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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.
An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen.
The Calgary–Cambridge model (Calgary-Cambridge guide) is a method for structuring medical interviews. It focuses on giving a clear structure of initiating a session, gathering information, physical examination , explaining results and planning, and closing a session.
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
A peripheral vascular examination is a medical examination to discover signs of pathology in the peripheral vascular system. It is performed as part of a physical examination , or when a patient presents with leg pain suggestive of a cardiovascular pathology.
In both tests, the patient is placed in a standing or sitting position, and the arms are raised parallel to the ground in the scapular plane. [2] The tests differ in the rotation of the arm; in the empty can test, the arm is rotated to full internal rotation (thumb down) and in the full can test, the arm is rotated to 45° external rotation, thumb up. [1]
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.