PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE

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 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.