Assessment Techniques

Chapter 9: Assessment

Techniques and the Clinical

Setting

Written by Carolyn Jarvis, PhD, APN, CNP

Adapted by June MacDonald-Jenkins, RN, BScN, MSc

Cultivating Your Senses

The health history described in the preceding chapters provides

subjective data for health assessment: the individual’s own

perception of the health state. Objective data are gathered through

the use of technical measurements and observations by the health

care provider.

You will use your senses—sight, smell, touch, and hearing—to

gather data during the physical examination. You have always

perceived the world through your senses, but now they are focused

in a new way. The skills required for the physical examination are

inspection, palpation, percussion, and auscultation. As a rule of

practice, they are performed one at a time and in this order, except

for the abdominal assessment, which will be discussed in later

chapters.

Inspection

Inspection is concentrated watching. It is close, careful scrutiny,

first of the individual patient as a whole and then of each body

system. Inspection begins the moment you first meet the patient

and develop a “general survey.

” (Specific data to consider for the

general survey are described in Chapter 10.) As you proceed through

the examination, start the assessment of each body system with

inspection.

Inspection is always performed first. Initially you may feel

embarrassed “staring” at the patient without also “doing

something.

” However, do not be too eager to touch the patient. A

focused inspection takes time and yields a surprising amount of

data. Learn to use each patient as their own baseline by comparing

the right and left sides of the body. The two sides are nearly

symmetrical. Inspection requires good lighting, adequate exposure,

and occasional use of certain instruments (otoscope,

ophthalmoscope, penlight, nasal and vaginal specula) to enlarge

your view.

Palpation

Palpation follows and often confirms points you noted during

inspection. In palpation, you apply your sense of touch to assess

texture, temperature, moisture, and organ location and size, as well

as any swelling, vibration or pulsation, rigidity or spasticity,

crepitation, presence of lumps or masses, and presence of

tenderness or pain. Different parts of your hands are best suited for

assessing different factors:

• Fingertips: best for fine tactile discrimination such as skin

texture, swelling, pulsation, and determining presence of

lumps

• A grasping action between the fingers and thumb: best for

detecting the position, shape, and consistency of an organ or

mass

• The dorsa (backs) of hands and fingers: best for determining

temperature because the skin is thinner on the dorsa than

on the palms

• Base of fingers (metacarpophalangeal joints) or ulnar surface

of the hand: best for vibration

Your palpation technique should be slow and systematic. A

patient stiffens when touched suddenly, which makes it difficult for

you to feel very much. Use a calm, gentle approach. Warm your

hands by kneading them together or holding them under warm

water. Identify any tender areas, and palpate them last.

Start with light palpation, using the pads of your fingertips to

detect surface characteristics and accustom the patient to being

touched. Then perform deeper palpation, perhaps by helping the

patient use relaxation techniques such as imagery or deep

breathing. Your sense of touch becomes blunted with heavy or

continuous pressure. When deep palpation is needed (as for

abdominal contents), intermittent pressure is better than one long,

continuous palpation. Avoid deep palpation in situations in which it

could cause internal injury or pain. Also avoid “digging in”

with the

ends of your fingers; it will cause pain or discomfort to your patient

and may result in increased guarding, by the patient, of the affected

areas.

Bimanual palpation requires the use of both of your hands to

envelop or detect certain body parts or organs—such as the kidneys,

uterus, or adnexa—for more precise delimitation (see Chapters 22

and 27).

Percussion

Percussion is tapping the person’s skin with short, sharp strokes

to assess underlying structures. The strokes yield a palpable

vibration and a characteristic sound that depicts the location, size,

and density of the underlying organ. Why learn percussion when an

X-ray study is so much more accurate? Because your percussing

hands are always available, are easily portable, and give instant

feedback. Percussion has the following uses:

9.1

A close up for direct percussion. A nurse hyper extends their index

and ring fingers a little away from the middle finger and place the

dorsal side of the same hand on a patient's back shoulder. The

middle finger of the other hand gently presses the already placed

middle finger.

• Mapping out the location and size of an organ by exploring

where the percussion note changes between the borders of

an organ and its neighbours

• Signalling the density (air, fluid, or solid) of a structure by a

characteristic note

• Detecting an abnormal mass if it is fairly superficial; the