Learning Objectives

At the end of this module, the participant will be

able to:
1. List strategies to enhance communication
when obtaining assessment information from a
client.
2. Identify the pertinent information that
should be obtained by the nurse to complete
the patient's history.
 Cont. Learning Objectives
3. Describe the assessment tools used to
perform a physical assessment.
4. Demonstrate the proper use of
stethoscope and other paraphernalia
5. Obtain accurate Vital signs
6. Demonstrate different assessment
techniques
 Physical Assessment
Performed by the nurse to obtain subjective and
objective data that will be used to formulate a Nursing
Diagnosis/a nursing problem and care plan

An accurate assessment provides an essential foundation

for the care of the patient
(Carpenito, 1997)

Nurses need to use critical thinking to determine

which assessment skills to use with each client
 INSPECTION
TECHNIQUES
PALPATION
PERCUSSION
AUSCULTATION Head-to-toe

APPROACH Systems
In Assessment , NEVER ASSUME!
 Therapeutics General Health Assessment
For frail or elderly Expose only Explain each step of the
patients, perform examination; warn the
several short
areas to be patient
assessments in order examined | Ex. I’m going to touch
not to tire them Provide Privacy your back

Be sensitive to Ask the patient their

patient verbal and height and weight before
nonverbal measuring them in order
expressions of to get an idea of person’s
discomfort. self -image.

Position the Wash hands

patient before and after
comfortably the procedure.
 Integrated Skills
Assessment

Prior Post
During
Assessment Assessment
Remember this steps
❖ Prior Doing Assessment
Hand hygiene
Identify the patient correctly
Explain the intervention and level expectations

Hi I am ______ I am your nurse,

What is your name? your date of birth ?
Today ill be checking your _________ and will do
________ , will that be ok?
Remember this steps
❖ Prior Doing Assessment
Hand hygiene
Identify the patient correctly
Explain the intervention and level expectations
Gain Consent
General inspection
Check any treatment or adjuncts around the bed
Do your Assessment
VITAL SIGNS
 POLICY STATEMENT
• Vital signs (VS) are defines as temperature, pulse,
respiration and blood pressure.
• All VS are taken on admission, on arrival from another
unit, pre-post operatively, and on the day of discharge
• VS are also taken twice a shift (every 4 hours)
• In NP ward, VS are taken once a day or as ordered.
• More frequent monitoring of any or all VS must be
done when ordered by the Physician and or when
indicated by patient care needs
• All abnormal vital signs are reported Attending
Physician/s caring for the patient. Document all
readings on the Graphic Sheet or Vital Signs EMR.
TEMPERATURE PULSE RATE

RESPIRATORY BLOOD
RATE PRESSURE

PAIN*
TEMPERATURE PULSE RATE

RESPIRATORY BLOOD
RATE PRESSURE

PAIN*
Expected Outcomes
• Radial pulse is palpable and within normal range
• Rhythm is regular
• Radial pulse is strong, firm and regular

Unexpected outcomes
- Pulse is weak, difficult to palpate or absent
- Pulse rate for an adult is greater than 100bpm
- Pulse rate for an adult is less than 60bpm
- Pulse is irregular
Reference: https://ictr.johnshopkins.edu/wp-content/uploads/2015/01/
TEMPERATURE PULSE RATE

RESPIRATORY BLOOD
RATE PRESSURE

PAIN*
 • Observe rise and fall of
chest or abdomen. Count
respirations for a minute
(For regular asymptomatic
patients: 30 seconds and
multiply by 2.)
• Observe for signs of
respiratory distress
(retractions, nasal flaring,
grunting, use of accessory
muscles)
https://ictr.johnshopkins.edu/wp-content/uploads/2015/01/
TEMPERATURE PULSE RATE

RESPIRATORY BLOOD
RATE PRESSURE

PAIN*
 Pulse Pressure

Importance:
Measuring your pulse pressure may help your doctor predict if you're at
risk for a heart event, including a heart attack or stroke. If your pulse
pressure is greater than 60 it's considered a risk factor for cardiovascular
disease, especially for older adults.

