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Does he urinate frequently? Does he get up during the night to urinate? Musculoskeletal system Does the patient have any evidence of muscle wasting? Can he perform the full range of motion with his extremities? Does he have any difficulty walking? Do you note any obvious joint deformities? Anthropometric measurements The second part of the physical assessment is taking anthropometric measurements. These measurements can help identify nutritional problems, especially in patients who are seriously overweight or underweight.
Communicates well. Makes eye contact and expresses appropriate concern throughout exam. C. Smith, RN your findings. Document all information about one body system, for example, before proceeding to another. Locate landmarks Use anatomic landmarks in your descriptions so other people caring for the patient can compare their findings with yours. ” With some structures, such as the tympanic membrane and breast, you can pinpoint a finding by its position on a clock. ” If you use this method, however, make sure others recognize the same landmark for the 12 o’clock reference point.
Avoid using your thumb to assess pulse, and never palpate both carotid arteries at the same time. Respirations • Remember that 16 to 20 breaths/minute is normal. • Assess respiratory rate while taking the pulse. • Observe the number and rhythm of the breaths, symmetry of the chest, and depth of respirations. • Watch for the use of accessory muscles, crackles, wheezing, and stridor. Blood pressure • Remember that normal systolic pressure is 100 to 119 mm Hg; normal diastolic pressure, 60 to 79 mm Hg.
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