lOMoARcPSD|14985576
Assessment Strategies- 246 HESI Prep
Assessment is the first stage of the nursing process. It includes the gathering
of a patient’s physiological, psychological, sociological, and spiritual status.
Objective and Subjective strategies included.
Symptoms- a subjective experience reported by the patient.
Signs- an objective finding by the examiner.
Inspection-critical observation that requires good lighting. Looks at the color,
shape, symmetry, and position of body parts.
Palpation- purposeful and careful feeling with hands during the physical
examination. Examines size, consistency, texture, location, and tenderness
of an organ or body part. Use the palm of hand or fingertips to assess
consistency of tissues, alignment and intactness of structures, symmetry of
body parts or movements, and transmission of sound and fine vibrations.
Back of hand assesses skin temperature.
Percussion- method of tapping on a surface to assess the underlying
structure’s location, size, or density. The sound changes as the examiner
moves from one section to the next. Done with the middle finger of the right
hand tapping on the middle finger of the left hand, while the left palm is on
the body. Sounds are classified as tympanic, resonant, flat, and dull. A
flat/dull sound indicates the presence of a solid mass under the surface. A
tympanic/resonant sound indicates hollow, air-containing structures.
Auscultation- listening to the internal sounds of the body, usually using a
stethoscope. Used to examine the circulatory, respiratory, and
gastrointestinal systems. High-pitched tones are best heard with the
diaphragm of the stethoscope, while low-pitched tones are best heard with
the bell of the stethoscope.
,lOMoARcPSD|14985576
, lOMoARcPSD|14985576
Cardiovascular System
Assess-
Pulses (peripheral and JVD) assess bilaterally and compare. Palpable pulses
indicate the body and extremities are receiving adequate perfusion. Radial,
brachial, femoral, popliteal, tibial, and dorsalis pedal pulses.
Capillary refill > 3 seconds
Auscultate heart sounds- S1, S2. Listen for intensity, rhythm, duration, and
quality of sounds. Evaluate extra heart sounds and murmurs. 5 auscultation
points= aortic, pulmonic, Erb’s Point, Tricuspid, and Mitral. Remember that
the Apical Pulse is taken at the mitral valve.
Heart rate and rhythm- notice if pulse if increased or decreased with
arrhythmias.
Blood Pressure- systolic (90-120) and diastolic (60-90). Mean Arterial
Pressure (MAP). MAP = x2 diastolic + systolic /3. Example: 120/90 = MAP of
100. Normal range is 70-110. A MAP of 60 and above is necessary to
adequately perfuse the kidneys, coronary arteries, and the brain. Report
anything under 60. Over 110 indicates excess pressure and should also be
addressed.
Assess for decreased level of consciousness (LOC) and syncope. A patient
that is alert and responsive indicated adequate perfusion to the brain.
Urine output- equal of greater than 30 mL per hour. Less than 30 must be
reported. Compare intake vs. output and monitor daily weight. Compare,
Downloaded by Clare Kemmy ()
Assessment Strategies- 246 HESI Prep
Assessment is the first stage of the nursing process. It includes the gathering
of a patient’s physiological, psychological, sociological, and spiritual status.
Objective and Subjective strategies included.
Symptoms- a subjective experience reported by the patient.
Signs- an objective finding by the examiner.
Inspection-critical observation that requires good lighting. Looks at the color,
shape, symmetry, and position of body parts.
Palpation- purposeful and careful feeling with hands during the physical
examination. Examines size, consistency, texture, location, and tenderness
of an organ or body part. Use the palm of hand or fingertips to assess
consistency of tissues, alignment and intactness of structures, symmetry of
body parts or movements, and transmission of sound and fine vibrations.
Back of hand assesses skin temperature.
Percussion- method of tapping on a surface to assess the underlying
structure’s location, size, or density. The sound changes as the examiner
moves from one section to the next. Done with the middle finger of the right
hand tapping on the middle finger of the left hand, while the left palm is on
the body. Sounds are classified as tympanic, resonant, flat, and dull. A
flat/dull sound indicates the presence of a solid mass under the surface. A
tympanic/resonant sound indicates hollow, air-containing structures.
Auscultation- listening to the internal sounds of the body, usually using a
stethoscope. Used to examine the circulatory, respiratory, and
gastrointestinal systems. High-pitched tones are best heard with the
diaphragm of the stethoscope, while low-pitched tones are best heard with
the bell of the stethoscope.
,lOMoARcPSD|14985576
, lOMoARcPSD|14985576
Cardiovascular System
Assess-
Pulses (peripheral and JVD) assess bilaterally and compare. Palpable pulses
indicate the body and extremities are receiving adequate perfusion. Radial,
brachial, femoral, popliteal, tibial, and dorsalis pedal pulses.
Capillary refill > 3 seconds
Auscultate heart sounds- S1, S2. Listen for intensity, rhythm, duration, and
quality of sounds. Evaluate extra heart sounds and murmurs. 5 auscultation
points= aortic, pulmonic, Erb’s Point, Tricuspid, and Mitral. Remember that
the Apical Pulse is taken at the mitral valve.
Heart rate and rhythm- notice if pulse if increased or decreased with
arrhythmias.
Blood Pressure- systolic (90-120) and diastolic (60-90). Mean Arterial
Pressure (MAP). MAP = x2 diastolic + systolic /3. Example: 120/90 = MAP of
100. Normal range is 70-110. A MAP of 60 and above is necessary to
adequately perfuse the kidneys, coronary arteries, and the brain. Report
anything under 60. Over 110 indicates excess pressure and should also be
addressed.
Assess for decreased level of consciousness (LOC) and syncope. A patient
that is alert and responsive indicated adequate perfusion to the brain.
Urine output- equal of greater than 30 mL per hour. Less than 30 must be
reported. Compare intake vs. output and monitor daily weight. Compare,
Downloaded by Clare Kemmy ()
