CHAPTER

5
INTRODUCTION
Assessment Techniques

Health assessment requires essential data to accurately and safely care for 1. Inspection
every patient. Nurses need to be able to recognize the assessment findings 2. Palpation
that are not normal variants. Assessment techniques are learned, which 3. Percussion
takes time and practice. The four assessment techniques that will provide 4. Auscultation
objective assessment data are:

PREPARATION FOR ASSESSMENT

Standard Precautions
Health assessment requires direct contact with the patient. Nurses
must protect themselves from acquiring and transferring any infectious
agents. The Centers for Disease Control and Prevention (CDC) and the
Hospital Infection Control Practices Advisory Committee (HICPAC)
reaffirm standard precautions as the foundation for preventing transmis-
sion of infectious agents during patient care in all healthcare settings.
Standard precautions are the minimum infection prevention practices that
apply to all patient care, regardless of suspected or confirmed infection
status of the patient, in any setting where healthcare is delivered (CDC,
2016). They include:
■ Perform hand hygiene.
■ Hand hygiene includes both hand washing with either plain or
antiseptic-containing soap and water for at least 20 seconds or use of
alcohol-based products (gels, rinses, foams) that do not require the
use of water. The CDC recommends using Alcohol Based Hand Rub
(ABHR) with 60-95% alcohol in healthcare settings (CDC, 2019).
■ TIP The World Health Organization (2020) recommends that health-
care workers use the “My 5 Moments for Hand Hygiene” approach.
This is an evidence-based, field-tested, and user-centered approach
designed to be applicable in a wide range of settings. The approach
recommends that healthcare workers clean their hands:
1. Before touching a patient.
2. Before clean/aseptic procedures.
3. After body fluid exposure/risk.
4. After touching a patient.
5. After touching patient surroundings.

