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Physical Assessment Check Off Notes: Nurse Clinical Pocket Guide

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Physical Assessment Check-Off Notes Nurse's Clinical Pocket Guide (Nurse's Clinical Pocket Guides)

by Brenda Walters Holloway

4.5 out of 5

Language	:	English
File size	:	15796 KB
Print length	:	200 pages
Screen Reader	:	Supported
X-Ray for textbooks	:	Enabled

Physical assessment is an essential skill for all nurses. It allows nurses to assess a patient's overall health and identify any potential problems. This pocket guide provides quick and easy access to the key steps and findings for each physical assessment skill.

General Survey
Respiratory Assessment
Cardiovascular Assessment
Abdominal Assessment
Neurological Assessment
Musculoskeletal Assessment

General Survey

The general survey is a quick and easy way to assess a patient's overall health. It includes the following steps:

Observe the patient's overall appearance. Note their posture, body habitus, and any obvious deformities.
Measure the patient's vital signs (temperature, pulse, respirations, and blood pressure).
Assess the patient's skin for any rashes, lesions, or other abnormalities.
Palpate the patient's lymph nodes for any enlargement or tenderness.
Auscultate the patient's heart and lungs for any abnormal sounds.

Respiratory Assessment

Respiratory assessment is important for assessing a patient's ability to breathe. It includes the following steps:

Observe the patient's respiratory rate and pattern.
Palpate the patient's chest for any tenderness or crepitus.
Percuss the patient's chest for any dullness or hyperresonance.
Auscultate the patient's lungs for any abnormal sounds (e.g., wheezes, rales, or rhonchi).

Cardiovascular Assessment

Cardiovascular assessment is important for assessing a patient's heart and blood vessels. It includes the following steps:

Take the patient's blood pressure.
Palpate the patient's pulse for any abnormalities (e.g., rate, rhythm, or volume).
Auscultate the patient's heart for any abnormal sounds (e.g., murmurs, gallops, or clicks).
Inspect the patient's peripheral pulses for any abnormalities (e.g., weak or absent pulses).

Abdominal Assessment

Abdominal assessment is important for assessing a patient's gastrointestinal system. It includes the following steps:

Inspect the patient's abdomen for any distension, scars, or hernias.
Palpate the patient's abdomen for any masses, tenderness, or organomegaly.
Percuss the patient's abdomen for any dullness or hyperresonance.
Auscultate the patient's abdomen for any abnormal sounds (e.g., bowel sounds or bruits).

Neurological Assessment

Neurological assessment is important for assessing a patient's nervous system. It includes the following steps:

Assess the patient's mental status (e.g., orientation, memory, and concentration).
Test the patient's cranial nerves (e.g., vision, hearing, smell, taste, and touch).
Test the patient's motor function (e.g., strength, coordination, and balance).
Test the patient's sensory function (e.g., pain, temperature, and vibration).

Musculoskeletal Assessment

Musculoskeletal assessment is important for assessing a patient's bones, muscles, and joints. It includes the following steps:

Inspect the patient's musculoskeletal system for any deformities, swelling, or tenderness.
Palpate the patient's muscles for any tenderness or masses.
Test the patient's range of motion.
Test the patient's strength.

This pocket guide is a valuable resource for all nurses who perform physical assessments. It provides quick and easy access to the key steps and findings for each physical assessment skill.

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