TNCC Physical Assessments
Physical Assessment
Method for gathering health data - ANSWER:Assessment is 1st step of the nursing
process and is ongoing throughout the nurse-patient relationship.
It is process you use to collect physical data relevant to the patient's health.
Use four of your senses: sight, smell, hearing, and touch
Goal: To gather objective data about a client.
What is objective data? (measurable by nurse, classified as signs)
What is subjective data? (verbalized by patient, not directly measurable, classified as
symptoms)
Clients are examined:
on admission (comprehensive, in depth)
briefly at the beginning of each shift (more focused)
any time the client's condition changes
When evaluating the effectiveness of nursing care
Anytime things do not "feel right"
PURPOSES of ASSESSMENT - ANSWER:Evaluate client's current physical condition
Detect early signs of developing health problems
Establish a baseline for future comparisons (done on admission)
Evaluate client's responses to medical and nursing interventions
Monitor for changes in body function
Detect specific body systems that need further assessment or testing
There are 5 basic techniques:
Inspection (look)
Palpation (feel)
Percussion
Auscultation (listen)
Olfaction (smell)
3 Levels of Physical Assessment - ANSWER:1. Comprehensive Health Assessment
In-depth assessment of whole person (physical, mental, emotional, cultural,
spiritual)
Data is collected through physical exam and interview
Generally done on admission to facility
2. Focused Assessment
Exam and interview regarding a specific body system (ex. Respiratory system)
Allows nurse to check only system related to patient's disease process or when
performing reassessment of a system in which abnormal findings were obtained
earlier
3. Initial Head-to-Toe Shift Assessment
Quick overall assessment of patient's condition to establish baseline against which
you can compare later assessments (able to identify changes in pt.'s condition:
improvement or deterioration)
,Focused assessment of the following systems in sequence from head to toe:
Neurological
Cardiovascular
Respiratory
Integumentary
Gastrointestinal
Genitourinary
Muscular
Skeletal
Also includes specific assessment of the patient's:
Vital signs, including pain and O2 saturation (SpO2)
Appearance
Speech
Safety risk factors
Tubes and equipment
Comfort or complaints
Needs
Findings such as VS and from other systems will provide some info. about Immune
System
Physical Assessment - ANSWER:Abnormal findings should be reassessed within 4
hours or sooner depending on severity
Some abnormal findings are minor or may even be expected
Some abnormal findings may be totally unexpected and represent potentially serious
conditions
Example: patient is admitted with upper respiratory infection and you note an
occasional dry cough. You instruct pt. to let you know if it gets worse. You would
reassess the cough in 4 hrs. to see if better, worse, or same.
Example: You assess a fever of 103 degrees. You need to take immediate action to
treat fever and reassess in one hour
Assessment Techniques - ANSWER:Most important tools you will need are your eyes,
ears, hands, nose, and critical thinking ability.
Always wash your hands prior to assessment
Interviewing (asking questions to determine the following):
Personal identity and demographics
Details of current condition (complaints, problems, reason for seeking medical care)
Medical history
Social history
Food and drug allergies
Height and weight
Expectation for hospitalization
Review Box 21-1, page 424-ways to foster rapport & communication
Use therapeutic communication techniques (review chapter 6)
INSPECTION - ANSWER:Purposeful observation of anything about the body that you
can see with naked eye or with use of equipment such as penlight, otoscope, etc...
, Most frequently used assessment technique
Particular parts of the body are examined
Look for specific normal and abnormal characteristics
Need advanced instruction to use special instruments ex. To examine interior of the
eyes (ophthalmoscope)
Inspection begins with the first interaction with the client and continues throughout
the exam
PERCUSSION - ANSWER:Least used nursing assessment technique
Striking or tapping a part of the body with fingertips
Fingertips produce vibratory sounds which aid in determining the location, size, and
density of underlying structures (if structure is hollow or solid and containing air or
fluid)
Any unexpected sound can indicate a pathological change in that area
Any pain can indicate a disease process or tissue injury
PALPATION - ANSWER:Lightly touching or applying pressure to the body
Light Palpation-using the fingertips, back of hand, or palm of hand to feel surface of
the skin, structures just beneath skin, pulsations from peripheral arteries, &
vibrations in the chest (depress tissue between 1-2 cm)
Deep Palpation-depressing tissue about 1 inch or 4-5 cm with forefingers of one or
both hands (abdominal organs or masses)
Palpation provides the following information: - ANSWER:Size, shape, consistency, &
mobility of normal tissue and unusual masses or growths
-Symmetry or asymmetry of bilateral structures
-Skin temperature, texture, and moisture
use dorsal aspect of hand which is more sensitive to detect subtle differences in skin
temp. (see Figure 21-2, page 425)
Skin is normally warm and dry
Questions to answer: Is skin warm or cool? Is it dry or moist?
Diaphoretic=patient is perspiring
Skin may be moist due to fever, exertion, anxiety
Skin hot to touch=Does pt. have a fever? Is room temp. too hot? Too many
blankets?
Cool or cold skin=Is room temp. too cold? Poor circulation?
-Any tenderness or pain
-Unusual vibrations
Skin turgor
Edema
Bladder or abdominal distention
Location and strength of pulses
Review cultural beliefs in assessment, page 425
AUSCULTATION - ANSWER:Listening to body sounds
Frequently used
Lungs, heart, & abdomen most often assessed
Physical Assessment
Method for gathering health data - ANSWER:Assessment is 1st step of the nursing
process and is ongoing throughout the nurse-patient relationship.