CHAPTER 5 Assessment Techniques 66

■ Use personal protective
equipment (PPE) (e.g.,
gloves, gowns, masks,
eyewear, face shields,
shoe-covers) as needed
for safe practice
(Fig. 5-1).
Transmission-Based
Precautions Fig. 5-1. Personal protective equipment.
When standard precautions
alone cannot prevent transmission, they are supplemented with transmis-
sion-based precautions. This second tier of infection prevention is used
when patients have diseases that can spread through contact, droplet, or
airborne routes (e.g., skin contact, sneezing, coughing) and are always used
in addition to standard precautions (CDC, 2016).
■ Contact precautions are used for patients with known or suspected
infections that represent an increased risk for contact transmission.
■ Use PPE appropriately, including gloves and gown, for all interac-
tions that may involve contact with the patient or the patient’s envi-
ronment. Put on PPE upon room entry and properly discard before
exiting the patient’s room to contain pathogens.
■ Use disposable or dedicated patient-care equipment (e.g., blood
pressure cuffs or stethoscopes). If common use of equipment for
multiple patients is unavoidable, clean and disinfect such equipment
before use on the next patient.
■ Droplet precautions are used for patients known to be, or suspected to
be, infected with pathogens transmitted by respiratory droplets that are
generated by a patient who is coughing, sneezing, or talking.
■ Use PPE appropriately. Don mask prior to entry into the patient’s
room or patient space.
■ Limit transport and movement of patients outside of the room to
only medically necessary purposes. If transport or movement outside
CHAPTER 5 Assessment Techniques
of the room is necessary, instruct patient the to wear a mask and fol-
low respiratory hygiene/cough etiquette.
■ Airborne precautions are for patients known or suspected to be
infected with pathogens transmitted by the airborne route (e.g.,
tuberculosis, measles, chickenpox, or Covid-19). The placement of this
patient would be in an airborne infection isolation room (AIIR). Use
PPE appropriately, including a fit-tested NIOSH-approved N95 mask
for healthcare personnel (CDC, 2016).
SENC Safety Alert | Healthcare–associated infections (HAIs) are
major causes of morbidity and mortality in the United States. HAIs
are acquired when an individual is receiving health care for another
condition. These infections can occur in any healthcare facility. At
any given time, about one in 25 inpatients have an infection related
to hospital care. Bacteria, fungi, viruses, and other less common
pathogens can cause HAIs (HHS, 2020).
■ TIP Healthcare–associated infections are a major concern to
patients. Always wash your hands in front of the patient so the patient
knows that you have performed hand hygiene.
SENC Evidence-Based Practice | Watson (2016) performed a quasi-
experimental, 1-group pre-post survey design study to determine if
a multimodal strategy using the World Health Organization’s (WHO’s)
“My 5 Moments for Hand Hygiene” methodology increases health-
care worker (HCWs) compliance with hand washing and awareness
of the importance of good hand hygiene in the prevention of HAIs.
The target population was HCWs with direct contact with patients.
A simple interrupted time series methodology at baseline and three
months was used to monitor hand hygiene compliance. Overall,
HCWs’ hand hygiene compliance increased from 51.3% to 98.6%.
Eight postsurvey questions focusing on the strategies used to
promote hand hygiene demonstrated statistical significance using
67
CHAPTER 5 Assessment Techniques
a 1-sample t test, with P values ranging from .000-.024. A multi-
modal approach using the WHO’s “My 5 Moments for Hand Hygiene”
does increase HCWs’ hand hygiene compliance and awareness, and
knowledge of the importance of hand hygiene in the prevention of
HAIs. Using this approach can produce a positive social change by
reducing preventable disease and decreasing HAIs, not only within a
facility but also in the community.
SENC Safety Alert | A patient may have an allergy to latex. Symp-
toms of latex allergy include hives, rash, swelling, sneezing, head-
ache, and a severe allergic reaction, anaphylaxis. Always ask your
patient if he or she has a latex allergy; check to see whether you are
wearing latex-free gloves and using latex-free equipment.
Coronavirus Pandemic
The coronavirus [COVID-19] pandemic is the defining global health cri-
sis of our time and the greatest challenge we have faced since World War
Two (United Nations Development Program, 2020). The COVID-19
virus is transmitted mainly person-to-person within a six foot radius or by
touching a surface or object that has the virus on it and then touching your
own mouth, nose, or possibly eyes. The CDC (2020) guidelines include:
■ Maintain social or physical distancing; stay at least six feet (about two
arms’ length) from other people.
■ Wash your hands thoroughly for at least 20 seconds or use an alcohol-
based hand sanitizer that contains at least 60% alcohol.
■ Clean and disinfect routinely high-touch surfaces (i.e., electronics,
doorknobs, light switches, tables).
■ Wear a face covering in public settings and when around people who
don’t live in your household, especially when other social distancing
measures are difficult to maintain.
■ Healthcare workers should adhere to standard and transmission-based
precautions.
68
Patient’s Rights
Patient-centered care is at the core of essential health assessment and per-
forming health assessment techniques. Patients need to be respected and
cared for without any type of discrimination. All patients have the right to
be completely informed about the assessment and what to expect during
the assessment. All patient findings must be confidential.
■ TIP A competent adult patient has the right to refuse being as-
sessed. Nurses must document if a patient refuses an assessment and
depending on the urgency of the assessment, the healthcare provider
should be notified.
Patient Positions
Essential health assessment works best if you use an organized approach,
working from noninvasive to invasive assessments. The nurse asks the
patient to assume proper positions so that areas to be assessed are accessi-
ble. A patient’s ability to assume different positions depends on his or her
physical strength, limitations, and degree of wellness. Some patients may
not be able to change positions independently. Be aware of your patient’s
ability to change positions and assist as necessary to ensure patient safety.
During a complete head to toe assessment, minimal positional changes by
the patient are advised for patient comfort. Try to cluster your assessments
when the patient is sitting, standing, or lying down.
■ TIP The nurse should be standing on the right side of the patient
when performing the exam because most examination techniques are
performed with the nurse’s right hand even if the nurse is left handed.
Equipment Needed
Protective Personal Equipment (PPE) [if needed]
Stethoscope
Tangential light
Sequence of Assessment
The sequence of assessment is dependent upon the specific body system or region being assessed.
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
SENC Safety Alert | Always perform hand hygiene before and after the assessment.

