Nursing Assessment

By
Imavike

General objective

After studying this chapter, the

learner should be able to perform
nursing assessment

Specific objective

Identify the purposes of the nursing assessment

Describe the techniques used during a nursing
examination
Discuss the important client preparation for a
nursing assessment
Identify equipment used in performing a nursing
assessment
Describe positioning used for each body system
examination
Conduct a nursing assessment of each body system
in a systemic manner, identifying normal and
abnormal findings
Document significant findings in a concise,
descriptive manner

Definition

The nursing assessment of the client

is an integral component of holistic
care and of the nursing process.
It used to initiate and maintain
individualized plans of care to
promote wellness, prevent illness,
restore health, and facilitate coping,
thereby facilitating the optimal level
of wellness

Purposes of nursing assessment

To establish a nurse-client relationship

To gather data about the clients general
health status, integrating physiologic,
psychologic, cognitive, sociocultural,
developmental, and spiritual
characteristics
To identify the client strengths and coping
abilities
To identify health problem
To establish a database for the nursing
process

Types of Assessment

Comprehensive assessment
Health history and complete physical examination
conducted when a patient first enters a healthcare
setting

Ongoing partial assessment

Conducted at regular interval during care of the patient

Focused assessment
Conducted to assess specific problem

Emergency assessment
A type of rapid focused assessment conducted to
determine potentially fatal situation

Component of nursing
assessment

A health history and (carried out

first)
Nursing examination (a head-to-toe,
system-by-system physical
examination)
Review of record

Health history

The health history is a collection data

that provides a detailed profile of the
clients health status

Component of the health history

Biographical data
(name, address, sex, age, marital status,
occupation, ethnic origin)
Informant
(most reliable source is client, other
source information)
Chief complaint
(reason the client requires health care)

Component of the health history

History of present illness

(PQRST)

Past health history

(immunization, allergic, physical exam and
diagnostic test, illness, surgery and injury)
Family history
(to determine risk factor for certain
disease condition)
Review of system (head to toe --objective data given by client)

Component of the health history

Patient profile

Developmental factors
Education and occupation
Environment
Spiritual factors
Interpersonal factors
Life style (personal habits, diet, sleep/ rest
pattern, ADLs, recreation/ hobbies)
Self concept
Sexuality
Stress response

Preparation for Assessment

Environment
Equipment
Client

Preparing for environment

The nurse should plan time that is

appropriate for both the client and the
nurse
Have a special examination room that
provides a quiet, private space for
assessment
Warm
Comfortable temperature
Adequate direct lighting
Precaution to prevent interruptions by
visitor or other health care personel

Preparing for client

Physiologic and psychologic needs of

the client must be considered when
doing nursing examination
The client is told that a nursing
examination will be done and the
assessment are painless
The client is asked to change into the
gown

Preparing for client

The client asked to empty the

bladder
The nurse should answer any
questions asked by client directly and
honestly

Position for examination

Preparing for equipment

Stethoscope
Sphygmomanometer
Thermometer
Digital watch
Tape measure
Ophthalmoscope
Otoscope
Snellen chart
Nasal Speculum
Percussion hammer
Clean non latex gloves

Nursing examination

Techniques
Inspection
Palpation
Percussion
Auscultation

Inspection

Inspection is the systematic and deliberate

observation of the person using the senses
of vision, smell, and hearing to determine
any normal or abnormal findings
Guidelines

Focus on observation
Use good lighting
Expose body part
Make comparison

Palpation

Palpation is the use of touch during the

physical examination
Guidelines

Warm your hand

Minimize discomfort
Use the correct part of your hand
Start light
Light palpation
Deep palpation
Bimanual palpation
Any area of tenderness is palpated last
Nurse should be sensitive to the clients verbal and
facial expressions indicating discomfort

Uses of your hand

Light Palpation

Deep palpation

Bimanual palpation

Palpation is use to determine:

Texture (eg, of the hair)

Temperature (eg, of a skin area)
Vibration (eg, of a joint)
Position, size, consistency, and mobility
of organs or masses
Distention (eg, of the urinary bladder)
Presence and rate of peripheral pulses
Tenderness or pain

Percussion

Percussion is the act of striking one object

against another for the purpose of
producing sound
Uses to assess the location, shape, size,
and density of tissue
Two percussion method
Direct
Indirect/ Mediate

Mediate Percussion

Sound produced by Percussion

Auscultation
Auscultation is the act of listening to
sound produced within the body
Two methods of auscultation:
- Direct (eg, respiration wheeze,
grating of the moving joint)
- Indirect (using stethoscope)

Order --- IPPA,

except abdomen used IAPP

Vital signs

Measures :
Body temperature
Pulse
Respirations
Blood pressure

Body temperature

The balance between the heat

produced by the body and the heat
lost from the body
Two kinds of body temperature:
Core temperature (deep tissues, eg.
Cranium, thorax, abdominal + pelvic
cavity)
Surface temperature (skin,
subcutaneous tissues, fat)

WHAT PARTS OF THE BODY ARE USED

IN DETERMINING TEMPERATURE?

Factors affecting body

temperature

Age
Diurnal variation (highest temp 8pmmidnight, lowest temp 4-6am)
Exercise
Hormones
Stress
Environment

Variation in body temperatures by

age
Age

Average temperature

Newborn

Axillary

36.1-37.7 C

97.0-100F

1 year

Oral

37.7C

99.7F

3 years

Oral

37.2C

99.0F

5 years

Oral

37.0C

98.6F

Adult

Oral

37.0C

98.6F

Axillary

36.4C

97.6F

Rectal

37.6C

99.6F

Forehead

34.4C

94.0F

Tympanic

37.7C

99.9F

Oral

36.0C

96.8F

Elderly (over
70yr)

Pulse

A wave of blood created by

contraction of the left ventricle of the
heart.
The pulse wave represents the stroke
volume output and the compliance of
the arteries

Factors affecting pulse rate

Age
Sex
Exercise
Fever
Medications
Hemorrhage
Stress
Position changes

Pulse sites

Respirations

The act of breathing; it includes the

intake of oxygen and the output of
carbon dioxide

Blood pressure

Arterial blood pressure is a measure of

the pressure exerted by the blood as it
flows through the arteries
Systolic pressure (peak level when
ventricle giving contraction)
Diastolic pressure (lowest level when
ventricle rest)
Normal range (adult) 100/60 sampai
140/90.

Factors affecting blood pressure

Age
Exercise
Stress
Race
Obesity
Sex
Medications
Diurnal variations
Disease process

Any Questions

Summary

Basic knowledge and skill are

required to successfully conduct the
physical examination

Suggested reading

Health assessment, a nursing

approach
Fundamental of nursing, the art and
science of nursing care
Fundamentals of nursing: concepts,
process and practice