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WORLD’S #1 QUICK REFERENCE GUIDE
COMPONENTS OF THE NURSING PROCESS
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• Assessment: The process by which a nurse investigates the physical,
psychosocial, and spiritual needs of a patient through the collection of
subjective and objective data.
• Analysis (a.k.a. diagnosis): The data collected during the assessment
phase is evaluated to determine a plan of care.
• Planning: The data from the assessment and analysis phases is used to
develop measurable goals and outcomes (i.e., nursing interventions).
• Implementation: The nursing interventions are put into practice.
• Evaluation: The outcomes of the nursing interventions are assessed.
BASIC HEAD-TO-TOE ASSESSMENT
• General: Assess general appearance and behavior, posture, gait,
hygiene, speech, mental status, height and weight, hearing and visual
acuity, vital signs, and nutrition.
• Head and neck: Assess skull size, shape, and symmetry, as well as
hair and scalp. Palpate for masses on scalp, ears, face, throat, and
neck. Palpate sinuses for tenderness and masses. Inspect sclera and
conjunctiva. Assess pupil response by using PERRLA (pupils equal,
round, reactive to light and accommodation). Test convergence (as
eyes shift from a far object to a near object, pupils constrict), confrontation (the extent of the peripheral field), and corneal light reflex. Inspect
and palpate teeth and gums. Test rise of uvula and gag reflex. Assess
sense of smell and taste. Check range of motion (ROM) in neck and
shoulders. Palpate lymph nodes for tenderness and swelling, trachea
for symmetry, and thyroid for masses.
• Upper extremities: Inspect skin, test capillary refill, palpate peripheral pulses, rate muscle strength, assess ROM, and check deep tendon
reflexes.
• Posterior thorax: Inspect spine for alignment, assess anteroposterior
to lateral diameter, assess thoracic expansion, palpate tactile fremitus, auscultate breath sounds, and perform blunt percussion over
costovertebral angles for tenderness.
• Anterior thorax: Observe respiratory pattern, palpate respiratory
excursion, auscultate breath sounds, auscultate heart sounds, inspect
jugular veins, and perform breast exam.
• Abdomen: Auscultate for bowel sounds, percuss for masses and tenderness, percuss the liver, and palpate the kidneys and spleen.
• Lower extremities: Inspect skin, palpate peripheral pulses, assess for
Homans’ sign, inspect and palpate joints for swelling, assess for pedal
and ankle edema, and assess ROM.
ASSESSING LUNG SOUNDS
To auscultate lung sounds, move the diaphragm of your stethoscope according to
the numbers on the corresponding figures. There are three normal breath sounds:
(B) Bronchial breath sounds: Loud, harsh, and high-pitched; heard over trachea, bronchi (between clavicles and midsternum), and main bronchus
(BV) Bronchovesicular breath sounds: Blowing sounds of moderate intensity and
pitch; heard in the posterior chest between the scapulae and in the center
part of the anterior chest
(V) Vesicular breath sounds: Soft, breezy, and low-pitched; heard over the peripheral lung area and throughout most of the lung fields
Back View
Front View
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ADVENTITIOUS LUNG SOUNDS & POTENTIAL CAUSES
Sound
Characteristics
Crackles
Popping, crackling, bubbling, moist
sounds on inspiration
Rhonchi
Wheezes
Pleural
friction rub
Lung Problems
Congestive heart failure,
pneumonia, pulmonary edema,
pulmonary fibrosis
Rattling sound on expiration
Bronchiectasis, bronchitis,
emphysema, pneumonia
High-pitched musical sound during both Anaphylaxis, asthma,
emphysema, foreign bodies
inspiration and expiration (louder)
Dry, grating sound on both inspiration
and expiration
Pleural infarct, pleurisy,
pneumonia
ASSESSMENT TECHNIQUES
• Inspection is the careful examination of the patient as a whole, as well as of
–– There are five types of percussion sounds:
each body system, using the visual, auditory, and olfactory senses to gather
1. Tympany: Loud, drumlike sound
information. This process:
2. Resonance: Moderate to loud, low-pitched, hollow sound
–– Examines color, shape, symmetry, and position of body parts.
3. Hyperresonance: Very loud, low-pitched booming sound
–– Should be purposeful and systematic, with body parts compared bilaterally
4. Flatness: Soft, high-pitched, flat sound
during the entire examination.
5. Dullness: Soft to moderate, high-pitched, thud-like sound
–– Requires good lighting to allow visual inspection of the body without disPERCUSSION SOUNDS & POTENTIAL CAUSES
tortion or shadows.
• Palpation is the technique of using touch to gather information about temPercussion
Where
Potential Cause
perature, turgor, texture, moisture, size, shape, consistency, location, and tenSound
Normally
derness of an organ or body part.
Heard
–– Palpation can be light (the application of pressure by depressing the skin
Tympany
Abdomen
Normal
and underlying structures about a half inch) or deep (palpation using inward
Resonance
Chest
Healthy lungs
pressure to depress the skin and underlying structures about an inch).
–– The patient should be provided with privacy, and the nurse should have
Hyperresonance Chest
Asthma, COPD, pneumothorax
warm hands and short fingernails. Any areas of tenderness should be palFlatness
Solid
areas
Muscle or bone, severe pneumonia
pated last.
Dullness
Liver or heart Organs, pleural effusion, pneumonia, tumor
–– During palpation, assess consistency of tissues, alignment and intactness
of structures, symmetry of body parts or movements, and transmission of
• Auscultation involves listening to sounds produced by the body using a
fine vibrations.
stethoscope. Auscultation is performed for the purposes of examining the
• Percussion involves striking one object with another to create sound as a
circulatory system, respiratory system, and gastrointestinal (GI) system:
means of assessing the location, size, and density of underlying tissues. The
–– Sounds must be isolated for proper identification and evaluation.
sound will change as you move from one area to the next. Percussion is
–– The stethoscope has a diaphragm that detects high-pitched sounds and a
done with the middle finger of the dominant hand tapping on the middle
bell that detects low-pitched sounds.
finger of the nondominant hand while the nondominant palm is on the body.
–– Four characteristics of sounds should be noted:
–– The nondominant hand is placed on the area to be percussed, with fingers
1. Pitch
slightly separated.
2. Loudness
–– The dominant hand is used as the striking force by exerting a sharp down3. Quality
ward wrist movement so that the tip of the middle finger of the dominant
hand
strikes the
joint of
the middle
finger on -the
nondominant
hand.3:44 PM via4.LOS
Duration
EBSCO
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