Assessment Techniques

what is assessment?

foundation of nursing care and the information we gather/observe

purpose of assessment

assess current health state, identify known or unknown problems, create an overall impression of the patient

3 types of physical assessments

1. “well visit”

2. focused exam

3. complete assessment

what is your most valuable tool in assessment?

you

5 key principles for all assessments

1. respect privacy and dignity

2. ensure patient comfort

3. give clear instructions

4. keep patient informed

5. practice cultural sensitivity

always start with …

vital signs, baseline data

7 vital signs, baseline data

1. height

2. weight

3. temperature

4. pulse

5. respiration

6. O2 saturation

7. blood pressure

hospital/bedside assessment can be ______ or _______ ____ _ ___

modified or complete head-to-toe; start where the problem is

4 core assessment techniques

1. inspect

2. palpate

3. percuss

4. auscultate

inspection

purposeful looking that starts with your first impression and compare side to side (symmetry, movement, appearance)

what info can you gather with inspection

appearance, symmetry, color, lesions, scar, posture, etc.

palpation

uses sense of touch to look for texture, temperature, moisture, organ location or size, masses, or tenderness

what info could you gather with palpation

texture, temperature, tenderness, moisture, masses, pulses, etc.

light palpation is how deep

1 cm

deep palpation is how deep

2-3 in

percussion

tap with short strokes and assess the location and size, density of tissue, and presence of pain

what info can you gather with percussion?

density of tissue, size and borders of organs, presence of air fluid or solid mass, etc.

auscultation

listen to heart, lungs, blood vessels

what info can you gather with auscultation

heart sounds, lung sounds, bowel sounds, vascular sounds (bruits)

what order do you almost always perform these techniques?

inspection, palpation, percussion, auscultation

2 parts of the stethescope

1. diaphragm

2. bell

the diaphragm hears what type of sounds

high pitched and normal heart sounds (S1 and S2)

the bell hears what type of sounds

low pitched and heart murmurs and extra heart sounds (S3 and S4)