ASSESSMENT

PATIENT ASSESSMENT
• Patient assessment is the first step in the
nursing process
• Patient assessment is necessary for;
1. Obtaining data on patient
2. Enables the nurse to formulate nursing
diagnosis, identify and implement nursing
interventions, and assess their effectiveness
3. The data collected is usually subjective data,
objective, or both
 PATIENT ASSESSMENT

• Data collection is carried out through

processes such as observation, interview etc.
• COMPONENTS OF ASSESSMENT:
 History
 Physical examination
 HISTORY:
This is the process of collecting data from
patient/family/significant others
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• During history taking the following areas are

considered
• Biographic Data: name, age, sex, address,
occupation, religion, marital status, source of
health care financing/usual source of medical
care
• Reason For Visit/Chief Complaint: what
brought you to the hospital or clinic? This
should be documented in patient’s own words
 PATIENT ASSESSMENT
History of Present Illness:
• When the symptoms started
• Whether onset of symptoms were
sudden/acute or gradual/chronic
• How often the problem occurs
• Exact location of the distress
• Character of the complaint(intensity of
complaint; pain)
• Factors that aggravate or alleviate the problem
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Attributes of a Symptom: There are 7 attributes

of every symptom. These are;
• Location
• Quality
• Quantity or severity (the number of occurrences
in a specified period of time/for example how
often the pain is experienced in a given time
period).
• Timing including onset, duration and frequency
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• Setting in which it occurs

• Aggravating/reliving factors
• Associated manifestations
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Past Medical History: Areas that are of concern
include,
• Childhood illness, childhood immunization
• Allergies to drugs, animals, insects or other
environmental agents
• Accidents or injuries, any surgery
• Hospitalization and reason for hospitalization
• Date of hospitalization, complications, course
of recovery
 PATIENT ASSESSMENT
Family History of Illness: hereditary disease, e.g.
diabetes, hypertension, mental illness, epilepsy,
haemophilia, sickle cell disease

Patient Lifesytle/Hobbies: hobbies, personal

habits, diet, sleep and rest pattern, activities of
daily living
Social Data: Family relationship/friendships (the
client support system) or those who help in times of
need.
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• Effect of client’s illness on the family

• Ethnic affiliation(health customs and beliefs,
cultural practices that may affect health care and
recovery)
• Occupational history(current employment
status, occupational hazards with potential for
future diseases, economic status(e.g. how patient
pays medical bills)
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Psychological Data:
Major stressors experienced and patient’s perception
of them

Communication style- ability to verbalize

appropriate emotions, non verbal communication
such as eye movement, gestures and posture.
 PATIENT ASSESSMENT
REVIEW OF SYSTEMS
The goal of the review is to gather from the
patient data from each of the major systems.
The process includes history on the following:
General Health: weight gain or loss, mood
changes, night sweats, weakness, bleeding
tendencies etc
Skin: colour, acne, rashes, pruritus(intense
itching), change in pigmentation, texture,
temperature etc
 PATIENT ASSEESSMENT
Head and neck: head for size, hair for texture,
hair loss(alopecia), rashes
Eyes: pain in the eye: difficulty seeing,
excessive lacrimation, double vision(diplopia),
photophobia, itching in the eyes, wearing glasses

Ears: loss of hearing, pain, any infection,

discharging, wearing hearing aids
Nose: nose bleeding(epistaxis), nasal polyps,
any allergies, pain, frequent cold
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Neck: pain, stiffness (nuchal rigidity), extended
neck veins, goitre, inflamed cervical nodes

Mouth: cleft lip (hare lip), cleft palate, halitosis,

stomatitis, tooth aches, hoarseness of voice,
white spots, cavities, bleeding gums, dentures,
tonsillitis, last appointment with dentist

