Chapter 2. Patient Assessment Show A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment specific to the affected body system. A physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 outlines the steps to take. Checklist 17: Head-to-Toe Assessment
What are you looking for in an abdominal assessment?The inspection of the abdomen includes looking for scars, striae, venous pattern, rashes, contour, symmetry, masses, peristalsis, and pulsations. Inspection is optimum with the patient lying flat on the examination table, breathing normally. As this is being done, note the comfort level of the patient.
How should a normal abdomen feel?Normal findings might be documented as: “Abdomen soft to touch with no masses, swelling, pain, and rigidity.” Abnormal findings might be documented as: “Client noted generalized pain all over abdomen upon palpation, rating it 5/10. Abdomen firm to touch in all quadrants.
Which of the following assessment findings may be noted on inspection of the abdomen?Inspection of the abdomen
Note any distension, abdominal respiration, bruising, scars, stoma, herniae and any visible peristalsis. A mass may be apparent. To exaggerate the presence of a mass, inspect with the head raised from the bed to tense the abdominal muscles and with the Valsalva manoeuvre for lateral regions.
What are the four components of a focused assessment in an abdominal assessment?The abdominal examination consists of four basic components: inspection, palpation, percussion, and auscultation.
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