The document provides a comprehensive overview of nursing assessment techniques, covering the organization of assessments, differentiation between subjective and objective data, and various physical examination methods such as inspection, palpation, percussion, and auscultation. It emphasizes the importance of holistic client assessment, including physical, psychological, social, and spiritual health, as well as cultural considerations in communication. Additionally, it outlines goals for client interviews, specific examination procedures for multiple body systems, and the necessity of establishing a thorough health database to inform nursing diagnoses and care planning.

1. Prepared by: Dr Hend Elazazy

2.  Upon completion of the lecture, the student will be
able to do the following:
 Organize a nursing assessment
 Discuss preparation of the client and environment to
foster data collection
 Differentiate between subjective and objective data
 Discuss methods to obtain subjective information
during the client interview
 Describe the technique of inspection, palpation,
percussion, and auscultation used in the physical
assessment.
 Describe methods to obtain objective data during the
physical examination

3.  Physical
 Psychological
 Social
 Spiritual

4.  Physical health includes basic functions such as
breathing, eating and walking.
 Psychological health includes intellect, self concept,
emotions and behavior.
 Social dimensions of health encompass relationships
and interaction s among family, friends, and coworkers.
 Spiritual health refers to belief in a higher being,
personal interpretation of the meaning of life, and
attitude toward moral decision and personal conduct.

5.  Assessment includes collecting subjective
data through interviewing the client and
obtaining objective data by physically
examining the client.

6.  Subjective data are those symptoms,
feelings, perceptions, preferences,
values and information that only
the client can state and validate.
 Objective data can be directly
observed or measured such as vital
sig or appearance.

7.  Establish a database for the client’s normal abilities,
risk factors, and any current alteration in function.
 Plan strategies to encourage continuation of healthy
patterns, prevent potential health problems, and
alleviate or manage existing health problems.
 Provide a holistic view of the client.
 Formulate a conclusion or a problem statement such as
a nursing diagnosis.
 Provide an essential foundation for the care of the
client.

9.  General information about the client is
obtained by using secondary data sources
which include the chart or other healthcare
providers that help to personalize the
interview and primary data source which
gathered from the client.

10.  The client’s language, customs, beliefs, and values
differ from client to client and from client to the
nurse.
 Examination of cultural customs, beliefs, and
values helps nurse and clients to avoid
miscommunication.

11.  Thoughtful preparation of the client and the
environment is advantageous for both the
client and the nurse since it can eliminate
sources of anxiety and help the patient to
provide more accurate and complete
information.

12.  The major portion of the client interview may
be conducted before performing the physical
examination.
 During most health assessment, a preprinted
form is used to record information.
 Health assessment forms vary in title and
format depending on the institution, the client
population, and the purpose of the
assessment.

13.  Introduce yourself to the client, and explain
the nature and purpose of the health
assessment.
 Describe assessment as a serious of
questions about the client past and present
state of health followed by a physical
examination.

15. Goals of the interview
 Obtain the client history and perception of
past experience.
 Identify factors that either positively or
negatively influence the health status.
 Describe how health status influences the
client’s abilities.
 Identify what changes the client had made
to adapt to the health status.

16.  Reason for seeking healthcare.
 Health history.
 Pain assessment.
 Health perception and health management.
 Activity and exercise.
 Posture
 Gait and balance
 Decreased mobility

17.  Nutrition and metabolism.
 Elimination.
 Sleep and rest.
 Cognition and perception.
 Self perception and self concept.
 Roles and relationships.
 Coping and stress tolerance.
 Sexuality and reproduction.
 Values and beliefs.

19.  Inspection
 Inspection is the natural beginning of
physical examination; it is used to make
specific observation of physical features and
behaviors by using vision.
 Inspections provide an overall impression of
the client’s present state of health and when
immediate interventions are indicated.

20.  Overall appearance of health or illness.
 Signs of stress.
 Facial expression and mood.
 Body size.
 Grooming and personal hygiene.

21.  Palpation is the use of hands and fingers to gather
information through touch; it is used to discriminate
position, texture, size, consistency, masses and fluid.
 Palpation can be superficial, light, or deep; with light
palpation, three or four fingers of the dominant hand
depresses an area of the client’s skin approximately 0.5
to 1 inch usually to evaluate the skin temperature and
moistness. Deep palpation involves compression of an
area to a depth of 1.5 to 2 inches and requires
significantly more pressure than light palpation.

22.  Percussion uses the sense of hearing,
involves using the fingers and hands to tap
an area on the client to produce sound.
 The type of percussion tone is determined
by the density of the medium through
which the sound is traveling, it provides
information about the nature of an
underlying structure, the size of an organ,
and to determine if a structure is air filled,
fluid filled, or solid.

23.  Auscultation is the listening for sound and
movement within the body, lungs are
auscultated for moving air, the heart and
blood vessels are auscultated for moving
blood, and the abdomen is auscultated for
the movement of gastrointestinal content.
 The stethoscope collects and transmits
sound, selects frequencies and screens out
extraneous sounds.

