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 technique does the nurse use to palpate a client's abdomen?Deep palpation
Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility. Depress the skin 1½ to 2 inches (about 4 to 5 cm) with firm, deep pressure. Use one hand on top of the other to exert firmer pressure, if needed.
When assessing the abdomen which assessment technique is used last?Always follow this sequence: inspection, auscultation, percussion, and palpation. Changing the order of these assessment techniques could alter the frequency of bowel sounds and make your findings less accurate.
Which action should the nurse take when Auscultating the abdomen of a client?Palpates the abdomen prior to performing auscultation. The nurse should auscultate the abdomen prior to palpating it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.
What is the correct sequence of steps for data collection of the abdomen?The physical examination of the patient begins with inspection. Unique to the sequence of the abdomen, the abdomen is then auscultated, percussed and finally, palpated. Auscultating before the percussion and palpation of the abdomen ensures that the examiner is listening to undisturbed bowel sounds.
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