Chapter 5 – Physical examination techniques: A nurse’s guide
Closing of the Objective Assessment
You should notify the client when you have completed the physical assessment and the collection of your objective data. You can provide a brief summary of your findings and the next steps based on these findings. You should also inquire whether there is anything you might not have seen or assessed that the client thinks might be of note.
Here are some examples of what you might say:
- “The physical assessment is coming to a close. There were no abnormal findings, but you will have your blood taken next. Before I finish, is there anything else that you would like to share with me or have me look at?”
- “The physical assessment is coming to a close. I am going to notify the physician of the mole on your back that you and I were talking about. Because of the changes in the mole colour and size, it is important that the physician looks at it to see if further assessment is required. Before I finish, do you have any concerns that I have not addressed or any questions?”
At the end of the assessment, ensure that you lower the bed and place the call bell in reach if the client is on an inpatient unit. Otherwise, you can notify the client that you will step out of the room and they can get dressed; you should also tell them where to place their gown.
Always finish by asking if the client has any questions, and of course, perform hand hygiene.