- Assessing General Status And Vital Signs Physical Assessment Guide To Collect Objective Client Data Questions Findings O 1 (61.69 KiB) Viewed 214 times
Assessing General Status and Vital Signs Physical Assessment Guide to Collect Objective Client Data
Questions Findings Overail Impression of the Client 1. Observe physical development (appears to be chronologic age) and sexual development (appropriate for gender and age). 2. Observe skin (generalized color, color variation, and condition). 3. Observe dress (occasion and weather appropriate). 4. Observe hygiene (cleanliness, odor, grooming) 5. Observe posture (erect and comfortable) and gait (rhythmic and coordinated) 6. Observe body build (muscle mass and fat distribution). 7. Observe consciousness level (alertness, orientation, appropriateness). 8. Observe comfort level. 9. Observe behavior (body movements, affect, cooperativeness, purposefulness, and appropriateness), 10. Observe facial expression (culture-appropriate eye contact and facial expression) 11. Observe speech (pattern and style). Vital Signs 1. Gather equipment (thermometer, sphygmomanometer, stethoscope, and watch) 2. Measure temperature (oral, axilary, rectal, tympanic). 3. Measure radial pulse (rate, rhythm, amplitude and contour, and elasticity). 4. Monitor respirations (rate, rhythm, and depth). 5. Measure blood pressure. Analysis of Data 1. Formulate nursing diagnoses (wellness, risk, actual). 2. Formulate collaborative problems