Physical assessment

Focus topic: Nursing process

Perform hand hygiene in front of the patient before begining the physical assessment. Use drapes
so only the area being examined is exposed. Develop a pattern for your assessments, starting
with the same body system and proceeding in the same sequence. Organize your steps to
minimize the number of times the patient needs to change position. By using a systematic
approach, you’ll be less likely to forget an area.

Count ’em — four

No matter where you start your physical assessment, you’ll use four techniques:

• inspection
• palpation
• percussion
• auscultation.
Use these techniques in sequence except when you perform an abdominal assessment.
Because palpation and percussion can alter bowel sounds, the sequence for assessing the
abdomen is inspection, auscultation, percussion, and palpation. Let’s look at each step in
the sequence.

Inspection
Inspect the patient using vision, smell, and hearing to observe normal conditions and deviations.
Performed correctly, inspection can reveal more than other techniques. Inspection begins when
you first meet the patient and continues throughout the health history and physical examination.
As you assess each body system, observe for color, size, location, movement, texture, symmetry,
odor, and sounds.

Palpation
Palpation requires you to touch the patient with different parts of your hands, using varying
degrees of pressure. To do this, you need short fingernails and warm hands. Always palpate
tender areas last. Tell your patient the purpose of your touch and what you’re feeling with your
hands.

Palpate to evaluate

As you palpate each body system, evaluate the following features:

• texture — rough or smooth?

• temperature — warm, hot, or cold?
• moisture — dry, wet, or moist?
• motion — still or vibrating?
• consistency of structures — solid or fluid-filled?
Percussion
Percussion involves tapping your fingers or hands quickly and sharply against parts of the
patient’s body, usually the chest or abdomen. The technique helps you locate organ borders,
identify organ shape and position, and determine if an organ is solid or filled with fluid or gas.

Do you hear what I hear?

Percussion requires a skilled touch and an ear trained to detect slight variations in sound. Organs
and tissues, depending on their density, produce sounds of varying loudness, pitch, and duration.
For instance, air-filled cavities, such as the lungs, produce markedly different sounds than do the
liver and other dense tissues. As you percuss, move gradually from areas of resonance to those of
dullness and then compare sounds. Also, compare sounds on one side of the body with those on
the other side.

Auscultation
Auscultation, usually the last assessment step, involves listening for various breath, heart, and
bowel sounds with a stethoscope. To prevent the spread of infection among patients, clean the
heads and end pieces of the stethoscope with alcohol or a disinfectant after every use.

Diagnostic test findings

Focus topic: Nursing process

Diagnostic test findings complete the objective database. Together with the nursing history and
physical examination, they form a significant profile of the patient’s condition.

Analyzing the data

The final aspect of assessment involves analyzing the data you’ve compiled. In your analysis,
include the following steps:

• Group significant data into logical clusters. You’ll base your nursing diagnosis not on a
single sign or symptom but on a cluster of assessment findings. By analyzing the
clustered data and identifying patterns of illness-related behavior, you can begin to
perceive the patient’s problem or risk of developing other problems.
• Identify data gaps. Signs, symptoms, and isolated incidents that don’t fit into consistent
patterns can provide the missing facts you need to determine the overall pattern of your
patient’s problem.
• Identify conflicting or inconsistent data. Clarify information that conflicts with other
assessment findings, and determine what’s causing the inconsistency. For example, a
patient with diabetes who says that she complies with her prescribed diet and insulin
 administration schedule, but whose serum glucose is greatly elevated, may need to have
her treatment regimen reviewed or revised.
• Determine the patient’s perception of normal health. A patient may find it harder to
comply with the treatment regimen when his idea of “normal” doesn’t agree with yours.
• Determine how the patient handles his health problem. For instance, is the patient coping
with his health problem successfully, or does he need help? Does he deny that he has a
problem, or does he admit it but lack solutions to the problem?
• Form an opinion about the patient’s health status. Base your opinion on actual, potential,
or possible concerns reflected by the patient’s responses to his condition and use this to
formulate your nursing diagnosis.