Question

Subjective Data

• Married
• Exercises daily
• Nonsmoker, never smoked
• Registered nurse in hospital setting
• Has two children who live at home
• No complaints at this time

Objective Data

• Vital signs: T 36.7, BP 108/62, HR 62, R 14
• Height 5 feet 6 inches
• Weight 160
• Immunizations up to date
• Medications: no medications, multivitamin daily
• Allergy to penicillin: hives

Questions:

1. How will the nurse proceed with the physical exam?

2. What interventions will help the patient be more comfortable during the physical exam?

3. What pointers or tips would an experienced nurse give to a new nurse who wants to improve his or her technique?

4. What are the components of the general survey?

5.            How should the nurse perform the abdominal assessment?

Answer 1

Physical examination: A structured physical examination allows the nurse to obtain a complete assessment of the patient.The four basic techniques that are used for physical assessment are: Inspection, palpation, percussion, and auscultation.Inspection is a visual examination of the patient; palpitation is done when the person doing the assessment places their fingers on the body to determine things like swelling,masses,and areas of pain.Percussion is tapping the patients bodily surfaces and hearing the resulting sounds to determine the presence of things like air and solid masses affecting the internal organs.Auscultation is listening to an area of the body using a stethoscope.

The nurse will proceed with the physical examination with a baseline data collected by

• A complete medical history
• A general survey
• A complete physical assessment.

Interventions to make the patient more comfortable during the physical examination : Prepare and position the patient for physical examination by providing privacy, and explaining the procedure and insure that the client is as comfortable as possible.

Experienced Nurses tips for the new nurse to improve her technique : Before beginning the assessment,try to develop a rapport with the patient by introducing themselves,explaining what she will be doing during the assessment.

The Components of the general survey,including patients weight, height, body build,posture,gait,obvious signs of distress,level of hygiene and grooming, skin integrity,vital signs,oxygen saturation,and the patients actual age compared and contrasted to the age that the patients actually appears like.

5) Abdominal Assessment: By Inspection- Unblemished skin,uniform in color,symmetric contour,not distended and the presence of any lesions.Also inspect to determine the presence of any pulsation,indicates the possible presence of an abdominal aortic aneurysm.

Palpation: light palpation,which is then followed with deep palpitation,is done to assess for the presence of any masses,tenderness,pain,guarding and rebound tenderness.