ATI Assessment

The last ATI assignment for this semester is about performing a physical assessment on an adult patient. Several instruments are used to perform an assessment but the most used tools are gloves, stethoscope, pen light, tongue depressor, and an otoscope. Among these instruments, the nurse may also use a cotton ball (to test the patient’s sensation to light touch), fragrances (to test the patient’s ability to identify certain odors), and measuring tools (to measure existent wounds and lesions).

During the beginning of the physical assessment, the nurse will be checking the patient’s level of consciousness by asking the patient’s name, date of birth, knowledge of place and time. If patient is able to respond to these questions correctly, the

When assessing the respirations, blood oxygenation (percentage) is evaluated along with respiration’s rate, depth and auscultation of the lung sounds. Any abnormal findings should be reported immediately for an early intervention. When listening to the heart, the nurse should look for abnormal rhythm, and sounds (such as S3 and S4 that are normally not heard). The best site to auscultate the heart is on the patient’s left side of the chest. Place the stethoscope’s diaphragm on the fifth intercostal space where the apex of the heart is located. This site the called the point of maximal impulse or PMI. Bowel sounds are heard over four quadrants of the patient’s abdomen. The proper sequence is inspection, auscultation, palpation and percussion. The nurse should start listening for bowel sounds on the right lower quadrant, ascend to the right upper quadrant, then move to the left upper quadrant and finally to the left lower quadrant. This sequence follows the ascending, transverse and descending colon (parts of the large intestine). Bowel sounds are usually heard more than one minute because of the peristaltic activity. Along with bowel auscultation, the nurse must ask if the patient’s is passing gas to confirm peristalsis. To finalize the