2. Basic Assessment
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Perform physical assessment:
•
Inspection – use vision, smell and hearing; observe for
color, size, location, movement, texture, symmetry,
odors and sounds
•
Palpation – light palpation to assess surface
abnormalities, texture, tenderness, temperature,
moisture, pulsations and masses; deep palpation to
feel internal organs and masses
•
Percussion – use fingers to locate organ borders,
identify organ shape and position; listen to sounds
produced such as loudness, pitch and duration; use
direct percussion to revel tenderness
•
Auscultation – use stethoscope to listen for breath,
heart and bowel sounds; close eyes to focus and note
intensity and location of sounds
•
Documentation – document general information;
record information from observations and organize by
body system; use anatomic landmarks in descriptions
Physical assessment techniques:
•
Body temperature (35.9 to 38.1 C)
•
Pulse (60 to 100 beats / minute)
•
Respirations (16 to 20
breaths/minute)
•
Blood pressure (100 to 119 over 60
to 79 mm Hg)
•
Pulse oximetry (≥95% blood oxygen
saturation)