STEPS OF HEALTH ASSESSMENT

The assessment phase of the nursing process has four major or significant steps:

1. Collection of subjective data

2. Collection of objective data

3. Validation of data

4. Documentation of data

COLLECTING SUBJECTIVE DATA. Subjective data are sensations or symptoms (e.g., pain,
hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values,
and personal information that can be elicited and verified only by the client. To produce accurate
subjective data, learn to use practical interviewing skills with various clients in different settings. The
significant areas of subjective data include:

Biographical information

Name

Address

Phone

Gender

Provider of history (patient or other)

Birthdate

Place of birth

Race or ethnic background

Primary and secondary languages (spoken

and read)

Marital Status

Religious or Spiritual Practices

Educational Level

Occupation
Reasons for Seeking Health Care

Reason for seeking health care (major health problem or concern)

Feelings about seeking health care (fears and past experiences)

History of Present Health Concern Using COLDSPA

Character (How does it feel, look, smell, sound, etc.?)

Onset (When did it begin; is it better, worse, or the same since?)

Location (Where is it? Does it radiate?)

Duration (How long does it last? Does it recur?)

Severity (How bad is it on a scale of 1 [barely noticeable] to 10 [worst pain ever experienced]?)

Pattern (What makes it better? What makes it worse?)

Associated factors (What other symptoms do you have with it? Will you be able to continue doing
your work or other activities [leisure or exercise]?)

Past Health History

Problems at birth

Childhood illnesses

Immunizations to date

Adult illnesses (physical, emotional,

mental)

Surgeries

Accidents

Prolonged pain or pain patterns

Allergies

Physical, emotional, social, or spiritual

weaknesses

Physical, emotional, social, or spiritual

strengths
Family Health History

Age of parents (Living? Deceased date?)

Parents’ illnesses and longevity

Grandparents’ illnesses and longevity

Aunts’ and uncles’ age and illnesses and longevity

Children’s ages and illnesses or handicaps and longevity Significant others or support
persons (availability)

COLLECTING OBJECTIVE DATA

Objective data include information about the client that the nurse directly observes during
interaction with the client and information elicited through physical assessment (examination)
techniques. To become proficient with physical assessment skills, the nurse must have basic
knowledge in three areas:

- Types and operation of equipment needed for the examination (e.g., penlight,
sphygmomanometer, otoscope, tuning fork, and stethoscope).
- Preparation of the setting, oneself, and the client for the physical assessment.
- Performance of the four assessment techniques: inspection, palpation, percussion, and
auscultation.

The examiner directly observes objective data. These data include:

• Physical characteristics (e.g., skin color, posture)

• Body functions (e.g., heart rate, respiratory rate)

• Appearance (e.g., dress and hygiene)

• Behavior (e.g., mood, affect)

• Measurements (e.g., blood pressure, temperature, height, weight)

• Results of laboratory testing (e.g., platelet count, x-ray findings)

 PHYSICAL EXAMINATION TECHNIQUES

Four basic techniques must be mastered before performing a thorough and complete
assessment of the client. These techniques are inspection, palpation, percussion, and auscultation.

Inspection

The inspection involves using vision, smell, and hearing to observe and detect any normal or
abnormal findings. This technique is used when you meet the client and continues throughout the
examination. Inspection precedes palpation, percussion, and auscultation because the latter methods
can potentially alter the appearance of what is being inspected. Although most of the inspection
involves the use of the senses only, a few body systems require special equipment (e.g.,
ophthalmoscope for the eye inspection, otoscope for the ear inspection).

Use the following guidelines as you practice the technique of inspection:

• Make sure the room is at a comfortable temperature. A too cold or too-hot room can alter the
normal behavior of the client and the appearance of the client’s skin.
• Use good lighting, preferably sunlight. Fluorescent lights
can alter the actual color of the skin. In addition, abnormalities may be overlooked with dim lighting.
• Look and observe before touching. Touch can alter the appearance and distract you from a
complete, focused observation.
• Completely expose the body part you are inspecting while draping the rest of the client as
appropriate.
• Note the following characteristics while inspecting the client: color, patterns, size, location,
consistency, symmetry, movement, behavior, odors, or sounds.
• Compare the appearance of symmetric body parts (e.g., eyes, ears, arms, hands) or both sides of
any individual.