FOCUSED ASSESSMENT

TECHNIQUE 51: Inspection

Purpose: To look and assess the physical aspects of the body, posture, appearance, and behavior carefully
Equipment: Tangential lighting, PPE (if needed)
■ Inspection should start when you first meet with the patient. There are two types of inspection:
■ Direct inspection is carefully observing and inspecting a specific area or the whole individual.
■ Indirect inspection is using specific equipment to improve your visualization of an area (i.e., ophthalmoscope to look at the internal structures of
the eyes).
■ Inspection requires the use of three of your senses:
1. Seeing
2. Hearing
3. Smelling
■ Inspection requires:
■ Room temperature to be a comfortable level for the patient.
■ Good lighting in the room.
• Tangential lighting is a form of additional lighting placed at an
angle in order to see more specific details for a specific assessment,
such as a penlight used to assess the characteristics of a skin lesion Fig. 5-2. Tangential lighting.
or mole (Fig. 5-2).
■ TIP Fluorescent lights can change the color of the skin. Natural lighting is the best lighting, if available.
■ Draping the patient appropriately and exposing only the body part being assessed.
■ Always observing and comparing the symmetry of body parts from one side to the other side.
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■ Inspecting the following characteristics:

• Location
• Size
• Color
• Pattern
• Shape
• Odors
• Symmetry
■ TIP Do not rush during inspection; inspection takes time and requires concentration.

TECHNIQUE 52: Palpation

■ Palpation is feeling with your fingers or hands to assess parts of the body.
■ The nurse should wear gloves during this step and wear additional PPE, if needed.
SENC Safety Alert | Each patient encounter is unique, and PPE must be individualized for each patient encounter. Always wear gloves, as well
as eyewear and gown if needed, when palpating any part of the body with open areas, wounds, or internal structures of the body such as the
tongue or mouth.
■ There are three different parts of your hand that are more sensitive to assessing different surface Index finger Finger tips
Finger
characteristics (Fig. 5-3): pads
■ Finger pads: Assess fine discrimination and sensations on the surface areas such as texture,
shape, consistency, pulses, and crepitus (popping sounds under the skin).
Ball of
■ Dorsal surface of the hand: The back of the hand is used to assess temperature. hand
■ Ulnar surface or ball of the hand: Assess vibrations, fremitus (vibration transmitted through Ulnar Ulnar
the body), and thrills (vibration over the chest wall). surface surface

SENC Safety Alert | Keep fingernails short. Long fingernails could cause discomfort or harm the Dorsal Palmar
surface surface
patient while performing the assessment.
Fig. 5-3. Surfaces of hand used in palpation.
■ There are two types of palpation: light palpation and deep palpation.
■ Light or deep palpation is determined by the depth of the structure being palpated and the thickness of the tissue overlying that structure.
■ Perform light palpation prior to deep palpation.

SENC Safety Alert | If pain has been reported in an area, gently palpate this area last.
TECHNIQUE 52A: Light Palpation

Purpose: To assess and feel for surface characteristics

Equipment: Gloves, additional PPE (if needed)
ASSESSMENT STEPS
1. Explain the technique to the patient.
2. Warm your hands by rubbing them together.
3. Using the finger pads of your dominant hand, gently press down about 1 cm or ½ inch (Fig. 5-4).
4. Gently press down or use gentle, light circular motions to palpate surface characteristics for:
■ Texture
■ Masses
■ Moisture
Fig. 5-4. Light palpation using finger pads.
■ Pulsations
■ Temperature
■ Tenderness
5. Gently lift your fingers and move to the adjacent area; palpate the entire area that needs to be assessed.

TECHNIQUE 52B: Deep Palpation

Purpose: To assess and feel for the location and size of internal organs, masses, and tenderness
Equipment: Gloves, additional PPE (if needed)
■ TIP Deep palpation can be done using one or two hands (bimanual) (Fig. 5-5). Bimanual palpation can also be used to stabilize an internal organ.
ASSESSMENT STEPS
1. Explain the technique to the
patient.
2. Warm your hands by rubbing
them together.

