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Assessment
Physical Assessment
Part 1
Helen Harkreader, RN, PhD
Nursing Assessment
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gathering information about the health
status of a person
identify concerns and needs that can be
treated or managed by nursing care.
look, listen, touch,
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to make an informed decision about care.
Types of Assessment
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Initial
Focused
Ongoing
Shift Assessment
Emergency
Health History
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Reason for admission/chief complaint
Demographic information
History of present illness
Family history
Other history
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Medical: diabetes, heart disease, renal disease
Surgical history
Health History
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It’s important to remember:
Nursing care is more concerned with
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helping the person manage or function
with a health problem
Not with
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diagnosing and treating illnesses.
Physical Exam
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Usually follows history
Head to toe approach
Includes (as needed): inspection,
palpation, auscultation, and percussion
General Survey
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How do they look overall?
What can you discern just by looking at
and talking with them?
Are they oriented?
What is their mood?
How about nutritional status?
Vital signs?
General Survey
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As you introduce your self and establish
trust with the patient your are beginning
the general survey
General Survey
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Level of consciousness
Orientation
Confusion
Memory
Mood, affect
Signs of distress: dyspnea, anxiety
Planes of the Body
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Sagittal (through midline)-divides right
and left; medial and lateral
Frontal plane- divides anterior and
posterior
Transverse – divides top to bottom
through pelvis; superior and inferior
Proximal and distal
Inspection
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Visual examination - looking
Color, shape, size, symmetry, position and
movement
Good lighting is very important
Palpation
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Assessment through touch
Temperature, moisture, texture,
tenderness, masses, and edema
May be light or deep, one hand or two
Make sure your hands are clean and
fingernails short!
Percussion
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Short, sharp strikes to the body surface to
produce palpable vibrations and sounds
Maybe direct (one hand) or indirect (two
hands)
Can detect size, shape, density and
location of structures
Auscultation
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Listening to the sounds in the body
(usually with a stethoscope)
Used to listen to lung sounds, heart
sounds and abdominal sounds
Keep your stethoscope clean!
HEENT
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Head, Eyes, Ears, Nose, Throat
Look at distribution of hair. Are there any
lumps on the head? Discolorations?
Is head normal size? Upright? Are the
facial structures symmetrical in shape?
HEENT
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Basically a Cranial nerve assessment
You do not need to check each cranial
nerve at this point, but be aware of what
they are and how to assess them.
HEENT
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Does the mouth droop?
Talk to the patient. Do all the facial muscles move
together?
Can the person see and hear well?
Pupils equal, round and reactive to light and
accommodation.
What does this mean?
Check the eye muscle function. Have the patient follow
your finger to all eight positions.
Inspect the ear and assess hearing by talking to the
patient
Cranial Nerves
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examine sensation and movement of the
face: the facial nerve--CN VII and the
trigeminal nerve--CN V
List the function of each cranial nerve.
Which ones are used for swallowing?
Other HEENT
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Check the nose for abnormalities
If warranted, palpate the sinuses for tenderness
Look at mouth and neck. Take a look at the
tongue. Are there white patches? Red patches?
Check range of motion for the neck (gently!).
Look at the neck for jugular vein distention.
This could indicate a heart problem.
Other HEENT
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Where are these structures?
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Lymph nodes
Jugular veins
Carotid arteries
Trachea
Trapezius and sternocleidomastoid
Other HEENT
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To assess the lymph nodes, place both
hands on the neck at the same time and
palpate using the pads of your fingers.
Normal: not palpable or smooth, firm, less
than 1 cm, mobile, and nontender
Head and Neck
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size, symmetry, position and movement of
head
temporomandibular joint
Skin
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Inspection
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Intact, free of lesions
Pink toned or underlying healthy glow
Palpation
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Warm, cold, moist, dry
Lesion: Hard, firm, feels like fluid
Movable, fixed, attached to underlying
structures
Skin Color
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cyanosis (central, peripheral, circumoral),
jaundice,
pink tone, glowing, ashen
pallor,
erythema
Skin
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Turgor
Moisture
Temperature
Skin Disruptions
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macules, papules, nodules
vesicles, bulla
scales, plaque, patches (vitiligo)
petechiae, necrosis, keloid
linear, annular
Describing Lesions
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Size, color, type (primary, secondary),
location, distribution
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local vs. generalized
Annular, linear
Abrasion, laceration
Hair
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Distribution
Texture
Cleanliness, grooming
Scalp for lesions
Infestations
Nails
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Capillary refill
Abnormal shape
Clubbing