A comprehensive physical assessment in nursing involves systematic evaluation of vital signs, respiratory and cardiac systems, and peripheral circulation through methods including lung auscultation (anterior and posterior), heart valve assessment using stethoscope diaphragm and bell, pulse checks, capillary refill testing, and edema examination, with normal findings indicating clear lung sounds, regular heart sounds (S1 and S2), equal chest expansion, and good peripheral perfusion.
Deep Dive
Prerequisite Knowledge
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Deep Dive
547 - Unintentional ASMR - Assessment / Exam / Head to ToeAdded:
I'm coming. You're going to say you're okay being recorded. I'm okay being recorded.
All right, so I'm going to come in. I'm going to do an anti-shaking.
Catching a room check.
Okay, so just doing a room check as well.
All right.
I'm not sure.
All right.
So you'll come in and do the clean and hygiene. Hello, my name is Dorothy. I'm going to be your nurse today. How are we doing today? I'm good, yeah. It's a really good day. That's good.
>> Sunny out. That's good. We like a sunny day.
>> Yes, yeah. Perfect.
>> Can you tell me your name? Uh yeah, my name's Tara Bell. And your date of birth? Um September 14th, 2000. Perfect.
All right, Tara, can you tell me a little bit about why you're here today?
Um I was just looking to see if we could um do a health assessment on myself.
Okay.
>> See how everything's looking. Okay.
>> Just like a normal checkup. Perfect. And when was your last health assessment? Um maybe like a year ago. Okay. No worries.
Yeah, we can't really remember the last time. Okay. Perfect. I'm just going to ask you a couple of questions. Um and let me know if you feel uncomfortable at any point, okay?
Uh do you have any past medical histories that would be concerning? No, not really. Okay. Any medications? Nope.
Okay. Do you have any known allergies?
No, not that I know of. Not that you know.
>> had an allergy test, but no. Okay.
All right.
Uh do you have any pain?
No, actually. Okay. So. Perfect. All right, so for the health assessment, I'm just going to be doing like an overall just looking over. I'm going to listen to your lungs, anterior which just means the front, and posterior which means the rear back, okay?
>> Okay. Um and then I'm going to listen to your heart with my uh stethoscope as well, but I'm going to do it twice, once with my diaphragm and once with the bell, okay? Okay. Um if at any point you feel any discomfort or pain with it, let me know. If you have any questions, feel free to ask, okay? Okay. All right.
Are you okay if we start?
>> Yeah, for sure. Okay. You can sit up a little bit here.
So, her skin is looking good. Um good for her density. There's no cyanosis.
Uh I don't see any uh scars, scratches, bruises on her at all. She has a couple of tattoos, which is fine. Uh her hair is clean and brushed. Clothes are also clean.
Um Yeah, she's looking good.
So, for vital signs, her temperature is 36.3, her pulse is 84, uh respiratory rate is 18, blood pressure is 128 over 80, and oxygen is 98 over uh sorry, on room air.
Cuz it's normal. Yes, it's normal.
>> Okay. Your vitals are all good. Okay, good.
Okay. So, I'm just going to first actually feel around here a little bit just to see if there's any masses or lumps or anything like that. Let me know if you have any pain or discomfort, okay?
>> Okay.
Okay. So, that all feels normal there, no concerns, okay?
Uh I'm just going to take a quick listen to your um anterior chest lung. Okay. For your chest. Um and then just when you feel my stethoscope, just take a deep breath each time. Okay. And then I'm just going to get you to move your shirt when I go when I go down here, and I might get you to move your breasts a little bit, okay?
>> And then I'll just take a deep breath.
Is that good?
Okay.
You sure about that?
And I'm just going to come down here a little bit and get you to take a deep breath. Deep breath.
So I'm going to go down just a little bit further. Deep breath.
Okay. And then let's get you to lift your shirt up for me, okay?
>> Okay.
And then deep breath.
I'm just going to go over here.
Deep breath.
And then once more.
All right, so your uh uh lungs sound clear. I don't hear any adventurous sounds, no wheezing, crackles, or rhonchi, okay? Everything sounds clear. I'm just going to get you to turn around for me.
