Physical Examination

Nursing Assessment

Physical Examination

Physical examination is the evaluation of anatomic findings by using observation, percussion, palpation, and auscultation to obtain information about the patient. Many people who visit healthcare providers follow their instructions but wonder what they are doing or what they are looking for. During a physical examination, a healthcare practitioner is gathering cues to be able to diagnose. When a physical examination is thoughtfully integrated with the information that they provide, history, and path physiology, they should yield at least 20% data that is necessary for diagnosis and management of the patient (Sawyer, 2012). An examination of a 12-year-old child to find the likely cause of the symptoms portrayed would assist in diagnosing the child.

You are admitting a 12-year-old child to your unit. The mother states that the child has a history of unexplained blackout episodes, headaches, sleep disturbances, and is presently exhibiting tremors. What is the most likely cause of these symptoms? What actions would you take during the interview process? Explain.

I have chosen the 12 year old patient for this discussion.

When conducting a physical assessment on children it is imperative to start the collaboration relationship process between the patient and their family members and myself, as the nurse with effective communication strategies. I would first introduce myself to the patient and mother of the patient and explain to the both of them the purpose of the assessment being performed and how the information that they provide will be utilize appropriately. One important aspect to explain to both of them is that the information that they provide to me is protected by HIPAA.

I would then use open-ended questions (i.e. what brings you in today) to direct the interview to gain the patient’s history from either the child or from the mother. If more information is needed then I would utilize closed-ended questions or direct statements (i.e. how long has these symptoms been going on) to clarify any additional information.

Next, I would take the patient’s vitals and a complete head-to-toe assessment with an emphasis on the neurological system exam, all while explaining to the patient and the mother the reason for me having to do this. By me explaining step-by-step what I am doing will help me to better build a rapport with them as well as giving the patient and the mother a sense of being aware of what is going on, so that if they have any questions I will be able to answer these for them.

It would be pretty apparent that with the symptoms that the patient is experiencing may be due to some type of neurological condition. Patient would then need to be referred to a neurologist for further testing to confirm a proper diagnosis.

Reference:

Assessment Technologies Institute. (n.d.). Physical assessment (child). Retrieved fromhttp://www.atitesting.com/ati_next_gen/skillsmodules/content/physical-assessment-child/viewing/Neurological-a.html

Sawyer, S. (2012). Pediatric physical examination & health assessment. Sudbury, MA: Jones & Bartlett Learning.

Professor question/ needs to be answer.

Strong work.  When we thinking about our 1st pt-
Considering all aspects of the patient medical history, including the history of close family members, is important to ensure the complete clinical picture is evident. Asking if family members have a history of depression is an important point we must raise during a history assessment of our first patient. Would you agree?

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