Pls. help me.. what are the Do's & Dont's before a physical assessment

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it's really hard to find a better one on nets.. x.x

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i'm sitting here thinking, "what do i do before a physical exam?" then, i thought about the process. the patient is usually questioned about their medical history before an actual physical exam is done. this is called the review of systems (ros). in medical offices this is done by having the patient fill out a questionnaire (here's an example: http://patients.e-baptisthealth.com/pc/docs/bsim_newpatient.pdf). in hospitals a nurse questions the patient during the admission process. a lot of times the ros is often entwined with the physical exam to save time. the ros is how you determine what has happened to the patient in the past, what diseases or treatments they may have received. it is done in the same systematic way you will approach the physical exam. since physicians generally approach examination by a body system approach that is how the ros is done. in nursing, if you are assessing by a system such as gordon's 11 functional health needs, you would ask health history questions and physical assessment questions by those categories. the ros and physical exam are all designed to help obtain data which is needed to help determine the patient's problems. each professional healthcare discipline does their own thing with the data that is collected and may collected even more to assist them with their work. doctors use it to determine the medical diagnoses. we nurses use it to determine the nursing diagnoses. etc.

hope that answers your question.

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oh my gosh! such a great help about the ROS ma'am! thank you very much! :wink2: it's really cool for i'm already cramming in looking for a complete standard data about nursing health history. or should i say, the 'format'.

the interview w/c includes the biographical data, chief complaint, present, past, family history, pyschosocial history, even the ADL, pls help me ma'am. it would be a really great help and a good tool for us to start the assessment. thank you very much, i really appreciate all the other people here within the grp. God bless to you ma'am! :wink2::yeah:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

I was just updating some of my posts on the Health Assessment Resources, Techniques, and Forms forum which is where all these websites are posted. It is a sticky thread on this forum. Most of this information is actually coming from medical school sites. The information taught by medical schools is the same taught to nurses.

ADL assessment is the only thing that is different for nurses and that is difficult to find posted on the Internet. It contains a lot of common sense and requires you to think about what you do every day. I remember when I was in nursing school 30 years ago just thinking about what it was that I did every day from morning to night that could be considered an ADL. Just about everything! I will keep looking for a form on the Internet though. The nurses whose theory centered around ADLs was Roper, Logan & Tierney. These are the 12 ADLs they identified:

  1. Maintaining a Safe Environment
  2. Communicating
  3. Breathing
  4. Eating and Drinking
  5. Eliminating
  6. Personal Cleansing and Dressing
  7. Controlling Body Temperature
  8. Mobilizing
  9. Working and Playing
  10. Expressing Sexuality
  11. Sleeping
  12. Dying

Here is an example of how the Roper, Logan & Tierney theory is used to assess a patient's ADLs: http://www.jcn.co.uk/journal.asp?MonthNum=11&YearNum=2007&Type=search&ArticleID=1112

http://en.wikipedia.org/wiki/Activities_of_daily_living - Activities of Daily Living

See the different posts on https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html (Health Assessment Resources, Techniques, and Forms).

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This may help (or may not) and it's kind of like common sense since we do it on a regular basis, but they drilled this into our heads - the 5 things you always do when you enter your patient's room:

* introduce yourself

* wash your hands

* ask client first/last name and DOB, then verify with their name band (or whatever method you use)

* provide privacy

* explain procedure & rationale

then do your assessment... :D

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Specializes in Psych ICU, addictions.

* introduce yourself

* wash your hands

* ask client first/last name and DOB, then verify with their name band (or whatever method you use)

* provide privacy

* explain procedure & rationale

then do your assessment... :D

And don't forget to ask their permission before beginning. I've gotten through all 5 of the steps above just to be told "No" by the patient when I've asked if it was OK for me to start ;)

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