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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.
The original purpose of the model was to be an assessment used throughout the patient's care, but it has become the norm in UK nursing to use it only as a checklist on admission. It is often used to assess how a patient's life has changed due to illness or admission to hospital rather than as a way of planning for increased independence and ...
see Physical examination#Example: labs and diagnostics studies "none" May cover studies performed at an outside hospital, during prior admissions, or in the ER before the current admission. assessment and plan (A&P) "Pt is a 30 yo female..." Assessment and plan are very closely related, and are often reported in a single section.
Health assessment has been separated by authors from physical assessment to include the focus on health occurring on a continuum as a fundamental teaching. [8] In the healthcare industry it is understood health occurs on a continuum, so the term used is assessment but may be preference by the speciality's focus such as nursing, physical therapy, etc.
• The pGALS assessment is a simple evidence-based approach to musculoskeletal assessment based on the adult GALS (Gait, Arms, Legs, Spine) screen and has been shown to have high sensitivity to detect significant abnormalities • pGALS is primarily aimed at the school aged child, but younger children will often comply with pGALS, especially ...
Palpation is the use of physical touch during examination. During palpation, the physician checks for areas of tenderness, abnormalities of the skin, respiratory expansion and fremitus. [14] To assess areas of tenderness, palpate areas of pain, bruises, or lesions on the front and back of the chest.
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical history, [1] but not deeper investigation such as neuroimaging.