assessment techniques

physical assessment

collect objective data using trained senses

help identify normal/abnormal findings

support clinical judgment and nursing diagnosis

core assessment techniques

inspection → palpation → percussion → auscultation

inspection

careful, intentional visual observation of pt/body system

tools: penlight, ophthalmoscope, specula

compare L/R side

take time (no rush)

expose areas needed (pt uncomfortable)

begin the moment you see pt, sight/smell

palpation

touch to assess physical characteristics

assess: texture, temp, moisture, tenderness, pulses, swelling

rules: clean/warm hands, light palpation then deep, tender area last

use hands:

• fingertips: texture, swell, pulsation

• dorsal: temp

• palm/ulnar: vibration

percussion

tapping body to assess density, location, function of underlying structures

purpose: determine air, fluid, solid tissue, fast/always available

technique:

• hyperextended middle finger non-dominant hand

• strick w/tip of dominant finger

• listen sound produced

percussion sound: resonant

normal air-filled tissue

lungs

percussion sound: hyperresonant

too much air

emphysema

percussion sound: tympany

hollow, drum-like

stomach/intestines

percussion sound: dull

dense tissue

liver, spleen

percussion sound: flat

very dense

bone, tumor

percussion: reflex hammer

tap areas of body to screen deep tendon reflexes

assess how well nerve/muscle work together

auscultation

listen to body sounds w stethoscope

common sounds: heart, lung, bowel

best results:

• quiet room

• warm stethoscope

• no clothing between skin/stethoscope

• avoid hair

• prevent patient shivering (blanket)

Always listen systematically, not randomly

stethoscope

diaphragm: high-pitch sound

• breath, bowel, normal heart sound

bell: low-pitched sounds

• murmur, extra heart sounds (S3, S4)

assessment equipment

Always prepare equipment before touching the patient

• BP cuff

• thermometer

• height/weight scale

• penlight

• gloves

• eye chart

• alcohol wipe

• stethoscope

exam room should be

Nurse responsibility: clean & restock between patients

1. clean

2. well-lit

3. quite

4. private

5. warm

nurse responsibility to prevent spread of infection

clean room/equipment, hand hygiene

Standard Precautions = for EVERY patient

• hand hygiene

• PPE

• cough etiquette

transmission based-precaution

contact

droplet

airborne (N95+door always closed)

approach patient

calm, confident, respectful, unhurried