It is process you use to collect physical data relevant to the patient's health.
Use four of your senses: sight, smell, hearing, and touch
Goal: To gather objective data about a client.
What is objective data? (measurable by nurse, classified as signs)
What is subjective data? (verbalized by patient, not directly measurable, classified as
symptoms)
Clients are examined:
on admission (comprehensive, in depth)
briefly at the beginning of each shift (more focused)
any time the client's condition changes
When evaluating the effectiveness of nursing care
Anytime things do not "feel right"
PURPOSES of ASSESSMENT - ANSWER:Evaluate client's current physical condition
Detect early signs of developing health problems
Establish a baseline for future comparisons (done on admission)
Evaluate client's responses to medical and nursing interventions
Monitor for changes in body function
Detect specific body systems that need further assessment or testing
There are 5 basic techniques:
Inspection (look)
Palpation (feel)
Percussion
Auscultation (listen)
Olfaction (smell)
3 Levels of Physical Assessment - ANSWER:1. Comprehensive Health Assessment
In-depth assessment of whole person (physical, mental, emotional, cultural,
spiritual)
Data is collected through physical exam and interview
Generally done on admission to facility
2. Focused Assessment
Exam and interview regarding a specific body system (ex. Respiratory system)
Allows nurse to check only system related to patient's disease process or when
performing reassessment of a system in which abnormal findings were obtained
earlier
3. Initial Head-to-Toe Shift Assessment
Quick overall assessment of patient's condition to establish baseline against which
you can compare later assessments (able to identify changes in pt.'s condition:
improvement or deterioration)
,Focused assessment of the following systems in sequence from head to toe:
Neurological
Cardiovascular
Respiratory
Integumentary
Gastrointestinal
Genitourinary
Muscular
Skeletal
Also includes specific assessment of the patient's:
Vital signs, including pain and O2 saturation (SpO2)
Appearance
Speech
Safety risk factors
Tubes and equipment
Comfort or complaints
Needs
Findings such as VS and from other systems will provide some info. about Immune
System
Physical Assessment - ANSWER:Abnormal findings should be reassessed within 4
hours or sooner depending on severity
Some abnormal findings are minor or may even be expected
Some abnormal findings may be totally unexpected and represent potentially serious
conditions
Example: patient is admitted with upper respiratory infection and you note an
occasional dry cough. You instruct pt. to let you know if it gets worse. You would
reassess the cough in 4 hrs. to see if better, worse, or same.
Example: You assess a fever of 103 degrees. You need to take immediate action to
treat fever and reassess in one hour
Assessment Techniques - ANSWER:Most important tools you will need are your eyes,
ears, hands, nose, and critical thinking ability.
Always wash your hands prior to assessment
Interviewing (asking questions to determine the following):
Personal identity and demographics
Details of current condition (complaints, problems, reason for seeking medical care)
Medical history
Social history
Food and drug allergies
Height and weight
Expectation for hospitalization
Review Box 21-1, page 424-ways to foster rapport & communication
Use therapeutic communication techniques (review chapter 6)
INSPECTION - ANSWER:Purposeful observation of anything about the body that you
can see with naked eye or with use of equipment such as penlight, otoscope, etc...
, Most frequently used assessment technique
Particular parts of the body are examined
Look for specific normal and abnormal characteristics
Need advanced instruction to use special instruments ex. To examine interior of the
eyes (ophthalmoscope)
Inspection begins with the first interaction with the client and continues throughout
the exam
PERCUSSION - ANSWER:Least used nursing assessment technique
Striking or tapping a part of the body with fingertips
Fingertips produce vibratory sounds which aid in determining the location, size, and
density of underlying structures (if structure is hollow or solid and containing air or
fluid)
Any unexpected sound can indicate a pathological change in that area
Any pain can indicate a disease process or tissue injury
PALPATION - ANSWER:Lightly touching or applying pressure to the body
Light Palpation-using the fingertips, back of hand, or palm of hand to feel surface of
the skin, structures just beneath skin, pulsations from peripheral arteries, &
vibrations in the chest (depress tissue between 1-2 cm)
Deep Palpation-depressing tissue about 1 inch or 4-5 cm with forefingers of one or
both hands (abdominal organs or masses)
Palpation provides the following information: - ANSWER:Size, shape, consistency, &
mobility of normal tissue and unusual masses or growths
-Symmetry or asymmetry of bilateral structures
-Skin temperature, texture, and moisture
use dorsal aspect of hand which is more sensitive to detect subtle differences in skin
temp. (see Figure 21-2, page 425)
Skin is normally warm and dry
Questions to answer: Is skin warm or cool? Is it dry or moist?
Diaphoretic=patient is perspiring
Skin may be moist due to fever, exertion, anxiety
Skin hot to touch=Does pt. have a fever? Is room temp. too hot? Too many
blankets?
Cool or cold skin=Is room temp. too cold? Poor circulation?
-Any tenderness or pain
-Unusual vibrations
Skin turgor
Edema
Bladder or abdominal distention
Location and strength of pulses
Review cultural beliefs in assessment, page 425
AUSCULTATION - ANSWER:Listening to body sounds
Frequently used
Lungs, heart, & abdomen most often assessed
