🩺 “Assessment is the foundation of quality nursing care.”
📚 Health assessment is the systematic method of collecting and analyzing data to determine a patient’s health status.
🗨️ A Health Assessment is a structured evaluation of an individual’s physical, psychological, and social health to identify needs, risks, and changes in condition.
It helps in creating a nursing care plan, making clinical decisions, and tracking progress.
| 🔢 Type | 📝 Description |
|---|---|
| 1️⃣ Comprehensive (Initial) Assessment | Full body, head-to-toe assessment done on admission or first visit |
| 2️⃣ Focused (Problem-Oriented) Assessment | Done for specific issue or body system (e.g., abdominal pain) |
| 3️⃣ Ongoing/Follow-Up Assessment | Repeated assessment to monitor status after treatment or surgery |
| 4️⃣ Emergency Assessment | Rapid, life-saving assessment during crises (e.g., trauma, cardiac arrest) |
| 5️⃣ Screening Assessment | Done in health camps, OPD for early detection (e.g., BP, glucose, cancer screening) |
| 6️⃣ Functional Assessment | Evaluates ability to perform ADLs and IADLs (especially in elderly or rehab) |
| 7️⃣ Psychosocial Assessment | Focuses on mental, emotional, cultural, and spiritual health |
| 8️⃣ Nutritional Assessment | Evaluates dietary intake, BMI, lab values, weight patterns |
| 9️⃣ Risk Assessment | Identifies fall risk, pressure ulcer risk, infection risk (e.g., Braden Scale) |
🔍 When? – On first interaction (e.g., hospital admission)
🔹 Includes:
🔍 When? – For a specific complaint or condition
🔹 Example: “Patient c/o chest pain” → Assess heart sounds, BP, ECG
✅ Purpose: To explore a problem in-depth
🔍 When? – Continuously during care
🔹 Includes:
🔍 When? – During critical events like trauma, stroke, shock
🔹 Use ABCDE or Primary Survey:
🔍 When? – In preventive health settings
🔹 Examples:
🔍 When? – In geriatric or rehab patients
🔹 Evaluates:
🔍 When? – Mental health, palliative, addiction, grief cases
🔹 Includes:
🔍 When? – In malnutrition, diabetes, pediatric, or elderly care
🔹 Includes:
🔍 When? – To prevent complications
🔹 Includes:
✅ Q: Which assessment is done during admission?
🅰️ Comprehensive/Initial Assessment
✅ Q: Which assessment is done in case of chest pain?
🅰️ Focused Assessment
✅ Q: Which tool is used for pressure ulcer risk?
🅰️ Braden Scale
✅ Q: Emergency assessment uses which format?
🅰️ ABCDE approach
✅ Q: What is the purpose of screening assessment?
🅰️ Early disease detection in apparently healthy individuals
🧠 “Hands, eyes, ears, and touch — the nurse’s tools for discovering the unseen.”
🩺 These techniques are the core methods used in physical examination to assess body systems and health conditions.
| 🔢 Step | 📝 Technique | 👁️ Tool Used | 🔍 Purpose |
|---|---|---|---|
| 1️⃣ | Inspection | Eyes | Look |
| 2️⃣ | Palpation | Hands/Fingers | Feel |
| 3️⃣ | Percussion | Fingers | Tap & Hear |
| 4️⃣ | Auscultation | Stethoscope | Listen |
🧑⚕️ Used in this specific order — except in abdominal assessment, where auscultation comes before palpation & percussion!
🗨️ “Looking with a purpose.”
It is the visual examination of body parts, movements, and behavior.
✅ What to Observe:
✅ Examples:
🗨️ “Feeling with hands to assess texture, temperature, size.”
Use fingertips, palm, and back of hand for different sensations.
| ✋ Type | 📝 Use |
|---|---|
| 🤏 Light Palpation | 1 cm depth → tenderness, skin texture |
| ✋ Deep Palpation | 4–5 cm → masses, organ size |
| 🔁 Bimanual Palpation | Two hands → kidneys, breast, spleen |
✅ What to Assess:
✅ Examples:
🗨️ “Tapping body parts to produce sound waves that reflect the underlying structure.”
| 🟢 Sound | 📍 Area | 🔉 Interpretation |
|---|---|---|
| Resonance | Normal lung | Air-filled space |
| Hyperresonance | Emphysematous lung | Extra air |
| Dullness | Liver, full bladder | Solid organ |
| Flatness | Bone, muscle | Dense |
| Tympany | Abdomen (stomach) | Air/gas in bowel |
✅ Used for:
🗨️ “Listening to internal body sounds using a stethoscope.”
| 👂 System | 🔉 Sounds to Hear |
|---|---|
| ❤️ Cardiac | Heart sounds (S1, S2, murmurs) |
| 🌬️ Respiratory | Breath sounds (crackles, wheeze, rhonchi) |
| 🍽️ Gastrointestinal | Bowel sounds (hypoactive, hyperactive) |
| 🩸 Vascular | Bruits in carotid or abdominal artery |
✅ Technique Tips:
🚨 Exception to the standard technique order:
Order: Inspection → Auscultation → Percussion → Palpation
🔸 Palpation and percussion may stimulate bowel activity, hence auscultation is done first.
| 🛠️ Technique | 📖 Use |
|---|---|
| 🧲 Olfaction (Smelling) | Detecting infection (e.g., wound odor, ketoacidosis breath) |
| 👁️🗨️ Mental Status Exam | Orientation, memory, behavior |
| 🎯 Neurological Checks | Reflexes, sensation, coordination |
✅ Q: What is the correct sequence of techniques in physical examination?
🅰️ Inspection → Palpation → Percussion → Auscultation
✅ Q: In abdominal exam, which technique is done second?
🅰️ Auscultation
✅ Q: Which part of the hand is used to assess temperature?
🅰️ Back of the hand (dorsum)
✅ Q: Which sound on percussion suggests fluid or solid organ?
🅰️ Dullness
✅ Q: Which instrument is used for auscultation?
🅰️ Stethoscope
🛏️ “A full-body approach to uncover patient needs and guide care.”
🩺 Done during comprehensive assessment, usually on admission or initial examination.
✅ Use inspection, palpation, percussion, auscultation (in proper order)
✅ Maintain privacy, use draping appropriately
✅ Ensure hand hygiene, clean equipment
✅ Provide clear explanation to patient
✅ Document findings accurately
✅ Assess:
✅ Inspect & Palpate:
✅ Assess:
✅ Inspect & Palpate:
✅ Check:
✅ Inspect:
✅ Check:
✅ Inspect & Palpate:
✅ Inspection:
✅ Assess:
✅ Follow correct order:
Inspection → Auscultation → Percussion → Palpation
✅ Assess:
✅ Inquire/Assess:
✅ Assess:
✅ Assess:
✅ Observe:
📝 “Patient alert and oriented x 4, pupils reactive, skin warm and pink, lungs clear bilaterally, heart sounds normal, abdomen soft/non-tender, bowel sounds present, no edema, ambulating independently.”
✅ Q: What is the correct order of abdominal assessment?
🅰️ Inspection → Auscultation → Percussion → Palpation
✅ Q: Which technique checks for capillary refill?
🅰️ Palpation of fingernail beds
✅ Q: How is neurological status initially assessed?
🅰️ Level of consciousness and orientation
✅ Q: What is PERRLA in eye assessment?
🅰️ Pupils Equal, Round, Reactive to Light and Accommodation
✅ Q: What is checked during respiratory auscultation?
🅰️ Breath sounds in all lobes