundry is ADL • Action done on regular basis to meet physical needs • Gardening and playing piano are not actions required to meet physical needs

  25. Pulse • Pulse points • Rate • Rhythm • Regular rhythm • Irregular rhythm • Regular irregular rhythm • Irregular irregular rhythm (continued)

  26. Pulse • Pulse volume • Radial pulse • Stethoscope • Apical pulse • Bradycardia (continued)

  27. Pulse • Tachycardia • Pulse rates vary with age • Apical-radial pulse deficit

  28. Respiration • Process of moving air through lungs • Inhalation (inspiration) • Exhalation (expiration) • Eupnea • Tachypnea • Bradypnea (continued)

  29. Respiration • Ensure patient is unaware of respirations being counted • Rate • Rhythm • Apnea • Cheyne-Stokes (continued)

  30. Respiration • Respiratory effort • Respiratory rates vary with age

  31. Question • What is tachycardia? • Abnormally high heart rate • Abnormally high respiratory rate • Abnormally low heart rate

  32. Answer • A. Abnormally high heart rate • Tachycardia • Abnormally high heart rate • Tachypnea • Abnormally high respiratory rate • Bradycardia • Abnormally low heart rate

  33. Blood Pressure (B/P) • Systolic • Diastolic • Hypotension • Hypertension • Sphygmomanometer (continued)

  34. Blood Pressure (BP) • White coat syndrome • Orthostatic (postural) hypotension • Blood pressure readings vary with age • When not to use arm to take blood pressure

  35. Question • True or False: • Orthostatic hypotension is a rapid rise in blood pressure when the patient stands.

  36. Answer • False • Orthostatic hypotension • Blood pressure falls when patient stands • Rather than rises

  37. Height and Weight • Height usually stable after adulthood • Except with osteoporosis • Many factors affect weight (continued)

  38. Height and Weight • Types of scales: • Standing balance • Chair and wheelchair • Mechanical lift • Bed • BMI

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