Thorax and Lungs: lung and heart sounds,

chest expansion, respiration( rate, rhythm, depth)
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Breasts: size, cracks on nipples, lumps, nipple
discharges, gynaecomastia, mammogram etc
Abdomen: for size, bowel sounds, pregnancy,
abnormalities such as Ascites etc.
Limbs: for abnormalities such as extra digits,
foot rot(athletes foot) etc
Rectum: for discharges, prolapse, haemorrhoids
etc
Genitalia: for pain, discharges, bleeding etc
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Cardiovascular System: heart sounds, blood

pressure, pulse, varicose veins, dysrhythmias,
palpitations, anaemia, chest pain
Respiratory System: chest pain, cough,
dyspnoea, asthma, haemoptysis, shortness of
breath, wheezing
Neurologic System: confusion, orientation to
person, place, and time, etc
 PATIENT ASSESSMENT
Tools and Equipment used in Physical Examination
• The basic tools for physical examination are vision,
hearing, touch and smell.
• These human senses may be augmented by special
tools.
Techniques for Physical Examination
Four major techniques are used in performing
physical examination
This is usually in the order;
Inspection, Palpation, Percussion, Auscultation
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• The techniques are usually performed in this
sequence, except for abdominal examination
(inspection, auscultation, percussion and palpation)
• Performing percussion and palpation of the
abdomen before auscultation can alter bowel sounds
and produce false findings
• Not every assessment area requires the use of all
four techniques.
• Example; the musculoskeletal system require only
inspection and palpation
 PATIENT ASSESSMENT
INSPECTION
 The first fundamental technique is inspection or
observation.
 General inspection begins with the first contact
with the patient
 Inspection is the visual examination of a part or
region of the body to assess normal conditions or
deviations.
 Inspection is more than just looking, and the
technique is deliberate, systematic, and focused
 PATIENT ASSESSMENT
• What is seen is compared with what is known,
generally visible characteristics of the body part
you are inspecting
• Rapport; introducing one and shaking hands
(not in this Covid-19 era) provide
opportunities for making initial observation
• Is the person old or young? How old? How
young?
• Does the person appear to be his or her stated
age?
 PATIENT ASSESSMENT
• Is the person thin or obese?
• Does the person appear anxious or depressed?
• Is the person’s body structure normal or
abnormal?
• If abnormal, in what way is it and how different
from normal?
• During inspection, it is essential to pay attention
to details
• Vague or general statements are not a substitute
for specific descriptions based on careful
 PATIENT ASSEESSMENT
For example: “The patient appears sick”. In what
way does he or she appear sick?
• Is the skin clammy, pale, jaundiced, or cyanotic?
• Is the patient grimacing in pain
• Does he or she have oedema
• What specific physical features or behavioral
manifestations indicate that the person is “sick”?
• Inspection is done alone or in combination with
other assessment techniques
 PATIENT ASSESSMENT
Vision:
• Use of sight can reveal many facts about a patient
For example, the visual inspection of a patient’s
respiratory status, might reveal an abnormality(e.g
38 breaths per minute and cyanotic nail beds)

• In such a case, the patient is tachypnoiec and

possibly hypoxic and would need a more thorough
respiratory assessment
 PATIENT ASSESSMENT
Smell:
• The nurse’s olfactory sense provides a valuable
information about a patient’s health status
For example, a patient may have a fruity odour
(characteristic of diabetic ketoacidosis)

• The classic odour that is emitted by a

pseudomonas infection is another well-recognized
smell, but to the experienced nurse
 PATIENT ASSESSMENT
During inspection:
• Ensure well ventilated, firm and comfortable
bed, and good lighting in the room
• Take time to observe with eyes, ears, nose(all
senses except taste )
• Body movements
• Look at colour, shape, symmetry, posture and stature
• Speech pattern
• Note odours from skin, breath, wound
• Develop and use nursing instincts
 PATIENT ASSESSMENT
PALPATION
 Palpation is the examination of the body using
touch
 It follows and often confirms points noted
during inspection
 With palpation, the nurse applies his/her sense
of touch to assess factors such as;
• Texture
• Temperature
• Moisture
 PATIENT ASSESSMENT
• Organ location and size
• Presence of lump or mass
• Mobility of structure or mass
• Vibration/pulsation. Tenderness/pain
• Muscle bulk/mass
Different parts of the hand are used to palpate the
various types of anatomical structures
i. Finger tips: they are used to examine skin
texture, swelling, pulsation and presence of lump
 PATIENT ASSESSMENT
ii. Grasping action of the fingers and thumb: this is
used to detect the position, shape, size, and mobility
of an organ or mass

