Clinical Assessment

2. One of the important factors that you need to establish is how much pain the person is feeling. This can be difficult as we all have different pain levels. Several methods have been developed to measure pain but the most common one is to ask the person to describe it on a scale 1 to 10, with 1 being the mildest to 10 being the worst pain they have ever felt. It is about individual experience and you need to react to the level at which that person describes their pain as one persons pain thresholds may be different to another.

The head to toe physical assessment is to be performed in less than 10 minutes using a stethescope, pen light, your hands, and observational skills. It comprises of four different techniques: IPPA inspection, palpation, percussion, and auscultation. This sequence, in apparent order, is used for al systems except for the abdominal assessment, which requires auscultation before palpation and percussion. Inspection is visually examining the person, focusing on one area of the body at a time. Palpation is using touch, feeling for texture, size, consistency, and location of body parts. Auscultation is listening for sounds within the body, mainly listening the lungs, heart, as well as the abdomen with the use of a stethoscope. Percussion is tapping an area of the body with the fingers and is usually a special assessment skill that the RN or physician uses, not a practical student nurse.

Trauma one Pediatric Emergency Department! Trauma one Pediatric Emergency Department responding over! Rescue Unit 29 transporting a 12 year-old boy, named Mike, hit by a car while riding his bicycle. This is a hit and run accident, but other motorists called a rescue unit. The child was not wearing a helmet. Facial bleeding is under control, but he suffered facial and head trauma. There appeared to be no facture of the extremities. Presently he is awake and semi-alert. Vitals signs: BP 120/56, Pulse 120, Oxygen

Assessment: the patient 's vital signs are 108/68, 125 beats per minute, respirations, even and non-labored at 14 breaths per minute, 92% on 2 liters of oxygen via nasal cannula, afebrile 98.5 F.

would be a CMP to check the patient chemistry. Some other tests that the doctor may

I enjoyed reading your post. I agree that when conducting a comprehensive assessment, it depends on what area of the hospital you work in. I work in the PACU, assessing a patient is much different than when I worked in the ICU. When I worked in the ICU, I would gather the necessary information from the ED and conduct my initial assessment based on prior documentation. I would do a complete head to toe assessment and physical assessment. For example, assessing a patient’s skin completely for pressure ulcers was mandatory. Working in the PACU, our patient usually receives a telephone interview prior to their surgery, which entails obtaining medical and surgical history, medication, support systems, allergies, living arrangements, etc.

Then I will start by inspecting the patient. I will observe the patient's state of consciousness by having the patient repeat their name and date of birth along with telling me where they are at, and what the date is. If there are any abnoramalities their, I will document them. Next I will observe their overall state of health, look for any signs of physical distress. I will then look for any lacerations, bruises, visible lumps or bumps, or things such as moles and birth marks, and body symmetry.

I then went onto percuss his chest in the appropriate places (see appendix 2 for places for percussion) using my two fingers to tap on my second finger, which I had placed over his intercostal spaces. I was observing for Resonance, hyper resonance dull and very dull sounds

Reflecting back on the past several weeks, I have learned the significance of assessing different systems to enhance the patient’s well-being. I have also learned the importance of completing a thorough assessment of the different body systems in order to pinpoint individual’s illnesses and to formulate the correct treatment plan.

Clinical judgment is an essential skill for nurses. The professionals have to be able to make decisions that are in the best interests of the patients at critical stages. Thus, it is a concern when studies have shown that a large number of graduate nurses do not possess adequate levels of this skill (Raymond-Seniuk & Profetto-McGrath, 2011). This means that the methods used in teaching baccalaureate courses are not effective. Mann (2012) examined the issue and found that the teaching strategies are not designed to help the students understand and apply clinical judgment in a healthcare situation. The author expresses her ideas on the topic clearly and helps to shed more light into an issue that is critical to nursing practice.

Objective data that should be assessed are, pain assessment should be conducted by asking the patient his pain levels by using the Position/Provoking, Quality Radiate, Severity, and Time (PQRST) method, keep an eye on the patient's facial expressions they may also grimace or wince in pain, this is to assess the amount of pain he is in and see if you may need to contact a doctor to review his pain medication dosage. Does Mr Jones look clammy/sweaty? Is he short of breath(SOB), monitoring the way he is breathing e.g. shallow or deep, is he struggling for breath? he may even have noticeable cyanosis, is there anything that makes the pain better or worse? Checking the capillary return It is used to monitor the amount of blood flow to tissues.

A head to toe assessment is the visual and manual inspection of each body part starting at the head and scalp and continuing downward to the feet and toes. These four techniques will be used: Inspection=what can be seen, Palpation=what can be felt, Percussion=what can be heard and Auscultation=what can be heard using a stethoscope. It is very important to perform a complete head to toe assessment on all patients at the beginning of the shift as this information will help determine if the patient is getting worse or starts having any unforeseen problems.

Inspection is used most frequently and involves examining particular body parts for normal and abnormal characteristics. Percussion is the least used assessment by nurses and requires striking or tapping on the client’s body with the fingertips to produce vibratory sound. The quality of the sound determines the location, size, and density of underlying structures. Palpation involves lightly touching or applying pressure to the body. Light palpation involves the fingertips, the back of the hand, or the palm of the hand. Deep palpation is performed by depressing tissue with the forefingers of one or both hands. Auscultation is used frequently, mostly to assess the heart, lungs, and abdomen. A stethoscope is required to her most internal

In general, your professional practitioner or healthcare provider will make an analysis of the issue via examining the garments and complexion.

The physical examination would include a thorough breast examination. The patient should be covered for decency and exposing one breast at a time should be done. Breasts are divided into four quadrants based on horizontal and vertical lines crossing at the nipple (Bickley, 2013). Palpation of lymph nodes in the lateral, central, subscapular, pectoral, supraclavicular and infraclavicular areas should be palpated to determine any further lumps. A thorough health