Nursing Assessment
1. Part of Nursing Process
2. Nurses use physical assessment skills to:
a) Obtain baseline data and expand the data base from which
... [Show More] subsequent phases of the
nursing process can evolve
b) To identify and manage a variety of patient problems (actual and potential)
c) Evaluate the effectiveness of nursing care
d) Enhance the nurse-patient relationship
e) Make clinical judgments
Gathering Data
Subjective data - Said by the client (S)
Objective data - Observed by the nurse (O)
Document: SOAPIER
Assessment Techniques:
The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for the
abdomen which is Inspect – Auscultation – Percuss – Palpate.
A. Inspection – critical observation *always first*
1. Take time to “observe” with eyes, ears, nose (all senses)
2. Use good lighting
3. Look at color, shape, symmetry, position
4. Observe for odors from skin, breath, wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with other assessment techniques
B. Palpation – light and deep touch
1. Back of hand (dorsal aspect) to assess skin temperature
2. Fingers to assess texture, moisture, areas of tenderness
3. Assess size, shape, and consistency of lesions and organs
4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep
C. Percussion – sounds produced by striking body surface
1. Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)
2. Used to determine size and shape of underlying structures by establishing their borders and
indicates if tissue is air-filled, fluid-filled, or solid
3. Action is performed in the wrist.
D. Auscultation – listening to sounds produced by the body
1. Direct auscultation – sounds are audible without stethoscope
2. Indirect auscultation – uses stethoscope
3. Know how to use stethoscope properly [practice skill]
4. Fine-tune your ears to pick up subtle changes [practice skill]
5. Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill]
6. Flat diaphragm picks up high-pitched respiratory sounds best.
7. Bell picks up low pitched sounds such as heart murmurs.
8. Practice using BOTH diaphragms
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 2 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
General Assessment
A general survey is an overall review or first impression a nurse has of a person’s well being. This is
done head to toe, or cephalo-caudal, lateral to lateral, proximal to distal, and front to back. General
surveying is visual observation and encompasses the following.
Appearance appears to be reported age;
sexual development appropriate;
alert & oriented;
facial features symmetric;
no signs of acute distress
Body structure/mobility weight and height within normal range (refer to Center for Disease Control
and Prevention (CDC) Body Mass Index (BMI) [adult] or BMI-for-age and
gender forms [children]);
body parts equal bilaterally;
stands erect,
sits comfortably;
gait is coordinated;
walk is smooth and well balanced;
full mobility of joints
Behavior maintains eye contact with appropriate expressions;
comfortable and cooperative;
speech clear;
clothing appropriate to climate;
looks clean and fit;
appears clean and well-groomed
Deviations from what would generally be considered to be normal or expected should be documented
and may require further evaluation or action, including a report and/or referral.
Standardized and routine screening such as audiometric screening, scoliosis and vision screening
using the Snellen Test are usually discussed in General Survey areas.
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Health History
A patient history should be done as indicated by the age specific prevention guidelines, usually set forth
by Center for Disease Control and Prevention (CDC), American Medical Association, American
Association of Pediatrics, and National Association of Pediatric Nurse Practitioners. The Healthy
People website (www.healthypeople.gov) provides an excellent source to determine benchmarks for
healthy living across the life span.
A comprehensive history, including chief complaint or reason for the visit, a complete review of
systems, and a complete past family and/or social history should be obtained on the first encounter with
a patient, regardless of setting and by a registered nurse. The history should be age and sex
appropriate and include all the necessary questions to enable an adequate delivery of services
according to prevention guidelines, scope of practice, patient need, visit requirement, and/or request.
Usually, completing a provider based Health History and Physical Examination Form will assist in the
assessment of the patient’s past and current health and behavior risk status. Certain health problems,
which may be identified on a health history, are more common in specific age groups and gender.
PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Page 3 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
An interval history (including an update of complaints, reason for visit, review of systems and past
family and/or social history) should be done. Usually family health histories are completed across three
generations looking specifically for patterns in genetic issues that negatively impact quality of life.
The health history gives picture of the patient’s current health and behavior risk status. Additional
information than what is on a form may be required depending on the specialized service(s) to be
provided or if the person presents with special needs or conditions. So a health history maybe may be
problem focused, expanded problem focused, detailed, or comprehensive. Regardless, documentation
must be completed for each visit and/or assessment.
Mental status evaluation may be done while doing health history (see neuro review) [Show Less]