Assessment
first stage of the nursing process. It includes the gathering of a patient's physiological, psychological, sociological, and spiritual status.Objective and Subjective strategies included
Symptoms
a subjective experience reported by the patient.
Signs
an objective finding by the examiner
Inspection
critical observation that requires good lighting. Looks at the color, shape, symmetry, and position of body parts.
Palpation
purposeful and careful feeling with hands during the physical examination. Examines size, consistency, texture, location, and tenderness of an organ or body part. Use the palm of hand or fingertips to assess consistency of tissues, alignment and intactness of structures, symmetry of body parts or movements, and transmission of sound and fine vibrations. Back of hand assesses skin temperature.
Percussion
method of tapping on a surface to assess the underlying structure's location, size, or density. The sound changes as the examiner moves from one section to the next. Done with the middle finger of the right hand tapping on the middle finger of the left hand, while the left palm is on the body. Sounds are classified as tympanic, resonant, flat, and dull. A flat/dull sound indicates the presence of a solid mass under the surface. A tympanic/resonant sound indicates hollow, air-containing structures.
Auscultation
listening to the internal sounds of the body, usually using a stethoscope. Used to examine the circulatory, respiratory, and gastrointestinal systems. High-pitched tones are best heard with the diaphragm of the stethoscope, while low-pitched tones are best heard with the bell of the stethoscope.
OLDCART
an acronym that can be used as a simple pain assessment guide together with a pain intensity scale
OLDCART"O:
Onset (new or chronic pain)
OLDCART"L:
Location (one or more sites)
OLDCART"D:
Duration (intermittent or persistent)
OLDCART"C:
Characteristics (somatic- sharp, dull, or aching)(Visceral- cramping, squeezing)(neuropathic- shooting, burning, electrical, tingling numbness)
OLDCART"A:
Aggravating factors(what makes the pain worse)
OLDCART"R:
Relieving factors(what makes the pain better)
OLDCART"T:
Treatment(pharmacological/nonpharmacological)(past or present)