question!

Daytonite, BSN, RN · Oct 29, 2008

An assessment consists of obtaining history, which requires talking to the patient, and physical examination which involves

inspection - observing and possibly a penlight and ophthalmoscope for some things
palpation - for which you use your hands
percussion - which also involves the use of your hands and ears
auscultation - for which you do need a stethoscope and your ears

We've gotten into the objective/subjective argument before on this forum:

Information that you collect and is undisputed fact is objective. Read the definitions of subjective and objective on the two threads posted above very carefully.

Pretty in Ink · Oct 31, 2008

Assessing a pt. may require some tools such as a penlight or stethascope. Basically what I do is start at the head and work my way down. I check for LOC by asking the pt. their name and birthday, what date is it etc. I'll check their pupils and the inside of their mouth with my penlight and check for PERRLA or any kind of thrush or stomatitis of the mouth (may be due to some med they are on). Next I will listen to their heart and get their apical and check their lung sounds to make sure they are CTA or if not then do what I need to do to make sure the pt.'s sats are wnl. I generally check their cap refills esp. if they have had surgery or some kind of illness that would decrease their circulation and get hand grips. I listen to their tummy to assess bowel sounds, then I palpate to check for firmness or distention. Moving my way down I check for homan's, pedal pulses and edema. I turn them over and also check for any skin irritation. This sounds like alot but it goes very quickly. The assessment can tell you alot of things, such as fluid retention, altered mental status, impaction, possible dvt, etc etc etc. It's your first introduction to your pt. so you need a baseline and everytime you have the pt. you will be able to tell if there are any changes. You need to also look them over well to check for pressure ulcers, skin tears, etc b/c all of this you will need to document in your nursing shift assessment and ultimately pass on to the next shift.