Data elicited and verified by the client Client Family and significant others Client record Other health care professionals

Data directly or indirectly observed through measurement Observations and physical assessment findings of the nurse or other health care professionals Documentation of assessment made in client record Observations made by client’s family or significant others Observation and physical examination Inspection Palpation Percussion Auscultation Respiration 16 breaths per minute BP 180/100, apical pulse 80 and irregular x-ray film reveals fractured pelvis


Methods used to obtain data

Client interview

Skills needed to obtain data

Interview and therapeutic communication skills Caring and empathy Listening skills “I have a headache” “It frightens me” “I am not hungry”


Source: Nurse’s Handbook of Health Assessment Janet R. Weber


using the sense of vision, smell, and hearing to observe the condition of various body parts, including any deviations from normal is the visual examination that is assessing using the sense of sight it should be deliberate, purposeful, and systematic the nurse inspects with the naked eye and with a lighted instrument such as an otoscope (used to view the ear) in addition to visual observation, olfactory (smell) and auditory (hearing) cues are noted Nurses frequently use visual inspection to assess moisture, color and texture of body surfaces, as well as shape, position, size, color and symmetry of the body Lighting must be sufficient for the nurse to see clearly: either natural or artificial light can be used. When using auditory senses it is important to have a quiet environment for accurate hearing Observation can be combined with the other assessment techniques

1) Expose body parts being observed while keeping the rest of the client’s body properly draped. 2) Always look before touching. 3) The good lighting. Tangential light is best. Be alert for the effect of bluishred tinted or fluorescent lights that interfere with observing bruises, cyanosis (bluish discoloration of a body part), erythema. 4) Provide a warm room for the client (a hot environment may alter skin color and appearance) 5) Observe for color, size, location, texture, symmetry, odor and sounds Sources: Mr. Lasurias Fundamentals of Nursing 7th edition by KOZIER Nursing Handbook of Health Assessment Janet R. Weber

AUSCULTATION Auscultation is listening for various breath, heart, vasculature, and towel sounds using a stethoscope. TECHNIQUE: Use a good stethoscope that has the following • Snug – fitting earplugs • Tubing not longer than 15 inches and internal diameter not greater than 1 inch. • Diaphragm and bell Auscultation is the process of listening to sounds produced within the body. • • Direct Auscultation – is the use of unaided ear, for example, to listen to respiration wheeze or the grating of a moving joint. Indirect Auscultation – is the use of a stethoscope, which transmits the sounds to the nurse’s ear. - a stethoscope is used primarily to listen to sounds from within the body, such as bowel sounds or valve sounds of the heart and blood pressure.

* Auscultated sounds are described according to their pitch intensity, duration, and quality * The pitch is the frequency of vibrations (the number of vibrations per second) * Low-pitched sounds, such as some heart sounds, have fewer vibrations per second than high-pitched sounds, such as bronchial sounds. * The intensity (amplitude) refers to the loudness or softness of a sound. * Some body sounds are loud, for example, bronchial sounds heard from the trachea; others are soft, for example, normal breath sounds heard in the lungs. * The duration of the sound is its length (long or short) * The quality of sound is a subjective description of a sound, for example, whistling, gurgling, or snapping.

Source: Fundamentals of Nursing 7th edition Barbara Kozier Glenoria Erb

Audrey Berman Shirley Snyber PALPATION Definition: Palpation is touching and feeling body parts with your hands to determine the following characteristics: o o o o o Texture (roughness / smoothness) Temperature (warm / hot / cold) Moisture (dry / wet / moist) Motion (stillness / vibration) Consistency of structures (solid / fluid filled)

- is the examination of the body using the sense of touch - the pads of the fingers are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination. Technique: o Examiner’s fingers should be short o The most sensitive part of the hand should be used to detect various sensations. a. fingertips for fine discrimination pulsations b. palmar surface for vibratory sensations (fremitus) c. dorsal surface for temperature o Light palpation precedes deep palpation o Tender areas are palpated last. (painful areas) o Three different types of palpation may be used depending on the purpose of the exam.

Source: Nurse’s Handbook of Health Assessment by Weber

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