INTRODUCTION TO PHYSICAL ASSESSMENT
An accurate physical assessment requires an organized and systematic
approach using the techniques of inspection, palpation, percussion, and auscultation. It
also requires a trusting relationship and rapport between the nurse and the patient to
decrease the stress the patient may have from being physically exposed and
vulnerable. The patient will be much more relaxed and cooperative if you explain what
will be done and the reason for doing it. While the findings of a nursing assessment do
sometimes contribute to the identification of a medical diagnosis, the unique focus of a
nursing assessment is on the patient's responses to actual or potential problems.
FACTS ABOUT PHYSICAL ASSESSMENT
a. Physical assessment is an organized systemic process of collecting objective
data based upon a health history and head-to-toe or general systems examination. A
physical assessment should be adjusted to the patient, based on his needs. It can be a
complete physical assessment, an assessment of a body system, or an assessment of
a body part.
b. The physical assessment is the first step in the nursing process. It provides
the foundation for the nursing care plan in which your observations play an integral part
in the assessment, intervention, and evaluation phases.
c. The chances of overlooking important data are greatly reduced because the
physical assessment is performed in an organized, systematic manner, instead of a
PURPOSES OF A PHYSICAL ASSESSMENT
a. A comprehensive patient assessment yields both subjective and objective
findings. Subjective findings are obtained from the health history and body systems
review. Objective findings are collected from the physical examination.
(1) Subjective data are apparent only to the person affected and can be
described or verified only by that person. Pain, itching, and worrying are examples of
(2) Objective data are detectable by an observer or can be tested by using an
accepted standard. A blood pressure reading, discoloration of the skin, and seeing the
patient in the act of crying are examples of objective data.