Adult Assessment

 

Adult Assessment Head to toe assessment is the baseline and ongoing data that is needed on every patient. Once a systematic technique is developed, the assessment can be completed in a relatively short period of time. Assessment is done at the beginning of each shift, and at regular intervals during the shift. Since many healthcare professionals work 12 hour shifts, assessment needs to be done more than once, and as a part of admission.

Physical assessment is an inevitable procedure not ust for nurses but also doctors. !stablishing a good assessment would later"on provide a more accurate diagnosis, planning planning and better interventions and evaluation, that#s why it#s important to have good and strong assessment is. WHAT ARE THE PURPOSES OF A PHYSICAL EXAI!ATIO!" A physical e$amination is performed for any of several reasons%  &o  &o obtain ba baseline seline data about about physical status and functional functional abilities abilities to serve serve as a comparison as the patient#s health status changes.  &o  &o identif identify y nursing diagnoses, diagnoses, collaborative collaborative problems, problems, and wellness wellness diagnoses, to form the basis for the plan of care.  &o  &o monitor th the e status of a previously previously identi'ed problem. problem.  &o  &o screen for health problems. (egular (egular checkups checkups can help help to identify identify health problems at early stages.  &he type of physical physical e$amin e$amination ation you perform perform will depend depend on the client#s client#s health status, the nature of the client encounter, and the setting. )or e$ample, at an outpatient appointment for an annual physical, on a client#s admission to an inpatient setting, or at the initial home health visit, you would perform a comprehensive physical assessment, which includes a health history interview and a complete head"to"toe e$amination of every body system. *n an emergency situation, your assessment will be rapid and focused on the presenting problem. A #ocused $hysical assessment  pertains to a particular topic, body part, or functional ability rather than overall health status, and it adds to the database created by the comprehensive assessment. A system"speci'c assessment is a focused assessment assessment limited to one body system +e.g., the lungs, the peripheral circulation.  &he following following are e$amples e$amples of focused focused and system"speci'c system"speci'c physical physical assessments, assessments, respectively% •

Assessing bowel sounds when a client has abdominal pain

 

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-istening to breath sounds, counting respirations, and obtaining pulse o$imetry readings to assess a patient#s respiratory status

On%oin% assessment is performed as needed, after the initial database is completed, and, ideally, at every interaction with the patient.

eneral observation /ata%