Physical Assessment Teqhniques for Nurses

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This is part 2 of a 4 part series covering health assessment. Part 1 is the overview of a health history. Part 3 is a complete guide to vital signs. Part 4 is a step-by-step guide of a head-to-toe assessment. Part 5 covers a mental assessment.

What Is Needed to Perform a Physical Assessment?

Check out this FREE, concise overview of what a physical (head-to-toe) assessment is!

0001 human anatomy 2

In this overview you will learn the following:

  1. The purpose of an assessment
  2. The guidelines/preparation for an assessment
  3. The 4 techniques of a physical assessment
    1. Inspection
    2. Palpation
    3. Percussion
    4. Auscultation
  4. The order the 4 techniques should be performed in
  5. What a focused assessment is
  6. The nursing process, and how the assessment plays a role in it

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Ace Nursing School – Physical Assessment Overview for Nurses

  • Purpose
    • Assessment is the first step of the nursing process
    • Nursing diagnoses, planning, and interventions are based on the assessment
    • Notify the physicians with any abnormal findings of concern
  • Guidelines
    • Gather equipment
    • Explain assessment to patient
      • Each time you move to a new technique, explain to the patient what you are doing beforehand
    • Position bed at comfortable height for examiner(s)
    • Expose each body part as needed
      • Keep patient covered except for when a body part must be examined to maintain privacy
    • Establish rapport and trust by having an innocent conversation with patient before the assessment
    • Compare right side of the body with the left side
    • Begin with a general head-to-toe physical assessment. As problems are found/stated by the patient, focus in on those areas
      • When problems (or potential problems) are found, use it as a moment to educate the patient

 

  • 4 Techniques of a Physical Assessment
    • Inspection
      • Visually observing the patient
      • Always done before the other 3 techniques
      • Assess (and make a note of any abnormalities):
        • Size
        • Shape
        • Color
        • Texture
        • Symmetry
        • Position
  • Palpation
    • Using the hands to feel the patient or press on the patient
    • Begin light, work deeper as needed
    • Fingertips used for fine discrimination (anything that is hard to feel or tender)
      • Also good for gripping and feeling consistency of tissues
  • The back of the hand is best to palpate for temperature of body parts
  • Palms are good for sensing vibration
  • Assess (and make note of any abnormalities):
    • Tenderness
    • Size
    • Pulse
    • Swelling
    • Temperature
    • Vibration
    • Masses/lumps
    • Crepitus
    • Texture
    • Moisture/dryness
  • Percussion
    • Light striking of body parts to produce sounds
    • Direct percussion – striking of body part with finger(s), palm, or fist
    • Indirect percussion – middle finger of non-dominant hand placed on body part. Use finger(s) of dominant hand to strike the finger.
  • Blunt – using reflex hammer for deep tendon reflexes
  • Percussion sounds:
    • Resonance: loud, low pitched sound heard over normal lung filled with air
    • Hyperresonance – louder, lower-pitched sound heard over overinflated lung (emphysema)
    • Tympany – loud, drum-like sound found over air-filled viscera (stomach or bowels)
    • Dull – soft, muffled sound found with fluid-filled tissue (liver)
    • Flat – soft, high-pitched sound found with very dense tissue such as bone or muscle
  • Assess (and make a note of any abnormalities):
    • Location, size, density of masses
    • Pain
  • Auscultation
    • Listening to the body, often done with a stethoscope
    • Bell (smaller side) is used for low-pitched sounds
    • Diaphragm (larger side) is used for higher pitched sounds
    • Listen over bare skin when possible – clothes and hair create distractive noise
  • Order of Techniques Performed
    • General Assessment (everything except abdominal assessment)
      1. Inspection
      2. Palpation
      3. Percussion
      4. Auscultation
    • Abdominal Assessment
      1. Inspection
      2. Auscultation
      3. Percussion
      4. Palpation

 

  • Focused Assessment
    • In-depth assessment that is focused on a patient’s particular need
      • Example: If the patient is having cardiovascular problems, do a focused cardiovascular assessment
    • Assess specific characteristics of problem
    • Determine what nursing intervention is necessary
    • Determine when intervention should be done
    • Detailed focused assessments will be discussed at the beginning of the chapter for each body system.
  • Nursing Process
    • Information obtained from the physical assessment is used as the base of the nursing process
    • To remember the order of the nursing process memorize: A Delicious PIE.
    • A – assessment
    • D – diagnosis
    • P – planning
    • I – Implementation
    • E – Evaluation
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