Fig. 5-5. Deep palpation using one hand, two hands, and bimanual technique.

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3. Using the finger pads of your dominant hand or placing your dominant hand over your nondominant hand, gently press down 5 cm (about 2
inches or more) to assess:
■ Organ size and location
■ Masses
■ Tenderness
4. Gently lift your fingers and move to the adjacent area; palpate the entire area that needs to be assessed.

TECHNIQUE 53: Percussion

■ Percussion is tapping body parts to create a sound wave that vibrates; different tones are elicited depending on the underlying tissue density.
■ There are three types of percussion: direct, indirect, and indirect fist (blunt).

TECHNIQUE 53A: Direct Percussion

Purpose: To assess the size, consistency, and borders of body organs, and the presence or absence of fluid in body areas
Equipment: Gloves, additional PPE (if needed)
ASSESSMENT STEPS
1. Explain the technique to your patient.
2. Expose only the area that you will be percussing.
3. Using one or two fingertips, directly and lightly tap the area that needs to be assessed (Fig. 5-6A).
4. Listen carefully for the sound and identify the following characteristics:
■ Pitch (frequency of the sound wave vibrations) is described as high, low, or dull.
■ Intensity is described as:
Fig. 5-6A. Direct percussion.
• Soft tones are heard over solid tissue
• Moderate tones are heard over fluid-filled areas
• Loud tones are heard over air-filled spaces.
■ TIP As the density of the underlying structure increases, the percussion sounds become softer.
■ Duration is the length of time the sound is heard.
■ Quality of sound (what does it sound like?)
 TABLE 51 Percussion Sounds
Sound Intensity Pitch Quality Example of Structure
Tympany Loud High Drumlike Gastric air-filled structures in abdomen such as the intestines
Heard over a chest indicates excessive air (i.e., pneumothorax)
Dull or thudlike Soft to moderate Medium Thudlike Liver
Full bladder
Solid organs or mass
Fluid or solid tissue replaces air in the lung (i.e., pneumonia)
Resonance Moderate to loud Low Hollow Normal lung
Hyperresonance Very loud Low Booming Hyperinflated lungs
(i.e., chronic obstructive lung disease or asthma)
Flatness Soft High Dull Muscle
Bone
Joints
Solid mass

■ There are five specific percussion sounds (Table 5-1):

• Tympany is heard over abdominal areas that may be filled with abdominal gas or air-filled structures.
• Dullness is heard over solid organs, fluid collection, or areas of consolidation (such as a tumor or mass).
• Resonance is heard over normal lung fields.
• Hyperresonance is heard over air-filled spaces such as lung fields in a patient with emphysema.
• Flatness is heard over increased tissue density such as bones.

TECHNIQUE 53B: Indirect Percussion

Purpose: To assess the size, consistency, and borders of body organs, and the presence or absence of fluid in body areas
Equipment: Gloves, additional PPE (if needed)
ASSESSMENT STEPS
1. Explain the technique to your patient.
2. Expose only the area to be percussed.

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3. Lay your middle finger of your nondominant hand (the pleximeter) on the area to be assessed. The
middle finger is the only finger that should be in contact with the skin while percussing.
4. Flex your wrist of your dominant hand and tap your middle finger of this hand (the plexor) on the
interphalangeal joint of the middle finger of your nondominant hand, the striking surface, to elicit a
sound (Fig. 5-6B). Plexor

■ TIP Each tap should be short and sharp to produce a sound. Pleximeter

5. Listen carefully to the percussion sounds.

Fig. 5-6B. Indirect percussion.