Normal range of pulse pressure is between 40 and 60 mm Hg

 Mean Arterial
Pressure

MAP is an important measurement that accounts for flow, resistance,

and pressure within your arteries. It allows doctors to evaluate how
well blood flows through your body and whether it’s reaching all your
major organs.
Normal MAP range is between 70 and 110 mmHg.
 Mean Arterial Pressure
Low MAP
sepsis When the MAP gets below 60, vital organs in the body do
not get the nourishment they need for survival. When it
gets low, it can lead to shock and eventually death of cells
stroke and organ systems

internal bleeding

High MAP
heart attack Prolonged elevated MAP results in heart muscle
kidney failure enlargement, which jeopardizes the life expectancy
of the heart.
heart failure
SYSTEM ASSESSMENT
For general assessment
Assess for LEVEL OF CONSIOUSNESS

PERSON
PLACE
TIME
 LEVEL OF CONSIOUSNESS
LOC Definition
Alert Conscious and coherent active.

Lethargic drowsy; sluggish. Responds to

questions and fell back asleep
Obtunded Open eyes and response slowly

Stuporous Response only to painful stimulation

Comatose Unarousable no response

42 year old man, intubated after traumatic
brain injury (TBI) for decreasing GCS.
Currently, he opens his eyes to pressure, is
intubated, and withdraws his left arm and
leg to pain

1979- GCS: E2, V 1t, M4 Combined GCS: 7t

2014- GCS E2, V NT, M4
It is no longer recommend to assign 1 point to non-testable
elements, therefore a combined score should not be used here as it
would imply that the patient is more unwell than they really are.
Any element that cannot be tested should be marked as NT, for “not
testable”.
HEAD AND NECK
 HEAD AND NECK
1. Inspect size, shape, symmetry, bleeding,
lesions and facial expression
2. Palpate for bleeding, tenderness,
welling and mass on the head
 HEAD AND NECK
3. Palpate
Lymphatic nodes
(Occipital, post
auricular, pre-
auricular,
parotid,
submandibular,
submental,
posterior neck Lymph nodes become swollen in response to
and clavicular) illness, infection, or stress. Swollen lymph nodes are one
sign that your lymphatic system is working to rid your body
of the responsible agents. Swollen lymph glands in the
head and neck are normally caused by illnesses such as:
ear infection.
 HEAD AND NECK
4. Inspect for carotid artery for visible
pulsations (jugular and carotid), measure
JVD
5. Palpate carotid arteries one at a time
6. Auscultate carotid artery for presence
of hum or bruit
A bruit is an audible vascular sound associated with turbulent blood flow. ... These sounds
may be normal, innocent findings (i.e., a venous hum in a child) or may point to underlying
pathology (i.e., a carotid artery bruit caused by atherosclerotic stenosis in an adult).
EYES, EARS, NOSE AND SINUS
 EYES
1.Inspect eyes for redness, swelling
of bulbar conjunctiva, sub-
conjunctiva and sclera
2.Check pupillary reaction to light
and accommodation (size in mm)
3.Test for extraocular movement
 NOSE, SINUS and EARS,
1.Check patency of airflow through nostrils; check
for swelling and bleeding
2.Palpate for Sinuses (frontal, sphenoidal and
maxillary) for tenderness
 NOSE, SINUS and EARS,
3. Test client’s hearing acuity
(right and left)
Voice test
For the voice test, have the patient occlude one
ear with his finger. Test the other ear by
standing behind the patient at a distance of (30
to 60 cm) and whispering a word or phrase. A
patient with normal acuity should be able to
repeat what was whispered.