Palpation

Palpation consists of using parts of the hand to touch and feel for the following characteristics:

• Texture (rough/smooth)
• Temperature (warm/cold)
• Moisture (dry/wet)
• Mobility (fixed/movable/still/vibrating)
• Consistency (soft/hard/fluid filled)
• Strength of pulses (strong/weak/thread/bounding)
• Size (small/medium/large)
• Shape (well defined/irregular)
• Degree of tenderness
 Three different parts of the hand—the finger pads, ulnar/ palmar surface, and dorsal surface—
are used during palpation. Each piece of the hand is susceptible to specific characteristics. The depth
of the structure being palpated and the tissue thickness overlying that structure determine whether
you should use light, moderate, or deep palpation. Bimanual palpation uses both hands to hold and
feel a body structure. In general, the examiner’s fingernails should be short, and the hands should be
at a comfortable temperature. Standard precautions should be followed if applicable. Proceed from
light palpation, which is safest and the most comfortable for the client, to moderate palpation, and
finally to deep palpation.

Specific instructions on how to perform the four types of palpation follow:

• Light palpation: To perform light palpation, places your dominant hand lightly on the surface of the
structure. There should be very little or no depression (less than 1 cm). Next, feel the surface
structure using a circular motion. Use this technique to feel for pulses, tenderness, surface skin
texture, temperature, and moisture.

• Moderate palpation: Depress the skin surface 1 to 2 cm (0.5 to 0.75 inches) with your dominant
hand and use a circular motion to feel for easily palpable body organs and masses. Note the size,
consistency, and mobility of structures you palpate.

• Deep palpation: Place your dominant hand on the skin surface and your non-dominant hand on top
of your dominant hand to apply pressure. This should result in a surface depression between 2.5 and
5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick
muscle.

• Bimanual palpation: Use two hands, placing one on each side of the body part (e.g., uterus,
breasts, spleen) being palpated. Use one hand to apply pressure and the other hand to feel the
structure. Note the size, shape, consistency, and mobility of the structures you palpate.

Percussion

Percussion involves tapping body parts to produce sound waves. These sound waves or
vibrations enable the examiner to assess underlying structures.

Percussion has several different assessments uses, including:

• Eliciting pain: Percussion helps to detect inflamed underlying structures. If an inflamed area is
percussed, the client’s physical response may indicate or the client will report that the area feels
tender, sore, or painful.

• Determining location, size, and shape: Percussion note changes between borders of an organ and
its neighboring organ can elicit information about location, size, and shape.

• Determining density: Percussion helps determine whether an underlying structure is filled with air
or fluid or is a solid structure.
• Detecting abnormal masses: Percussion can detect superficial abnormal structures or masses.
Percussion vibrations penetrate approximately 5 cm deep. Deep masses do not produce any change
in the normal percussion vibrations.

• Eliciting reflexes: Deep tendon reflexes are elicited using the percussion hammer.

The three types of percussion are direct, blunt, and indirect.

● Direct percussion is the direct tapping of a body part with one or two fingertips to elicit
possible tenderness (e.g., tenderness over the sinuses).
● Blunt percussion (Fig. 3-5) is used to detect tenderness over organs (e.g., kidneys) by placing
one hand flat on the body surface and using the fist of the other hand to strike the back of
the hand flat on the body surface.
● Indirect or mediate percussion is the most used method of percussion. The tapping done
with this type of percussion produces a sound or tone that varies with the density of
underlying structures. As density increases, the sound of the tone becomes quieter. For
example, solid tissue produces a soft tone, fluid produces a louder tone, and air produces an
even more audible tone. These tones are referred to as percussion notes and are classified
according to origin, quality, intensity, and pitch.

