Physical Assessment

H & P

General Assessment

Physical Assessment

Psychosocial Assessment

H & P

  • Date
  • Demographic data
  • Source of referral
  • Chief complaint(s)
  • History of present illness
  • Past history
  • Current health status
  • Family history of illness
  • Psychosocial history
  • Review of all systems
  • Information called baseline
  • General Assessment

  • Discriminate normal from abnormal
  • –Use observation skills

    –Ask questions

    –Note changes in condition

    –Employ strong assessment skills

  • Report variances to supervisor
  • Look at patient as whole
  • Overall impression valuable –Determines where to focus if time limited
  • What to look for in general survey
  • Psychosocial Assessment

  • Part of general survey
  • Emotional status
  • Mental status/history
  • Appearance
  • •True or False: A critical function of the health care worker is to be able to discriminate between normal and abnormal conditions and situations
  • Self Pacing acronym for psychosocial eval

    S – Self-Esteem: Include information pertaining to hygiene, grooming, eye contact, statements about oneself and any other characteristics that provide information about the patient’s self esteem.

    E – Energy Level: Patient’s with psychological problems often have an alteration in level of activity.

    L – Lifestyle: Living arrangements, significant relationships, occupation, hobbies or lack of interest in leisure activities, education, and any other data that provides information about the patient’s personal situation.

    F – Family System: This refers to the patient’s contact and support from family members or significant others, family stressors, crisis events, and usual coping skills.

    P – Physiological: This area relates to the results of the physical assessment.

    A – Affect: Include information about the patient’s mood or emotional feelings. It may be described as happy, euphoric, flat, inappropriate, and other descriptive terms.

    C – Culture: This refers to all cultural, racial, or anthropological variables that influence one’s lifestyle and mental health. This may refer to issues of homelessness. Assess religious and spiritual preferences, if any. Discuss any related food needs and other areas of impact spirituality will have on their health status.

    I – Interests: As expressed by the patient.

    N – Needs: As expressed by the patient (as opposed to those identified by the health care worker).

    G – Goals: As expressed by the patient (as opposed to those identified by the health care worker).

    Physical Assessment


  • Inspection
  • Auscultation
  • Palpation
  • Percussion
  • Next day: Body Systems  WNL vs ABN

    Body Systems

    Get Books out

    What is normal what is abnormal?

    Everyone will take a system, look up assessment of that and explain to class your system.

  • Musculoskeletal
  • Integumentary
  • Circulatory
  • Respiratory
  • Digestive
  • Urinary
  • •Eyes
  • •Ears
  • •Nervous
  • •Endocrine
  • •Female reproductive
  • •Male reproductive
  • •Which of the following is using the senses of vision, hearing, and smell for observation of patient condition?
  • A. Auscultation
  • B. Palpation
  • C. Inspection
  • •C. Inspection
  • •Inspection –Using senses of vision, hearing, and smell for observation of patient condition
  • •Auscultation –Listening to sounds inside body with aid of stethoscope
  •   •Palpation –Using hands and fingers on exterior of body to detect evidence of abnormalities in various internal body organs
  • Next Day: Pain/ADL's

    Pain Assessment

  • Subjective information
  • Use pain assessment scale
  • –0 to 10

  • 0 = no pain
  • 10 = worst pain imaginable
  • –Wong-Baker FACES Pain Rating Scale

    When would you use this?

  • Compare levels before and after pain medications
  • Note nonverbal cues
  • ADL'S
    Activities of Daily Living

  • Actions done on regular basis to meet physical needs
  • Inability to perform ADLs
  • –Assistance needed as long as unable to do so

  • Which of the following would be an ADL (activity of daily living)?
  • A.Doing laundry


    C.Playing piano

    Vital Signs!
    Are They Important?

    Vital signs include:

    your heart beat (BPM)

    breathing rate (Resp)

    temperature  (degrees F)

    blood pressure (systolic/diastolic)


    Your health care provider may watch, measure, or monitor your vital signs to check your level of physical functioning.

    Normal vital signs change with age, sex, weight, exercise tolerance, and overall health.



  • Normal range essential to homeostasis
  • Afebrile and febrile
  • Intermittent fever
  • Continuous fever
  • Night sweats
  • •Oral •Axillary •Rectal •Aural •Temporal artery
  • watch video

    Pulse points


  • Rhythm
  • –Regular rhythm

    –Irregular rhythm

  • Regular irregular rhythm
  • Irregular irregular rhythm
  • •Pulse volume •Radial pulse •Stethoscope •Apical pulse 
  • Bradycardia
  • Tachycardia
  • Pulse rates vary with age
  • Apical-radial pulse deficit
  • watch pulse video


  • Process of moving air through lungs
  • Inhalation (inspiration)
  • Exhalation (expiration)
  • Eupnea
  • Tachypnea
  • Bradypnea
  • •Ensure patient unaware of respirations being counted •Rate •Rhythm –Apnea –Cheyne-Stokes
  • •Respiratory effort •Respiratory rates vary with age
  • watch resp video
  • pop quiz
  • •What is tachycardia?
  • A.Abnormally high heart rate
  • B.Abnormally high respiratory rate
  • C.Abnormally low heart rate

    What is blood pressure?

    When measuring blood pressure, your doctor or nurse will use a stethoscope to listen to the blood moving through an artery.

  • Systolic
  • Diastolic
  • Hypotension
  • Hypertension
  • Sphygmomanometer
  • White coat syndrome
  • Orthostatic (postural) hypotension
  • Blood pressure readings vary with age
  • When not to use arm to take blood pressure
  • watch bp video
  • •True or False: Orthostatic hypotension is a rapid rise in blood pressure when the patient stands
  • HT/WT

  • Height usually stable after adulthood
  • –Except with osteoporosis

  • Many factors affect weight
  • •Types of scales: –Standing balance –Chair and wheelchair –Mechanical lift –Bed •BMI