25.  Assessment of cognition
 Objective data concerning the client’s
cognitive abilities are obtained through
the neurologic examination to assess
brain function and motor response.

26.  Level of consciousness: Is the awareness of and
responsiveness to the surrounding environment,
normally a person responds to environmental stimuli
with appropriate verbal and motor activity, attentive,
cooperative and completely oriented to self, time, and
place
 Orientation: Evaluation of the orientation is obtained
by asking simple questions about time, place, and
person. If the client is not oriented, information he
provides may not be accurate.

27.  Mood: Abnormalities of mood may indicate
psychological or neurologic problems.
Normal mood is described as happy or
pleasant, depression is being overly sad.
 Language and memory: Communication
and memory are specific aspects of cognitive
functioning that are important to effective
client teaching.

28.  Sensory aids: Document the use of glasses, contact
lenses, hearing aids and other assistive device in
the client health assessment to ensure proper use
and care of expensive device during
hospitalization.
 Visual acuity: Visual screening is an important
part of routine health examinations, The
Snellen”E” is used for assessing visual acuity, visual
problems with close objects occur more frequently
after the age of 40 years.

29.  Extra ocular movement and visual fields: The oculomotor,
trochlear, and abducens nerves control the horizontal,
vertical, and diagonal movement of the eyes. Assessment
of peripheral visual field and six ocular movement is
important in comprehensive visual assessment.
 Pupils and papillary reflexes: Evaluate pupils bilaterally
for size, shape, accommodation and reaction to light.
Normally, pupils are black and round, and they constrict
briskly when exposed to a bright light source. Pupils can
appear cloudy when cataracts are present, dilated when
glaucoma is treated with drops or neurologic impairment
is present. Unilateral changes in pupil reflexes can signify
increased intracranial pressure caused by tumor, trauma
or cerebral vascular accident.

30.  Cranial nerve assessment: Intact cranial nerve function is
important for normal sensory functioning.
 External and internal eye structures: External eye
structures should be free from lesion or inflammation and
blink reflex should be present. The ophthalmoscope is the
instrument which is used to assess internal eye structures
such as retina, optic nerve disc, macula, fovea centralis and
retinal vessels.
 Auditory assessment: assessment of auditory function can
occur simply during normal conversation to evaluate
client’s ability to hear. External ear is examined for
inflammation or cerumen, while the otoscope is used to
visualize ear canal and ear drum. Health screening may
include hearing tests using an audiometer

31.  Examination of the mouth includes the buccal mucosa,
teeth, lips, gums, tonsils, and uvula.
 Evaluate the lips for color, moisture, cracks or lesions. By
using bright light and a tongue, inspect the mucus
membrane, teeth, and gums which should appear pink
and moist. Observe for lesion in the mouth tongue or
gums. Observe the uvula; it should rise symmetrically and
the tonsils should be pink, symmetric and slightly visible.
Inspect the teeth for stability and overall hygiene. A major
concern when examining the mouth is to detect any
abnormalities that might impede the client’s ability to
taste, chew, swallow or enjoy food.

32.  Auscultation is used to detect bruits, abnormal
arterial sound caused by increased turbulence of
blood flow.
 Palpate the lymph node for mobility, enlargement,
and tenderness in cases of inflammation or
infections.
 Evaluate neck veins for distension which can occur
with fluid volume excess.
 The trachea is normally in straight, vertical position,
shifting of the trachea from its normal midline
position may be caused by lung masses or
pneumothorax.
 Ask the client to swallow as you palpate thyroid gland.

33.  Skin: The skin is a reflection of the body‘s nutrition and
metabolism. Some skin disorders may potentially interfere
with client’s body image especially if it is present on the
face.
 Scalp and hair: Inspect the scalp and hair for color,
quantity, distribution, texture, hygiene, nodules and
lesions. Examine the base of the hair for follicle for pest
infestation and dandruff. Inspect nails for shape, color, and
texture.
 Skin turgor: Check for skin turgor by pinching a small area
of skin on the medial arm or anterior chest and noting how
quickly is returns to position when you release poor skin
turgor present if the skin remains elevated or slowly
resume position which indicate dehydration, aging or
weight loss.

34.  Skin lesions: Is an abnormality in the structure of the skin
as a result of injury or disease. Every skin lesion should be
assessed for size, color, type, and location
 Wounds: Accidents, pressure, or surgeries may cause
wounds. It is especially important to note the wound color,
character, color, and amount of drainage if any, and the
area around the wound.
 Nails: Clubbing of the nails (increase the angle between
the nailbed and the finger) is a sign of chronic hypoxia.
With advanced clubbing, the nail becomes less adherent
to the base of the nail and fells spongy, the nails and
fingertips appear large and swollen.

35.  Assessment of cardiac and peripheral vascular status
provides clues about circulation and oxygenation to every
part of the body.
The major areas for cardiovascular assessment include:
 Risk factors for cardiovascular disease.
 Signs and symptoms of cardiovascular dysfunction.
 The impact of cardiovascular dysfunction on activity of
daily livings.
 Specific adaptation to cardiac or circulatory impairment.