The following techniques help to develop proficiency in the technique of indirect percussion:

• Place the middle finger of your non-dominant hand on the body part you are going to percuss.
• Keep your other fingers off the body part being percussed because they will damp the tone you
elicit.
• Use the pad of your middle finger of the other hand (ensure that this fingernail is short) to strike
the middle finger of your non-dominant hand that is placed on the body part.
• Withdraw your finger immediately to avoid damping the tone.
• Deliver two quick taps and listen carefully to the tone.
• Use quick, sharp taps by quickly flexing your wrist, not your forearm.

Practice percussing by tapping your thigh to elicit a flat tone and by tapping your puffed-out
cheek to produce a tympanic tone. An excellent way to detect changes in tone is to fill a carton
halfway with fluid and practice percussing on it. The tone will change from resonance over the air
to a duller tone over the fluid.

Auscultation

Auscultation is a type of assessment technique that requires a stethoscope to listen for heart
sounds, movement of blood through the cardiovascular system, movement of the bowel, and
movement of air through the respiratory tract. A stethoscope is used because these body sounds
are not audible to the human ear. The sounds detected using auscultation are classified according
to the intensity (loud or soft), pitch (high or low), duration (length), and quality (musical, crackling,
raspy) of the sound.

These guidelines should be followed as you practice the technique of auscultation:

 • Eliminate distracting or competing noises from the environment (e.g., radio, television,
machinery).
• Expose the body part you are going to auscultate. Do not auscultate through the client’s clothing
or gown. Rubbing against the clothing obscures the body sounds.
• Use the stethoscope's diaphragm to listen for high-pitched sounds, such as normal heart sounds,
breath sounds, and bowel sounds, and press the diaphragm firmly on the body part being
auscultated.
• Use the stethoscope bell to listen for low pitch sounds such as abnormal heart sounds and bruits
(abnormal loud, blowing, or murmuring sounds). Hold the bell lightly on the body part being
auscultated.

SUBJECTIVES OBJECTIVES

Description Data elicited and verified by Data directly or indirectly

the client. observed through
measurement.

Sources Client -Observations and physical

assessment findings of the

nurse or other health care

professionals.

-Documentation of
assessments made in the
client record.

-Observations made by the

Client record client’s family or significant
others.

Other health care

professionals

Methods used to obtain Client interview. Observation and physical

data examination.

Skills needed to obtain data Interview and therapeutic– Inspection

communication skills.
Palpation
Caring ability and empathy.
Percussion
 Listening skills. Auscultation

Examples “I have a headache.” Respirations 16 per minute.

“It frightens me.” BP 180/100, apical pulse 80,

and irregular.
“I am not hungry.”
X-ray film reveals a fractured
pelvis.

A Diagnostic test is a medical procedure performed to detect, diagnose, or monitor diseases,

disease processes, susceptibility, or determine a treatment course. Medical tests such as physical and
visual exams, diagnostic imaging, genetic testing, chemical, and cellular analysis, relating to clinical
chemistry, and molecular diagnostics are typically performed in a medical setting

ACTIVITY 4
Instructions:
1. List the following subjective data described explicitly in the case study below.
2. List the following objective data described explicitly in the case study below.
You may answer in a separate sheet/s.

CASE STUDY: Sharon Faulkner is a 42-year-old woman admitted to the hospital with a diagnosis
of acute cholecystitis. She tells the nurse that the pain she is experiencing in her right upper abdomen
feels like a knife and goes all the way to her shoulder. She is also very nauseous. She tells the nurse
that she is exhausted and has not slept for three nights because the pain keeps her awake. The nurse
observes dark circles under Sharon's eyes. Her vital signs are blood pressure (BP), 132/90 mm Hg; heart
rate, 104 beats/min.; respiratory rate, 22 per minute; temperature, 101.8° F (38.8° C). A complete blood
count laboratory test reveals that Sharon has an elevated white blood cell count. She lies in her bed in
a fetal position and tells the nurse that she hurts too much to get up and move.