Assessment techniques and

approach in the clinical setting

Ms. Cres P. Quinzon RN MAN
Oman College of Health Sciences Dhofar
 I. Inspection
• Inspection involves using the senses of vision, smell,
and hearing to observe and detect any normal or
abnormal findings.
• Use of the senses only, a few body systems require
3. PHYSICAL
EXAMINATIONthe use of special equipment (e.g., ophthalmoscope
TECHNIQUESfor the eye inspection, otoscope for the ear
inspection).
• Note the following characteristics while inspecting
the client: color, patterns, size, location, consistency,
symmetry, movement, behavior, odors, or sounds.
 II. Palpation
Palpation consists of using parts of the hand to touch
and feel for the following characteristics:
• Texture (rough/smooth)
• Temperature (warm/cold)
3. PHYSICAL
• Moisture (dry/wet)
EXAMINATION
TECHNIQUES • Mobility (fixed/movable/still/ vibrating)
• Consistency (soft/hard/fluid filled)
• Strength of pulses (strong/weak/thready/bounding
• Size (small/medium/large)
• Shape (well defined/irregular)
 II. Palpation
Three different parts of the hand—the
fingerpads, ulnar/palmar surface, and
dorsal surface—are used during
palpation.
3. PHYSICAL
EXAMINATION
TECHNIQUES
 II. Palpation
TYPES OF PALPATION
i. Light palpation: little or no depression (less
than 1 cm).

3. PHYSICAL • Use this technique to feel for pulses,

EXAMINATION tenderness, surface skin texture,
TECHNIQUES temperature, and moisture
ii. Moderate palpation: Depress the skin surface
1 to 2 cm
• Use a circular motion to feel for easily
 i. Deep palpation:. Depression between 2.5
and 5 cm.
• This allows you to feel very deep organs or
structures that are covered by thick muscle.
ii.Bimanual palpation: Use two hands,
3. PHYSICAL
EXAMINATION placing one on each side of the body part
TECHNIQUES (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.
 III.Percussion.
Percussion involves tapping body parts to
produce sound waves.
These sound waves or vibrations enable

3. PHYSICAL the examiner to assess underlying

EXAMINATION structures.
TECHNIQUES  Eliciting pain:
 Determining location, size, and shape:
 Determining density:
 Detecting abnormal masses:
 III.Percussion.
Direct percussion is the direct tapping of a
body part with one or two fingertips to elicit
possible tenderness (e.g., tenderness over

3. PHYSICAL the sinuses).

EXAMINATION Blunt percussion is used to detect
TECHNIQUES 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
 Indirect or mediate percussion is the
most commonly used method of percussion.
The tapping done with this type of
percussion produces a sound or tone that

3. PHYSICAL varies
EXAMINATION
TECHNIQUES
 IV.Auscultation.
Auscultation is a type of assessment
technique that requires the use of a
3. PHYSICAL stethoscope to listen for heart sounds,
EXAMINATION movement of blood through the
TECHNIQUES
cardiovascular system, movement of the
bowel, and movement of air through the
respiratory tract.
 The sounds detected using auscultation are
classified according to the
• Intensity (loud or soft),
3. PHYSICAL • Pitch (high or low),
EXAMINATION • Duration (length), and
TECHNIQUES
• Quality (musical, crackling, raspy) of the
sound).
 Validation of data is the process of
confirming or verifying that the
subjective and objective data you have
collected are reliable and accurate.
Data Requiring Validation

VALIDATING  Discrepancies or gaps between the

subjective and objective data
DATA
 Discrepancies or gaps between what
the client says at one time then at
another time.
 Findings that are very abnormal and/or
inconsistent with other findings
 Methods of Validation
 Recheck your own data through a repeat
assessment.
 Clarify data with the client by asking
VALIDATING additional questions
DATA  Verify the data with another health care
professional
 Compare your objective findings with
your subjective findings to uncover
discrepancies.
 Record (something) in written, or other
form.
Purpose of Documentation
DOCUMENTING  provide the health care team with a
DATA database to identify health problems,
formulate nursing diagnoses, and plan
immediate and ongoing interventions.
 Establishes a way to communicate with
the multidisciplinary team members.
 Information Requiring Documentation
Two key elements need to be included in
every documentation: Nursing history
and physical assessment, also known as
subjective and objective data.

DOCUMENTING 1. Subjective data:

DATA  Biographic data
 The present health concern
 Past health history data
 Family history data
 Lifestyle and health practices
information
 Information Requiring Documentation
2. Objective Data
Make notes as you perform the assessments,
and document as concisely as possible.
Avoid documenting general non-descriptive or
DOCUMENTING non measurable terms such as normal,
DATA abnormal, good, fair,
satisfactory, or poor.
• Instead, use specific descriptive and
measurable terms
(i.e., 3 inches in diameter, red excoriated edges,
with purulent yellow drainage) about what you
inspected, palpated, percussed, and uscultated.
 Assessment Forms Used for
Documentation
DOCUMENTING Standardized assessment forms have
DATA been developed to ensure that content in
documentation and assessment data
meets regulatory requirements and
provides a thorough database
Thank you