Informed Consent... you must have have this from all pt's before obtaining any information from them. C/O, HPI, Vitals, etc..
you have tell the patient what going on and what is about to happen so the will know what's going and what you about to do
Always tell the pt whats going on and to expect from the nurse
Physical Assessment Function and Facts
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. The chances of overlooking important data are greatly reduced because the physical assessment is performed in an organized, systematic manner, instead of a random manner.
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.
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 subjective data.
(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.
(3) Objective data are sometimes called signs, and subjective data are sometimes called symptoms.
(4) Data means more than signs or symptoms; it also includes demographics, or patient information that is not related to a disease process.
b. The purposes for a physical assessment are:
(1) To obtain baseline physical and mental data on the patient.
(2) To supplement, confirm, or question data obtained in the nursing history.
(3) To obtain data that will help the nurse establish nursing diagnoses and plan patient care.
(4) To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems.
CONSIDERATIONS IN PREPARING A PATIENT FOR A PHYSICAL ASSESSMENT
a. Establish a Positive Nurse/Patient Rapport. This relationship will decrease the stress the patient may have in anticipation of what is about to be done to him.
b. Explain the Purpose for the Physical Assessment. The purpose of the nursing assessment is to gather information about the patient's health so that you can plan individualized care for that patient. All other steps in the nursing process depend on the collection of relevant, descriptive data. The data must be factual, not interpretive.
c. Obtain an Informed, Verbal Consent for the Assessment. The chief source of data is usually the patient unless the patient is too ill, too young, or too confused to communicate clearly. Patients often appreciate detailed concern for their problems and may even enjoy the attention they receive.
d. Ensure Confidentiality of All Data. If possible, choose a private place where others cannot overhear or see the patient. Explain what information is needed and how it will be used. It is also important to convey where the data will be recorded and who will see it. In some situations, you should explain to the patient his rights to privileged communication with health care providers.
e. Provide Privacy From Unnecessary Exposure. Assure as much privacy as possible by using drapes appropriately and closing doors.
f. Communicate Special Instructions to the Patient. As you proceed with the examination, inform the patient of what you intend to do and how he can help, especially when you anticipate possible embarrassment or discomfort.
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