collecting Objective Data

Collecting Objective Data: Assessment Techniques

Health Assessment

  • Property of: Susan Arnold, RN, MSN, ACUE

Unsung Heroes

  • Emphasis on the role of caring in nursing practice.

  • Nursing is presented as a skilled profession focused on healing patients.

  • Various roles in the medical field, such as:

    • Registered Nurse (RN)

    • Licensed Practical Nurse (LPN)

  • Importance of clinical education in providing care in medicine.

Goals of Assessment Techniques

  • Provide essential data to safely care for patients.

  • Identify normal and normal variants in patient assessment.

  • Provide objective assessment data to guide treatment plans.

Patients’ Rights

  • Patient-centered care: At the core of essential health assessment techniques.

  • Key rights of patients include:

    • Right to be completely informed about the assessment.

    • Understanding what to expect during the assessment.

    • Confidentiality must be upheld concerning all patient findings.

Standard Precautions

  • Health assessment requires direct contact with the patient.

  • These precautions serve as a foundation for preventing the transmission of infectious agents:

    • Hand hygiene: Wash or sanitize hands before and after assessment.

    • Personal protective equipment (PPE) includes:

    • Gloves

    • Gown

    • Mask

The Four Assessment Techniques

  1. Inspection:

    • Purpose: Examine the physical aspects of the body, including posture and appearance.

  2. Auscultation:

    • Purpose: Listen to sounds produced by the body.

  3. Percussion:

    • Purpose: Evaluate the size, consistency, and borders of body organs, and presence or absence of fluid in body areas (will not be discussed in this course).

  4. Palpation:

    • Purpose: Feel and touch for surface characteristics.

Organizing the Assessment

  • Use a systematic approach for effective health assessments:

    • Work from noninvasive to invasive assessments.

    • Use an organized approach with minimal positional changes.

    • Cluster assessments to increase efficiency and patient comfort.

Sample Question

  • Question: The FIRST step just prior to performing an assessment on a patient is to:

    • a. Look at the patient

    • b. Wash your hands

    • c. Stand on the left side

    • d. Put on gloves

Answer

  • Correct answer: B - Always wash your hands before and after an assessment due to the requirement of direct contact with the patient.

Start with Inspection

  • Requirements for Inspection:

    • Requires the use of three senses: Seeing, Hearing, Smelling.

    • Key aspects include:

    • Comfortable room temperature.

    • Good lighting, preferably with tangential lighting.

    • Exposure of only the body part being assessed.

    • Comparison of symmetry of body parts from one side to the other.

Characteristics to Inspect

  • Inspect the following characteristics of the body:

    • Location

    • Size

    • Color

    • Pattern

    • Shape

    • Odors

    • Symmetry

Sample Question

  • Question: Inspection requires the use of three senses, but not the sense of:

    • a. Hearing

    • b. Seeing

    • c. Smelling

    • d. Feeling

Answer

  • Correct answer: D - You do not feel the patient during the inspection process.

Auscultation

  • Purpose of Auscultation: Assess cardiovascular, respiratory, gastrointestinal, and peripheral vascular sounds.

  • Equipment Required: Stethoscope.

Indirect Auscultation

  • Purpose: To listen to sounds produced by the body using an amplification device (stethoscope).

    • Techniques:

    • Warm the stethoscope by rubbing your hand over the diaphragm or the bell.

    • Place the diaphragm or bell firmly on the area to be assessed.

    • Concentrate to listen to the sounds.

    • Clean the stethoscope with an alcohol swab after use.

  • Sound Characteristics:

    • The bell detects low-pitched sounds.

    • The diaphragm detects high-pitched sounds.

  • Reminder: Never auscultate over clothing.

Percussion

  • Purpose of Percussion:

    • Evaluate size, consistency, and borders of body organs.

    • Assess presence or absence of fluid in body areas by tapping body parts to produce sound waves.

  • Assessment Uses Include:

    • Eliciting pain

    • Determining location, size, and shape of organs

    • Assessing density

    • Detecting abnormal masses

    • Eliciting reflexes

Palpation

  • Types of Palpation:

    • Light:

    • Using finger pads to assess texture, size, moisture, masses, and tenderness (depth: <1 cm or approximately ½ inch).

    • Moderate:

    • Depress skin 0.5 to 0.75 inches with circular motion to assess internal organs and tenderness.

    • Deep:

    • Assess organ size, position, and tenderness using one or two hands; press 1 to 2 inches deep.

    • Safety Alert: If pain is reported, palpate that area last.

  • Parts of the Hand Used:

    • Fingerpads: For fine discrimination, such as pulses and texture.

    • Ulnar or Palmar Surface: For vibrations, thrills, and shape.

    • Dorsal (back) Surface: For temperature.

Deep Palpation

  • Technique for Deep Palpation:

    • Using finger pads or bimanual techniques (one hand placed over the other) to assess organ size and position, masses, and tenderness.

    • Press down 5cm (about 1 to 2 inches) to assess.

Sample Question

  • Question: A patient states that he has a lump on his right forearm. What part of the hand is best to use to assess the lump?

    • a. Dorsal surface

    • b. Finger pads

    • c. Ulnar surface

    • d. Anterior surface

Answer

  • Correct answer: B - Finger pads are the best for assessing fine discrimination and sensations such as texture, shape, and consistency.