Here's how to do the basic four techniques
WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen.
1. Inspection
Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. Assess for color, size, location, movement, texture, symmetry, odors, and sounds as you assess each body system.
2. Palpation
Palpation requires you to touch the patient with different parts of your hands, using varying degrees of pressure. Because your hands are your tools, keep your fingernails short and your hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last.
Types of palpation
Light palpation
- ▪ Use this technique to feel for surface abnormalities.
- ▪ Depress the skin ½ to ¾ inch (about 1 to 2 cm) with your finger pads, using the lightest touch possible.
- ▪ Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.
Deep palpation
- ▪ Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.
- ▪ Depress the skin 1½ to 2 inches (about 4 to 5 cm) with firm, deep pressure.
- ▪ Use one hand on top of the other to exert firmer pressure, if needed.
3. Percussion
Percussion involves tapping your fingers or hands quickly and sharply against parts of the patient's body to help you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas.
Types of percussion
Direct percussion
This technique reveals tenderness; it's commonly used to assess an adult's sinuses.
- ▪ Using one or two fingers, tap directly on the body part.
- ▪ Ask the patient to tell you which areas are painful, and watch his face for signs of discomfort.
Indirect percussion
This technique elicits sounds that give clues to the makeup of the underlying tissue. Here's how to do it:
- ▪ Press the distal part of the middle finger of your nondominant hand firmly on the body part.
- ▪ Keep the rest of your hands off the body surface.
- ▪ Flex the wrist of your nondominant hand.
- ▪ Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient's skin.
- ▪ Listen to the sounds produced.
4. Auscultation
Auscultation involves listening for various lung, heart, and bowel sounds with a stethoscope.
Getting ready
- ▪ Provide a quiet environment.
- ▪ Make sure the area to be auscultated is exposed (a gown or bed linens can interfere with sounds.)
- ▪ Warm the stethoscope head in your hand.
- ▪ Close your eyes to help focus your attention.
How to auscultate
- ▪ Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. Hold the diaphragm firmly against the patient's skin, using enough pressure to leave a slight ring on the skin afterward.
- ▪ Use the bell to pick up low-pitched sounds, such as third (S3) and fourth (S4) heart sounds. Hold the bell lightly against the patient's skin, just hard enough to form a seal. Holding the bell too firmly causes the skin to act as a diaphragm, obliterating low-pitched sounds.
- ▪ Listen to and try to identify the characteristics of one sound at a time.
Source: Health Assessment made Incredibly Visual!, Lippincott Williams & Wilkins, 2007.
© 2006 Lippincott Williams & Wilkins, Inc.FAQs
Initial evaluation or the general survey may include:
- Stature.
- Overall health status.
- Body habitus.
- Personal hygiene, grooming.
- Skin condition such as signs of breakdown or chronic wounds.
- Breath and body odor.
- Overall mood and psychological state.
WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen.
What are steps in assessing a patient? ›
Assessment:
- Focused enquiry of the chief complaint: Physical examination. Inspection. Auscultation. Palpation. Review of systems to develop differential diagnosis.
- Patient assessment is an on-going and continual process; officers must manage presenting symptoms as they find them throughout the assessment process.
Head to Toe Assessment Checklist
- Collect their vital signs. (It's encouraged to ask permission before touching a patient. ...
- Check heart rate.
- Measure blood pressure.
- Take body temperature.
- Pulse oxymetry.
- Respiratory rate.
- Check pain levels.
- Check hight and weight and calculate their BMI.
Many healthcare facilities are using the method of rounding addressing the 4P's (possessions, position, pain, and potty).
What are the 4 steps of patient assessment? ›
- Perform a scene size up and primary assessment.
- Perform a secondary assessment based on the patient's chief complaint.
- Obtain baseline vital signs.
- Perform a reassessment, including the patient's vital signs, in order to identify any changes in the patient's condition.
The 4Cs - Critical Thinking, Communication, Collaboration, and Creativity - support and integrate assessment strategies into teaching and learning systems.
How to perform an assessment? ›
Overall, there are four general steps involved in conducting a needs assessment:
- Plan.
- Develop questions.
- Select data collection method.
- Analyze and prioritize data.
Inspection (looking at the body) Palpation (feeling the body with fingers or hands) Auscultation (listening to sounds, usually with a stethoscope) Percussion (producing sounds, usually by tapping on specific areas of the body)
How can I improve my nursing assessment skills? ›
- DEVELOP A PATIENT ASSESSMENT ROUTINE. The first thing you can do once you start learning in a clinical setting is to develop a routine. ...
- RECOGNIZE THE LITTLE SIGNS. ...
- USE EVERY INFORMATION SOURCE. ...
- KEEP LEARNING. ...
- WATCH AND LEARN. ...
- INTERACT WITH YOUR PATIENTS. ...
- WORK WITH THE TEAM.
Safety considerations:
- Perform hand hygiene.
- Check room for contact precautions.
- Introduce yourself to patient.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain process to patient.
- Be organized and systematic in your assessment.
- Use appropriate listening and questioning skills.
Initial patient assessment:
Physical examination and evaluation of the patient's airway by the trauma team are essential. Prior medical history (if obtainable from the patient or family) is important, concentrating especially on cardiac and pulmonary problems.
What is a basic assessment in nursing? ›
The nursing assessment includes two steps. (1) Collection and verification of data from a primary source (the patient) and secondary source (the family, health care professionals) (2) The analysis of that data to establish a baseline. b. Inspection - Observations using visual, auditory, and olfactory senses.
What is the assessment step in the nursing process? ›
Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
What does a nurse do during assessment? ›
A nursing assessment is a process where a nurse gathers, sorts and analyzes a patient's health information using evidence informed tools to learn more about a patient's overall health, symptoms and concerns.
What are the 5 major steps in nursing assessment? ›
These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.
What are four nursing assessments? ›
4 types of nursing assessments:
- Initial assessment. Also called a triage, the initial assessment's purpose is to determine the origin and nature of the problem and to use that information to prepare for the next assessment stages. ...
- Focused assessment. ...
- Time-lapsed assessment. ...
- Emergency assessment.
Nursing assessment checklists play a vital role in delivering high-quality patient care. These tools assist nurses in systematically evaluating a patient's health status, identifying potential risks, and developing appropriate care plans.
