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Nursing Assessment Techniques

The document describes four techniques used in nursing diagnosis: 1) Inspection involves purposeful visual observation of clients to assess overall appearance and specific body areas and systems. 2) Percussion uses tapping the body to elicit sounds and determine if they are normal. It can reveal masses close to the body surface. 3) Palpation uses touch to further examine cues identified during inspection, assessing temperature, texture, swelling and other factors. Comparing sides provides clinical significance. 4) Auscultation uses a stethoscope to listen to internal sounds of the heart, lungs, arteries and abdomen to assess the heart rate and rhythm and listen for abnormal sounds.

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793 views2 pages

Nursing Assessment Techniques

The document describes four techniques used in nursing diagnosis: 1) Inspection involves purposeful visual observation of clients to assess overall appearance and specific body areas and systems. 2) Percussion uses tapping the body to elicit sounds and determine if they are normal. It can reveal masses close to the body surface. 3) Palpation uses touch to further examine cues identified during inspection, assessing temperature, texture, swelling and other factors. Comparing sides provides clinical significance. 4) Auscultation uses a stethoscope to listen to internal sounds of the heart, lungs, arteries and abdomen to assess the heart rate and rhythm and listen for abnormal sounds.

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IPPA Nursing Process

Inspection
Inspection is a technique used in nursing diagnosis that involves the purposeful and systematic
observation of the client. It does not involve touching, only careful visual observation1. The
process involves inspecting the client overall to gain a general impression, and then inspecting
specific body areas and body systems to focus the assessment1. Inspection is an important
part of the nursing process, which is a clinical judgment that helps nurses determine the plan of
care for their patients.

Percussion
Percussion is a technique used in nursing diagnosis that involves tapping the body to elicit
sounds and determining whether the sounds are appropriate for a particular organ or area of the
body1. This technique can help reveal the presence of masses, particularly if they are close to
the surface of the body1. The most widely used approach to percussion is indirect percussion,
which is the application of a mediated force using parts of both of your hands1. Indirect
percussion is often used to assess the lungs and the abdomen (e.g., bowels, bladder, liver)1. As
a nurse, you need to become familiar with the expected percussion sounds so that you can
identify what is normal and what is abnormal.

Palpation
In the context of nursing diagnosis, palpation is a technique that involves using your hands or
fingers to assess the client based on your sensation of touch1. It provides the opportunity to use
your sense of touch to assess the body and further examine cues that were identified during
inspection. Palpation provides useful information to assess and evaluate findings related to
temperature, texture, moisture, thickness, swelling, elasticity, contour,
lumps/masses/deformities, consistency/density, organ location and size, vibration, crepitation ,
and presence of pain. Always compare the right side and the left side of the body when
palpating, because the best standard of comparison is the client’s own anatomy. The presence
of a bilateral versus a unilateral finding is of clinical significance1.For example, the left ankle
should be symmetrical with the right ankle. The presence of edema in one ankle versus both
ankles is meaningful for making judgements about the underlying pathology 1.

Auscultation
Auscultation is a technique performed by healthcare professionals, such as medical doctors
and registered nurses, during a physical examination to listen to the internal sounds of the
body. It involves using a stethoscope to listen to the sounds of the heart, lungs, arteries, and
abdomen. In the nursing process, auscultation is used to assess the heart’s rhythm, rate, and
sound of valve closure3. The nurse will listen for S1 and S2 while noting if there are any S1 and
S2 splits or extra heart sounds like S3, S4, or heart murmurs3.

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