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 just for nurses but also doctors. Establishing a good assessment would later-on provide a more accurate diagnosis, planning and better interventions and evaluation, thats why its important to have good and strong assessment is.

WHAT ARE THE PURPOSES OF A PHYSICAL EXAMINATION?

A physical examination is performed for any of several reasons:

To obtain baseline data about physical status and functional abilities to serve as a comparison as the patients health status changes. To identify nursing diagnoses, collaborative problems, and wellness diagnoses, to form the basis for the plan of care. To monitor the status of a previously identified problem. To screen for health problems. Regular checkups can help to identify health problems at early stages.

The type of physical examination you perform will depend on the clients health status, the nature of the client encounter, and the setting. For example, at an outpatient appointment for an annual physical, on a clients 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 examination of every body system.

In an emergency situation, your assessment will be rapid and focused on the presenting problem.

A focused physical 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-specific assessment is a focused assessment limited to one body system (e.g., the lungs, the peripheral circulation). The following are examples of focused and system-specific physical assessments, respectively:

Assessing bowel sounds when a client has abdominal pain Listening to breath sounds, counting respirations, and obtaining pulse oximetry readings to assess a patients respiratory status

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

General observation Data: