Physical assessment is one of the most essential duties of a nurse and is often the first effort directed at providing healthcare to patients. By definition, physical assessment is an organized medical process that involves collecting credible data about a patient. It might be a head-to-toe examination, or an assessment of a specific body part based on health history.
It is a particularly critical process that can help detect the source of discomfort and direct the proper treatment. This article will highlight the basic steps for physical assessment.
The purpose of physical assessment
Physical assessment is one of the first steps nurses must take when meeting a patient. It therefore sets the tone for other aspects of healthcare. Note that this assessment requires physical presence and cannot be achieved through online medical consultation. It is important for the following reasons:
- To get basic information relating to the patient’s physical and mental health.
- To confirm or add to the information present in a patient’s health history.
- To obtain credible data that will come in useful in diagnosing and planning a treatment plan.
Typically, the purpose of a physical assessment is to obtain objective data. Any incorrect information can have severe consequences on the diagnosis and treatment. So, nurses must deploy the proper techniques for optimal results.
Steps required for a physical assessment
Below are the steps nurses follow when carrying out a physical assessment on a patient:
Create a good relationship with the patient — Nurses should be cordial and welcoming to the patient. A gentle smile and some kind words will ease the patient’s anxiety during physical assessments.
Explain the purpose of the assessment — Nurses should take the time to explain that the objective data gathered during the evaluation is crucial to drawing out a care plan.
Get verbal consent for the physical assessment — Before asking questions and checking for those vital physical signs, ensure the patient gives the go-ahead to begin.
Perform the assessment — Physical examination is not a one-size-fits-all approach and should be adjusted to suit the needs of each patient. Nonetheless, an ideal physical assessment involves the deployment of the following techniques:
- Inspection — Visual inspection of the patient’s body.
- Palpation — Touching relevant parts of the body to spot any irregularity.
- Percussion — Tapping the patient’s body with the fingers.
- Auscultation — Examining the sounds produced within the body of the patient. This is a bit technical, so nurses should get higher qualifications before conducting this assessment. A hybrid ABSN program like the one offered at the University of Indianapolis will provide the skills necessary.
Ensure confidentiality — Inform patients that the data collected will only be used to improve their health. Also, only the professionals responsible for the patient’s health should have access to the relevant information.
Communicate every action during the assessment beforehand — Make sure the patient is aware of the next step of the assessment beforehand. Nurses should maintain proper communication with the patient at every step.
Conclusion
A physical exam is a complex process that requires a certain set of skills from healthcare providers. To improve patient outcome, it is important to focus on the patient as much as on the procedure. A balanced approach is needed to ensure it goes as well as possible.
