11.01 Introduction

Overview

  • While it is impossible to list every possible disorder of the various body systems, this book attempts to provide the outline for a basic physical assessment to allow the nurse the ability to determine if the patient has any outlying abnormalities. This is not intended to be a complete guide to pathophysiology but to provide a framework for completing a thorough head to toe assessment.

 

  • Checklist for General Assessment
    Body Structure/Mobility
    Behavior
    Health History

    Vital Signs
    Height Weight
    Pulse Rate
    Respirations
    Temperature
    Blood Pressure
    Pain

    Integumentary
    Inspect: color, moisture, hair, rashes, lesions, pallor, edema
    Palpate: temperature, turgor, lesions, edema, texture

    Scalp
    Inspect: shape, symmetry
    Palpate: tenderness, deformity

    Nails

    Inspect: shape, color
    Palpate: capillary refill

    Head

    Inspect: symmetry, shape, size, uniformity

    Neck

    Inspect: symmetry, lesions, scars
    Palpate: tenderness, lymph nodes, thyroid gland, TMJ

    Eyes

    Inspect: interior and exterior, visual fields, acuity, reflexes

    Ears

    Inspect: color, shape, symmetry, interior inspection
    Palpate: tenderness, deformity

    Nose

    Inspect: shape, symmetry, interior inspection
    Palpate: frontal sinus, maxillary sinuses

    Mouth and Throat
    Inspect: exterior and interior

    Thorax and Lungs (anterior and posterior)
    Inspection: respiration quality, symmetry, deformity, tracheal location
    Palpation: tenderness, fremitus, chest expansion
    Percussion: percussive tones, diaphragmatic excursion
    Auscultation: breath sounds and quality

    Heart and Great Vessels
    Inspection: jugular venous pulse
    Palpate: pulses, PMI
    Auscultate: heart sounds (bell and diaphragm)

    Peripheral Vascular System
    Inspect: color, edema
    Palpate: temperature, edema

    Abdomen
    Inspect: discomfort, uniformity, color, symmetry, scars, hernia, peristalsis, pulsations
    Auscultate: bowel sounds, bruits
    Percussion: four quadrants, liver, spleen, renal tenderness
    Palpation: light to deep, liver, spleen, aorta, rebound tenderness, fluid wave

    Musculoskeletal
    Inspection: asymmetry, deformity, atrophy
    Palpation: major joints, tenderness, deformity, range of motion

    Neurological
    Inspect: mental status (health history), cranial nerves, coordination, movement, senses
    Palpate: motor strength, muscle tone, reflexes, senses

    Genitourinary
    Inspect: general appearance, lesions, scars
    Palpate: breast exam, testicular exam, prostate exam, vaginal exam, Pap smear

    Lymphatic
    Palpate: assess lymph node locations

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Video Transcript

Hey there! This is Jon Haws and I wanted to welcome you to this assessment module of our Fundamentals course. The purpose of this module is to really give you a framework for how to conduct a thorough assessment on your patient. We’re not gonna list every abnormality you can find. We’re gonna talk about that more in the different courses, in the Med Surg course, Cardiac Course, OB course, etc. With this module, it’s really designed to do is it’s designed to help you develop a framework, develop a step by step process for conducting an assessment and then to help you kinda determine, does the patient have any abnormalities? Does the patient deviate from the norm? And if it deviate from the norm, then we need to investigate that further. So, I want you to dive into this course. I want you to use this checklist, use this method, because it’s really gonna help you conduct a thorough head to toe complete assessment on your patient. So, go ahead and dive in and I’m excited to cover all this.

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Module 0 – Fundamentals Course Introduction

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