Weber test
The Weber test evaluates bone conduction.
Perform the test by placing a vibrating tuning
fork on top of the patient’s head at mid line or in
the middle of the patient’s forehead. The
patient should perceive the sound equally in
both ears.
NOSE, SINUS and EARS,
 NOSE, SINUS and EARS
4. Inspect the gums and tongue for color,
consistency and lesions
5.Assess the tongue for movement (right and left)
POSTERIOR THORAX
 VISUAL PRESENTATION
BARREL CHEST TRAUMATIC FLAIL CHEST

THORACIC KYPHOSCOLIOSIS

PIGEON CHEST (Pectus FUNNEL CHEST (Pectus

Carinatum Excavatum)
1.Assess shoulder strength (right and left)
2.Percuss lung fields for resonance
3.Auscultate for breath sounds
4.Note quality and pattern of respirations
(Check RR)
5.Percuss tenderness over the posterior flank
or costovertebral angle (Blunt percussion)

POSTERIOR THORAX
Asymmetry in percussion
Areas of dullness or flatness
over lung tissue (associated
with consolidation of lung
tissue or a mass)
https://www.youtube.com/watch?v=ObZFU3YUqyE
TACTILE FREMITUS
ANTERIOR THORAX
 ANTERIOR THORAX
1.Inspect breast for symmetry,
dimpling and retractions (show 3
positions- Over head; waist, leaning
forward)
2.Palpate breast (start medial to
axillary)
 CARDIOVASCULAR
1.Auscultate for heart sounds:
(Aortic area, Pulmonic area, Tricuspid area,
mitral area or Apical Pulses). Identify Types of
murmurs
 Assess Jugular Vein Pressure

https://www.youtube.com/watch?v=baxNxWIWdK8
Remember this steps
For cardiovascular system
Inspect the face particularly periorbital and the eye

XANTHELASMA Corneal Arcus

hypercholesterolemia hyperdyslipedimia
Chest Shortness
Palpitations of Breath
Pain
PERIPHERAL ARTERIAL PULSES
DIAGNOSTICS

▪ Cardiac Enzymes
▪ 2-D Echocardiogram
▪ TROPONIN (I or T)
▪ CKMB (Creatinine Kinase)
▪ Myoglobin
▪ Pro BNP ( Brain Natriuretic Peptide)
▪ D- Dimer
▪ 2 –D Echocardiogram
Remember this steps
For cardiovascular system
VP’s Best Pal Just Had Pasta Deluxe
PNEMONICS ASSESSMENT
PARAMETERS
VP Visual Presentation
BP Blood Pressure and Heart
Rate
J Jugular Vein
H Heart Sounds
P Peripheral Pulses
D Diagnostic Examination
ABDOMEN
 ABDOMEN
1.Inspect for symmetry and contour
2.Auscultate bowel sounds on 4
quadrants (start at RLQ clockwise)
Normoactive, Hypoactive, Hyperactive

3.Percuss for tympanic and dull sounds

all 4 quadrants
4.Palpate liver and measure liver span
5.Palpate spleen and kidney
 Upper and Lower Extremities
1.Test for muscle strength and ROM
of the upper and lower extremities
(RUE & LUE):
• Flexion with resistance
• Extension with resistance
• Cross-over hand grip strength
 Upper and Lower Extremities
2.Test muscle strength of the lower
extremities (RLE& LLE):
• Right and left knee flexion with
resistance
• Right and left lower leg extension
with resistance
 Upper and Lower Extremities
3.Check for presence of edema (grade
+1 to +4 edema on shin and ankle)
 Upper and Lower Extremities
4.Palpate dorsalis-pedis and posterior-
tibial pulses
5.Assess for capillary refill (big toe)
6.Test for foot dorsiflexion with
resistance
Upper and Lower Extremities
 Upper and Lower Extremities

7.Observe client’s balance

•Romberg’s test
8.Check posture and gait
Remember this steps
AFTER Doing Assessment
Explain what assessment data you gather in your
scope only

Thank the patient

Do hand hygiene

Construct a summary of your assessment for

documentation or referral
Thank You Very Much!