I'm going to say you can move here. Like this or like You just You can turn all the way. Yeah, perfect. And then I'll just get you to lift your shirt up for me.
Okay.
And then I'll just get you to take deep breaths every time you feel my stethoscope, okay?
Okay.
Can we go a little bit?
Deep breath.
I'll just get you to put your arms out in front of you there for a second.
Okay, and deep breath.
I'm just going to go around on this side.
And then one more deep breath for me.
Okay. I'm just going to do one more thing to test test your chest expansion, okay? So, I'm just going to put my hands here, okay? And I'm just going to quickly pinch a little bit.
All right. I'm just going to move your tie a little bit. Sorry. It's all right.
Okay, I'm just going to do this. Okay, pinch. All right, I'll get you to take a deep breath.
Okay.
Perfect.
All right, so your posterior lung sounds sound clear. No adventitious sounds, so no crackle, wheezes, or rhonchi. Everything sounds good and clear, and your chest expansion is also equal. So, I'll push you there. I'll just get you to put your shirt back on, and you can lie back over here.
You're still doing okay? Yeah. Okay.
Any questions so far? No. First of all, that's First of all, Okay. So, now I'm just going to do your cardiac assessment, so I'm just going to listen to the different areas of your heart heart here, okay? And um Yes.
Okay. So, I'm going to the right uh sternal border where the aortic valve is.
Uh it's at the second second intercostal space, and this is where S2 is going to be the loudest. Okay.
Okay, so I heard a clear lub dub there.
S2 was the loudest. I'm now going to move over to the left sternal border, which which is where the pulmonic valve is. I will also hear S2 the loudest at this point.
Okay, so I heard a clear S2 sound there.
I'm just going down to the third intercostal space, which is where herbs point is and I will hear clear equal sounds for S1 and S2.
I'm just going to lift your shirt down just a little bit.
Okay.
Perfect. Now I'm just going to get you to lift your shirt up, okay?
Now I'm just going down to the fourth intercostal space.
Okay, which is where S1 will be heard the most.
Okay.
And then the fifth intercostal space.
Okay. So I heard clear S1 sounds for both of those. Uh that all sounds clear and good. Heard clear equal heart beats there. Also no concerns. I'm just going to do it again with my bell, okay?
All right, again.
Down to the third intercostal space, sorry.
Perfect. I'll just get you to lift your shirt up again for me.
Okay, back down to the fourth.
And then the fifth.
Which is mid-clavicular line.
Perfect. All right, going to heard clear S1 and S2 sounds. Everything sounds good. I don't hear any extra heart sounds, okay?
I'm just going to check your pulses now.
So I'm going to do one side at a time.
Okay, just also check your all bowel sounds for your legs for everything, okay?
>> So this side is good and equal and strong.
You want to come around this side.
Looking good and strong and then we're going to clean your hair again.
Okay. So your pulses all felt good and equal and strong, okay? I'm just going to check your capillary refill.
So I'm going to push down your fingernail a little bit. Cuz that's cool. Yeah.
And capillary refill is good under 3 seconds. Her skin is also warm, no cold spots, looking good there too. I'm just going to look at your legs as well just to check to see if there's any edema.
And skin is also warm, so that's good. I'm just going to check your pedal pulse too now.
And that's all good here.
>> Okay. So, a little bit more nice and equal as well. You don't have any edema on your legs. Your skin is warm, so that is good.
So, that is everything. Everything is looking good. Your vitals are normal.
Your lungs sound nice and clear. I don't hear any wheezing, crackles, or rhonchi, which is a good sign. Your heart sounds clear as well. I heard clear S1 S2 sounds, which is the normal. So, every time I listen, I just hear a clear lub-dub. That's all I heard.
Um your skin tone everything looks good.
Capillary refill is good.
I have no concerns. Your chest expansion is also good as well. So, you don't You don't have anything going on there, okay? Okay. Do you have any questions for me today?
Um no, I think everything's good other than like um like when should I book back with you? Like when should I book for my next health assessment?
We can go and look at that, and we can get you booked again, okay? Okay. Sounds good. Thank you. You're welcome. Thank you. You too.
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