Chapter 2. Patient Assessment Show
A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment specific to the affected body system. A physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 outlines the steps to take. Checklist 17: Head-to-Toe Assessment
When assessing a patient's abdomen which finding should the nurse report as abnormal *?Abnormal findings might be documented as: “Client noted generalized pain all over abdomen upon palpation, rating it 5/10. Abdomen firm to touch in all quadrants.. Overall consistency (soft or firm) and associated pain/tenderness. ... . Presence of masses. ... . Presence of swelling. ... . Presence of pain.. When assessing a patient's abdomen the nurse uses assessment techniques in which order?Assessing your patient's abdomen can provide critical information about his internal organs. Always follow this sequence: inspection, auscultation, percussion, and palpation. Changing the order of these assessment techniques could alter the frequency of bowel sounds and make your findings less accurate.
Which head assessment findings would be considered abnormal?Abnormal findings include: Crepitus, swelling , pain/tenderness, limited or no range of motion, hyperactive response, pain, tenderness, no response, hyperactive response.
Which symptoms noted in a patient reporting abdominal pain are suggestive of appendicitis?Several clinical signs and symptoms have been described as suggestive of appendicitis, including central abdominal pain migrating to the right iliac fossa, fever and nausea/vomiting, signs of peritoneal irritation (rebound tenderness, guarding, rigidity), and classic signs elicited by clinical examination (e.g., the ...
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