iii. The dorsa(back): the back of the palm is best

used for determining temperature because the skin of
the dorsa is lighter than on the palms

iv. Base of the fingers(palmer surface) or ulnar

surface: they are best used to detect vibration
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The process:
 Patient should be made comfortable and
relaxed to reduce muscle tension
 Painful areas should be palpated last
 The amount of pressure to apply is governed
by;
 The structure being examined and,
 The degree to which palpation may cause
discomfort
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TYPES OF PALPATION
Light Palpation:
 It is the safest and least uncomfortable
 The nurse exerts a gentle pressure with his/her
fingers
 The skin may be depressed approximately 0.5-1.0
inch (1-2cm)
Deep Palpation:
 This usually follows light palpation
 It is used to detect organs lying within cavities;
 ASSESSMENT
 Particularly the abdominal cavity
 To assess an abdominal organ or mass
 The fingers unlike light palpation are held at larger
angles
 The skin is pressed for about 1.5-2inches(4.5cm)
 Another variation in this type is placing the
fingertips of one hand on top of another one;
 To guide the bottom one in detecting underlying
organ or mass
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 Bimanual Palpation: it involves the use of both
hands to trap or grasp a structure between them
 This technique is used to evaluate or assess the
nature of the spleen, kidney, breast, uterus and
other organs
PERCUSSION
 The technique of percussion translates the
application of physical force into sound
 It is a skill requiring practice but one that yields
much information;
 About disease processes in the chest and abdomen
 ASSESSMENT
 The principle is to set the chest wall or abdominal
wall into vibration by striking it with a firm object
 The sound produced reflects the density of the
underlying structure
 Five basic notes are produced by percussion
 These notes are distinguished by the differences in
the;
o Quality of sound
o Pitch
o Duration and Intensity
 ASSESSMENT
The notes;
Tympany: is the drum-like sound produced by
percussing the air-filled stomach
Resonance: is the sound elicited over the air –filled
lungs
Hyperrosonance: is audible when one percusses
over inflated lung tissue in someone with emphysema
Dullness: percussion of the liver produces a dull
sound
Flatness: percussion of the thigh or bone results in a
flat sound
 ASSESSMENT
The process;
• The stationary hand
• Hyperextend the middle finger of your non-
dominant hand called the Pleximeter
• Place its distal portion firmly against the patient’s
skin
• Lift the rest of the stationary hand off the patient’s
skin
• Otherwise the resting hand/s will dampen off the
produced vibration just as the drummer uses his
hand to halt a drummer
 ASSESSMENT
The striking hand
 Use the middle finger of the dominant hand as
the striking finger also called the Plexor
 Hold your forearm close to the skin surface
with your shoulder steady but not rigid
 The wrist must be relaxed
 Use the middle finger of the dominant hand to
strike the middle finger of the stationary one
 Flex the striking finger so that its tip makes the
contact during the striking
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 Percuss two times in the location
 Then move to another part of the body if
necessary to repeat the process
Note:
During percussion, the nurse/midwife must percuss
from a more resonant area to a less resonant area;
in order to detect the change in sound.
AVOIDING ERRORS IN PERCUSSION
i. Remove the striking finger immediately after
tapping
 ASSESSMENT
 Avoid the use of long finger nails
 Eliminate environmental noise including noise
caused by bracelets or loose fitting watches
 If note is difficult to hear then change your
technique;
 Or call another nurse to percuss
AUSCULTATION
 Auscultation is the skill of listening to sounds
produced within the body
 It (sound) is created by the movement of air or
 ASSESSMENT
 Examples include breath sounds, cardiac
murmurs, bowel sounds, bruit, heart sounds
and crackles in the lungs
• Auscultation can be done directly by the use
of the ear or indirectly with a stethoscope

Performing auscultation with a stethoscope:

 The stethoscope must be in good shape and
must fit the user
 The earpiece should be comfortable
 ASSESSMENT
 The length of the tubing should be 25 to 38 cm
(10 -15 inches)