36.  Auscultation: Listening to the heart sound can provide
valuable information. Normal heart sounds include S1
and S2; systole (ventricular contraction) is the period
from the beginning of the first heart sound (S1) to the
beginning of the second heart sound (S2) while
diastole (ventricular relaxation) is the period from the
beginning of the second heart sound to the beginning
of the next ventricular contraction.

37.  Inspection: Inspect the entire precordium for
movement; a visible pulsation occurs with ventricular
contraction as the left heart strikes the anterior chest
wall.
 Palpation: Palpate in the precordial area, noting any
vibration or pulsation, normal point of maximal
impulse is a light tap, located at the medial to
midclavicular line, confined to the area of one
intercostals space.

38. Respiratory assessment focus on four main
areas:
 Risk factors for lung disease
 Signs and symptoms of respiratory
dysfunction
 Impact of respiratory status on activity of
daily living
 Adaptive measures for any respiratory
dysfunction

39. Inspection: Inspection related to the respiratory
examination focuses on:
 Configuration of the thorax
 Breathing pattern
 Signs of labored breathing
 Observation of the skin and nails

40.  Normally; the anterior posterior diameter of the
chest drawn as a straight line through the thorax,
normal breathing is silent, effortless smooth,
regular, symmetric, rhythmic and occurs at a rate
of 12 to 20 times per minute
 Palpation: Is used to evaluate painful or abnormal
areas on the chest wall, to test for symmetry of
chest expansion, and to detect tracheal deviation,
note tenderness, masses or bulges or crackling
feeling that indicate air leakage into subcutaneous
tissues.

41.  Percussion: Percussion of the lung normally
reveals a hollow, loud, low-pitched resonant
sound because the lung is air filled.
 Auscultation: Lung auscultation involves
listening with the stethoscope over anterior
and posterior chest wall for variation in
breath sound.

42.  Inspection: Teach the client to do a breast self
examination while you are performing the breast
examination, normal breast appear round and essentially
symmetric, although one breast is often slightly larger
than the other, the skin should be smooth and intact with
the areola darker in color, round and symmetric, the
nipple should be everted and without discharge or
lesions.
 Palpation: Palpation is done to determine if masses or
lumps are present in the breast, Palpate each breast for
tenderness, nodules or masses, during the palpation
teach the women how to perform breast self palpation.

43.  The abdomen contains organs for digestion
for food, elimination of waste, major arteries
and veins, and organs of production in the
female.

44.  Inspection: During inspection, note the contour, skin
and movement of the abdomen, normal abdomen is
flat and rounded, abdominal skin should be similar in
color and texture to skin on other area of the body,
note the presence and location of scars, rashes, lesions,
petechiae, or striae, wavelike movement of intestinal
peristalsis may be present in thin client, normal aortic
pulsation is frequently present visible in epigastrium.

45.  Auscultation: Bowel sounds are created as air and fluid
mix in the intestine, normal bowel sounds are tinkling,
gurgling noises that occur between 5 to 34 times per
minute, only after listening to a quadrant for 5 minutes
and hearing no sounds can the nurse conclude absence of
bowel sounds.
 Percussion: Is used to detect the location of organs not
normally palpable, and to give clues about the
characteristics of the masses underlying the skin.
 Palpation: Light palpation is performed to obtain
information about pain or discomfort, relaxation of the
abdominal wall is necessary for accurate assessment.

46.  Inspection: Assessment of the bladder for distension
due to urinary retention is warranted when a client
complains of lower abdominal discomfort or reports a
history of difficulty urination, or when a prolonged
time has elapsed since the last voiding occurred.
 Percussion: To determine the presence of distended
bladder, percussion begins at the umbilicus and
proceeds toward the symphysis pubis.

47.  Inspection: Examine the skin for color, and
temperature, observes varicosities (swollen,
twisted veins), edema or fluid.
 Palpation: Is important in peripheral
vascular assessment.
 Arterial pulses: Palpate arterial pulses,
noting rate, rhythm, amplitude, and
symmetry, comparing pulses between sides
to evaluate for differences in circulation.

48.  Capillary refill: Palpation is also used to assess capillary
refill to test circulatory status using nailbed, normally
refill time is 3 second or less.
 Edema: Is fluid accumulation in the tissues and
evaluated through palpation, assess edema in dependent
area such as the hands, feet, ankles, and lower leg.
 Joint mobility: Joint movement is important to activity
and exercise function; all joints should have appropriate
range of motion.
 Muscle strength: Perform a simple screening of motor
function in the arms and legs, evaluate symmetry of
strength.

49.  Circulation, movement and sensation: Assess circulation
by color, temperature, pulses, and capillary refill; assess
movement by asking the client voluntarily to move the
extremity, assess sensation by asking the client to say
when he feels the touch.
 Deep tendon reflexes: Testing deep tendon reflexes by
using the hummer to tap various tendons in the body to
see if this action elicits the appropriate reflex arc through
the spinal cord.