Introduction to Assessment and Collection Techniques

What is subjective data?

Info reported by pt

What is objective data?

Observable/measurable findings

What is a symptom?

Subjective experience reported by pt

What is a sign?

Objective finding

What are the 4 main physical assessment techniques?

Inspection, palpation, percussion and auscultation.

What does inspection involve?

Looking at appearance, colour, symmetry, movement, posture and visible abnormalities.

What does palpation involve?

Using touch to assess temperature, texture, tenderness, masses, pulses and swelling.

What does percussion involve?

Tapping the body to assess underlying tissue density from the sound produced.

What does auscultation involve?

Listening to internal body sounds with a stethoscope.

Which systems are commonly assessed using auscultation?

Cardiovascular, respiratory and gastrointestinal systems.

What is the usual physical assessment sequence?

Inspection → Palpation → Percussion → Auscultation.

What is the abdominal assessment sequence?

Inspection → Auscultation → Percussion → Palpation.

Why is the abdominal assessment sequence different?

Palpation and percussion may stimulate bowel activity and alter bowel sounds.

What should be done before starting an assessment?

• Introduce

• Explain

• Consent

• Privacy

• Position

Why is patient identification important before assessment?

To ensure the correct patient receives the correct assessment and care.

Why should painful areas generally be assessed last?

To avoid increasing pain and affecting the rest of the assessment.

Why should both sides of the body be compared?

To ensure symmetry

What does light palpation assess?

• Surface tenderness

• Texture

• Temperature

What does deep palpation assess?

• Deeper structures

• Masses

• Organs

• Deeper tenderness

What is the purpose of percussion?

To estimate whether underlying tissue contains air, fluid or solid tissue.

What does resonance usually indicate?

Normal air-filled lung tissue

What does hyperresonance usually suggest?

Increased air in the underlying tissue.

What does dullness on percussion suggest?

• Dense tissue

• Fluid

• Organ

What does tympany usually indicate?

Air/gas in hollow structure like stomach or bowel

What should a nurse observe as soon as they see a patient?

• General appearance

• Distress

• Breathing

• Colour

• Consciousness

• Mobility

What is a focused assessment?

An assessment focused on a specific problem or body system.

What is a comprehensive assessment?

Broad assessment of pts overall health and multiple body systems

Why is reassessment important?

Determines whether pt is improving or worsening

What is primary data?

Information obtained directly from pt

What is secondary data?

Information obtained from other sources like family, records or other clinicians.

When might secondary data be especially useful?

When pt cannot provide reliable history

What does PQRST stand for?

• Provocation

• Quality

• Region/Radiation

• Severity

• Timing

What does P in PQRST assess?

What provokes the pain

What does Q in PQRST assess?

Quality of the pain like sharp or dull

What does R in PQRST assess?

Location of pain and whether it radiates

What does S in PQRST assess?

Severity of pain from 0-10

What does T in PQRST assess?

• Onset

• Duration

• Frequency

• Timing of pain