 The head should ideally have a diaphragm and a

bell
 The bell is used for low-pitched sounds such as
certain heart murmurs and bruit

 The diaphragm is good for hearing high-pitched

sounds such as breath sounds and bowel sounds
 ASSESSMENT
 Extraneous sounds can be produced by
clothing, hair and movement of the head of the
stethoscope
Procedure
 Prior to auscultation, remove dangling
necklaces or bracelets;
that can move during the examination and
cause false noises
 Warm the head piece of the stethoscope in
your hands prior to use;
 ASSESSMENT
o To prevent obscure assessment findings due to
shivering and movement
 To use the diaphragm, place it firmly against the
skin surface to be auscultated

 If the patient has a large quantity of hair in this

area;

 It may be necessary to wet the hair to prevent it

from interfering with the sound that is being
auscultated
 ASSESSMENT
 Otherwise, a grating sound may be heard

 To use the bell, place it lightly on the skin surface

that is to be auscultated
(If it is pressed too firmly on the skin, the bell will
stretch the skin and act like a diaphragm and
transmit high-pitched sounds)

 Auscultation requires a great deal of concentration

 ASSESSMENT
 It may be helpful to close your eyes during the
auscultation process

 This will help to isolate the sound

 Sometimes you can hear more than one sound

in a given location

 Try to listen to each sound and concentrate on

each separately
 ASSESSMENT
 It is important to clean your stethoscope after each
patient to prevent the transfer of pathogens
 Remember auscultation is a skill that requires
practice and patience
Requirements for Physical Examination
1. Thermometer
2. Sphygomomanometer
3. Ophthalmoscope
4. Penlight/Flash light
 ASSESSMENT
5. Reflex/patella hammer
6. Tuning fork
7. Otoscope
8. Safety pin
9. Fragrance/scented objects eg. Perfume
10. Tongue depressor
11. Cotton tip applicator
12. Cotton swabs
13. Examination/disposable gloves
14. Lubricants(for rectal examination)
 ASSESSMENT
15. Vaginal speculum
16. Nasal speculum
17. Measuring tape

Notable Special Physical Tests

Rebound Tenderness:
 This is a test for peritoneal irritation/inflammation
 Warn the patient what you about to do
 Press deeply on the abdomen with your hand
 After a moment, quickly release pressure
 ASSESSMENT
 If it hurts more when you release, the patient has
rebound tenderness, suggesting peritoneal irritation
Capillary Refill:
 Press down firmly on the patient’s finger or toe nail
so it blanches
 Release the pressure and observe how long it takes
the nail bed to “pink” up
 Capillary refill time greater than 2-3 seconds
suggests peripheral vascular disease OR arterial
blockage, heart failure OR shock
 ASSESSMENT
Psoas Sign:
 This is a test for appendicitis
 Place your hand above the patients right knee
 Ask the patient to flex the right hip against
resistance
 Increased abdominal pain indicates positive
psoas sign, suggests appendicitis
Obturator Sign:
 This is also a test for appendicitis
 Raise the patient’s right leg with the knee flexed
 ASSESSMENT
 Rotate the leg internally at the hip;
 Increased abdominal pain indicates a positive
obturator sign
Romberg Test:
 Ask the patient to stand with the feet together;
 And eyes closed for 5-10 seconds without support
 Be prepared to catch the patient if they are
unstable
 The test is said to be positive if the patient
becomes unstable(indicating a vestibular or
 ASSESSMENT
Note: Romberg’s sign is loss of balance
(tendency to sway or fall) that occurs when the
patient is standing upright with the eyes closed

Gait:
Ask the patient to;
 Walk across the room, turn and come back
 Walk heel to toe in a straight line
 Walk on his/her toe in a straight line
 Walk on his/her heels in a straight line
 ASSESSMENT
• Hop in place on each foot
• Do a shallow knee bend
• Rise from a sitting position
Costovertebral Tenderness:
 This is often associated with renal disease
 Warn the patient what you are about to do
 Have the patient sit up on the examination table
 Use the heel of your closed fist to strike the
patient firmly over the costovertebral angles
 Compare left and right sides