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进行身体评估的过程:护理视角。

The process of conducting a physical assessment: a nursing perspective.

作者信息

Baid Heather

机构信息

Surrey and Sussex Strategic Health Authority.

出版信息

Br J Nurs. 2006;15(13):710-4. doi: 10.12968/bjon.2006.15.13.21482.

Abstract

Physical assessment is a new responsibility for many nurses in the UK who are expanding their parameters of advanced clinical practice. A physical assessment framework can be used by both community and acute care nurses as a guide to the process of conducting a physical assessment. The framework presented here consists of the following sequence of steps: identifying the purpose of the assessment; taking a health history; choosing a comprehensive or focused approach; and examining the patient using the sequence of inspection, palpation, percussion and auscultation. The next step, interpretation of the clinical findings, which results in either the recognition of abnormality or identification of a differential diagnosis, then becomes the basis for clinical decision making. This paper describes a comprehensive, head-to-toe assessment as one example of the application of this physical assessment framework in clinical practice.

摘要

对于英国许多正在拓展其高级临床实践范畴的护士而言,体格检查是一项新的职责。社区护士和急症护理护士均可使用体格检查框架,作为进行体格检查过程的指南。此处呈现的框架包含以下步骤顺序:确定评估目的;获取健康史;选择全面或重点评估方法;按照视诊、触诊、叩诊和听诊顺序检查患者。下一步,对临床发现进行解读,这会导致识别异常或确定鉴别诊断,进而成为临床决策的基础。本文描述了一项从头到脚的全面评估,作为该体格检查框架在临床实践中应用的一个示例。

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