Organize physical assessment into "head-to-toe" systematic approach
Goal: gather accurate information thoroughly & efficiently
Order of assessment:·
General survey·
Head & neck
· Chest
· Abdomen·
Lower extremities
Therapeutic communication
ask open-ended questions & encourage patient to verbalize feel- ings.
OLDCARTS & PQRST mnemonics
Assess onset, location, duration, characteristics, aggravating/relieving factors, related symptoms,
severity, & treatment
o Do NOT assess any personal history or family history- Focus on present symptom & assess fully before
moving onto different parts of health history.
Gold standard for assessing pain
patient's self-report (use self-report whenever possible)o If patient unable to self-report (e.g., has
cognitive impairment), assess for nonverbal pain indicators (e.g., groaning or grimacing) instead
Acute pain may cause objective symptoms
increased BP & pulse, etc.
General Survey Purpose
to develop an overall first impression of patient & identify obvious needs
General Survey Components:
Physical appearance
Hygiene
Posture
Physical appearance
age, body structure, etc.
, Hygiene
body odor
Posture
sitting or standing up straight, etc.
Heart rate
60-100 beats per minute
Bradycardia
< 60 BPM
Tachycardia
> 100 BPM
Blood pressure
< 120/ < 80
Hypotension
low blood pressure
Avoid placing BP cuff
over a wound or dressing
SpO2
> 95%
Respiratory rate
12-20 breaths per minute
Bradypnea
< 12 breaths per minute
Tachypnea
> 20 breaths per minute
Temperature
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