TECHNIQUE 53C: Indirect Fist Percussion (Blunt Percussion)

Purpose: To assess organ tenderness

Equipment: Gloves, additional PPE (if needed)
ASSESSMENT STEPS
1. Explain the technique to your patient.
2. Expose only the area that you will be percussing.
3. Gently lay your nondominant hand over the area to be assessed.
4. Make a fist with your dominant hand.
5. Using the ulnar surface of your closed fist, firmly thump the dorsum of the nondominant hand (Fig. 5-6C).
6. Ask the patient if he or she experiences any discomfort.
■ TIP Indirect fist percussion is commonly done to assess for costovertebral angle tenderness for kidney inflammation. Fig. 5-6C. Indirect fist
percussion.
TECHNIQUE 54: Auscultation

■ Auscultation is used to listen to and assess cardiovascular, respiratory, gastrointestinal, and peripheral vascular sounds produced by the body.
■ For this step, the nurse needs a stethoscope (Fig. 5-7) and may need a Doppler ultrasonic blood flow detector (Fig. 5-8) if peripheral blood flow
sounds are not heard. If needed, the nurse should use PPE during this step.
■ Auscultation amplifies the following characteristics of sound:
■ Duration (length of time)
■ Intensity (loud or soft)
■ Pitch (high or low)
■ Quality (e.g., musical, blowing, bubbly)
■ There are two types of auscultation: direct and indirect.

Bell Ear tips

Diaphragm Metal tubes

Probe
Reading
Flexible tubing
Electronic stethoscope Amplification
of sound
On/Off Gel
Single sided chestpiece
Double sided chestpiece button
Chestpiece

Stem
Fig. 5-7. Parts of the stethoscope. Fig. 5-8. Doppler ultrasonic blood flow detector.

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TECHNIQUE 54A: Direct Auscultation

Purpose: To listen to and assess sounds produced by the body without a stethoscope
Equipment: PPE (if needed)
ASSESSMENT STEPS
1. Ensure there is a quiet environment.
2. Explain the technique to your patient.
3. Expose only the area that you will be directly auscultating.
4. Place your ear near the exposed area.
5. Listen for about a minute for sounds.
■ TIP Most common sounds that can be heard without equipment are respiratory and gastrointestinal sounds. Always confirm sounds with a
stethoscope.

TECHNIQUE 54B: Indirect Auscultation

Purpose: To listen to sounds produced by the body with an amplification device

Equipment: Stethoscope, Doppler, PPE (if needed)
■ TIP The stethoscope and Doppler must be placed directly on the skin; never auscultate over clothing because artifact sounds may be heard.
ASSESSMENT STEPS
1. Explain the technique to your patient.
2. Expose only the area to be auscultated.
3. Warm the stethoscope by gently rubbing your hand over the diaphragm or the bell of the stethoscope.
■ TIP The bell of the stethoscope is used best to hear low-pitched sounds (e.g., vascular sounds and
heart murmurs); the diaphragm of the stethoscope is best used to hear high-pitched sounds (e.g.,
respiratory sounds and bowel sounds).
4. Firmly place either the diaphragm or the bell of the stethoscope on the area to be assessed (Fig. 5-9).
■ TIP If the patient has much hair on the area to be auscultated, wet the hair with a warm washcloth
Fig. 5-9. Indirect auscultation.
to decrease the friction.
5. Concentrate and listen to the sounds.
6. When finished auscultating, clean off your stethoscope with an alcohol swab.
 SENC Safety Alert | There is a concern that stethoscopes may transmit infectious agents, which could result in healthcare-associated infections
(HCAI) (O’Flaherty & Fenelon, 2015). Clean the stethoscope after each patient to prevent cross-contamination of bacteria and germs. Healthcare
workers have their choice, as studies have found that various cleaning techniques, such as alcohol swabs, hydrogen peroxide wipes, and alcohol-
based hand sanitizers, all work; if Clostridium difficile is suspected, a bleach wipe should be used. With hand sanitizer available on the walls
inside or outside every patient room, it is easy to remember to perform hand hygiene when entering and to perform both hand and stethoscope
hygiene when exiting (American College of Physicians, 2019).

SENC Evidence-Based Practice | Bansal et al., (2019) researched stethoscope cleaning practices of medical personnel to assess the microbial
load on stethoscopes and efficacy of cleaning stethoscopes with alcohol-based disinfectant. Results concluded that regular cleaning practices
should be followed to prevent growth and transmission of pathogenic organisms and thereby prevent hospital-acquired infections. Alcohol-
based disinfectant is an efficacious agent for cleaning stethoscopes.

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