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Physical Assessment Nursing Procedure

PHYSICAL ASSESSMENT OF A PATIENT

Purpose

To obtain baseline data about patient’s health status.

Scope

Patient who are admitted in the Wards.

Definition

Assessing the patient head to foot using different parameters.

Applicable Areas

All admitted patients.

Responsible Person

Staff Nurse, Head Nurse.

Procedure

Collect relevant data from the patient, both subjective and objective

  • Objective data are detectable by an observer.
  • Subjective data are apparent only to the patient concerned.

Relevant data are collected from different sources such as

  • Patient himself.
  • Patient’s significant other friends / relatives.
  • Members of other health team.
  • Medical records.

Collect data by

  • Interviewing the patient and significant others to obtain data by asking relevant questions.
  • Using the skills of communication and listening.
  • Observing the patient by using senses like sight, smell, hearing and touch.
  • Examining the patient by making use of inspection, palpation, percussion and auscultation in the physical examination.
  • Systematically examine the patient starting from head to toe.
  • Skin Assessment.
  • Pain Assessment is done for every admitted patient on the Pain Assessment Form.
  • Rating of pain scale is 0-10.
  • Pain Rating Scale Form is used for patients who are in pain.
  • Use laboratory data as part of the information to give support to your understanding of the patient’s condition.
  • Reviewing the medical records.
  • Analyze the data and understand the patient’s problem by using principles of therapeutic communications.

Introducing self to a patient

  • Greet using patient’s name and introduce self to the patient. If patient is blind, introduce self as you come in the door.  Tell exactly what you are doing and when you are leaving.
  • Begin to establish a nurse patient relationship using clear open communication.

Beginning a patient interaction

  • After introducing itself, state your purpose of interaction.
  • Tell patient specifically what you will be doing in terms of his care.
  • Ask if patient understands or has any questions. Encourage patient to describe how he is feeling at the time.
  • Encourage patient to participate in his care verbally and non-verbally.
  • Pay attention to communication as well as the procedure you are doing.
  • Complete communication by asking patient for a feedback.
  • Inform patient when you will return and follow back.

Assisting a Patient to describe personal experience

  • Encourage describing his perceptions and feelings.
  • Use minimal verbal activity and listen attentively.
  • Assist patient to clarify feelings.
  • Maintain an accepting non-judgmental attitude.
  • Use broad opening statements and open-ended questions.

Encouraging a patient to express needs, feelings and thoughts

  • Focus on feelings during interactions.
  • Assist patients to identify thoughts and feelings.
  • Pick up on verbal clues, leads and signals from the patient.
  • Convey attitude of acceptance and empathy towards the patient.
  • Note, what is said and what is not said.
  • Assist the patient to become aware of difference between behaviour, feelings and thoughts.
  • Give honest, non-judgment feedback to the patient.

Utilizing communication to increase the patient’s sense of self worth

  • Use body language and verbal communication to convey empathy.
  • Encourage the patient to apply the problem solving approach for different situations.
  • Be non-judgmental.
  • Be patient’s advocate.

Reference

Documentation

Physical Assessment Form.