Nursing examination of the patient

Stage I of the nursing process

In addition to medical, there is a nursing examination of the patient as the first stage of the nursing process. At this stage, the nurse collects information about the patient using her senses:

vision;
hearing;
smell;
touch.

The nurse, examining the patient, collects subjective information :

passport data;
complaints to date;
anamnesis of life;
medical history;
epidemiological history.

Further, the nursing examination of the patient is aimed at collecting objective information :

inspection - general and detailed;
physical indicators (height, weight, in the presence of edema - their localization);
state of consciousness - conscious, unconscious, disorders of consciousness (apathy, depression, delirium, hallucinations);
memory - preserved, broken;
position - active, forced, passive;
respiratory system: nature and type of breathing, NPV;
the condition of the skin and mucous membranes - humidity, turgor, color, defects;
assessment of the state of the musculoskeletal system - the presence of deformities of bones and joints, muscle tone;
body temperature during the examination;
measurement and evaluation of blood pressure in both arms;
study of the pulse;
sense organs, speech, sleep, body functions, the ability to move, eat, drink, the presence of reserves - removable dentures, hearing aids, contact lenses, glasses;
emotional condition;
social environment;
risk factors.