Nursing Process::ASSESSMENT

BY : CATHERINE KUCKYT, RN

The nurse collects data about the health statis of the client. The data is subjective and objective.

Subjective data is usually documented in the clients own words. This data includes such things as previous experiences,and sensations or emotions that only the client can describe.

The Objective data is obtained by the health team, through observation, physical examination, or/and diagnosistic testing. Objective data can be seen or measured.
Sources of subjective data and objective data are the client, the family and significant others, medical records, and other health care team members.

Assessment includes, the "HEALTH HISTORY" and "physical assessment".

Physical assessment can be broken down into four components(2);

INSPECTION Defined:

Inspection is the visual examination of the client.
Guidelines for Effective Inspection

* Be systematic
* Fully expose the area to be inspected;cover other body parts to respect the client's modesty.
* Use good light, preferably natural light.
* Maintain comfortable room temperature.
* Observe color, shape, size, symmetry,position,and movement
* Compare bilateral structures for similarities and differencess.
PALPATION Defined:

Palpation uses the sense of touch to assess various parts of the body and helps to confirm findings that are noted on inspection.

The hands, especially the finger tips are used to assess skin temperature,check pulses, texture, moisture, masses, tenderness , or pain.

Ask the Client for permission first and explain to your client what you intend to examine. Establish client trust with being professional. Please remember to use warm hands.

Any tender areas should be palpated last.
Types of Palpation:

1. Light Palpation:To check muscle tone and assess for tenderness
2. Deep Palpation:To identify abdominal organs and abdominal masses.

Note when examining Abdomen, you auscultate first followed by percussion then palpation.
PERCUSSION Defined:

Percussion is the striking of the body surface with short, sharp strokes in order to produce palpable vibrations and characteristic sounds. It is used to determine the location, size, shape, and density of underlying structures; to detect the presences of air or fluid in a body space; and to elicit tenderness. (2)
Note when examining Abdomen, you auscultate first followed by percussion then palpation.
Types of Percussion

1. Direct Percussion: Percussion in which one hand is used and the striking finger of the examiner touches the surface being percussed.
2. Indirect Percussion:Percussion in which two hands are used and the plexor strikes the finger of the examiner's other hand, which is in contact with the body surface being percussed.
3. Blunt Percussion: Percussion which the ulnar surface of the hand or fist is used in place of the fingers to strike the body surfae, either directly or indirectly.

Percussion Sounds

* Resonance:A hollow sound.
* Hyperresonance:A booming sound.
* Tympany:A musical sound or drum sound like that produced by the stomach.
* Dullness: Thud sound produced by dense strucvtures such as the liver, and enlarged spleen, or a full bladder.
* Flatness:An extremely dull sound like that produced by very dense structures such as muscle or bone.
AUSCULTATION defined:

Auscultation is listening to sounds produced inside the body. These include breath sounds, heart sounds, vascular sounds, and bowel sounds. It is used to detect the presence of normal and abdomal sounds and to assess them in terms of loudness, pitch, quality , frequency and duration.
Note when examining Abdomen, you auscultate first followed by percussion then palpation.