Basic Nursing Skills and
Procedures:
Nursing Assessment and Physical Examination :
1. Health Assessment Techniques
Nursing assessment is a
fundamental part of patient care. It involves gathering information about the
patient’s physical, psychological, sociocultural, and spiritual health. The
four main health assessment techniques used during physical examination are:
a. Inspection
- Definition:
Visual examination of the body, including body movements, posture, skin
integrity, and overall appearance.
- Purpose:
To identify any signs of health issues like rashes, wounds, swelling,
deformities, or abnormal movements.
- Process:
o Ensure
proper lighting.
o Expose
only the area being inspected, maintaining patient’s privacy.
o Look
for symmetry, color, texture, size, and shape of body parts.
o Use
both direct inspection (with eyes) and indirect inspection (using instruments
like otoscopes for ears).
- Example:
Inspecting the skin for signs of pressure ulcers in bedridden patients.
b. Palpation
- Definition:
Using the hands to feel the body’s surface to identify abnormalities in
texture, temperature, moisture, swelling, or masses.
- Purpose:
To assess tenderness, pain, organ size, and temperature.
- Types:
o Light
Palpation: Used to feel surface abnormalities.
o Deep
Palpation: Used to feel internal organs or masses.
- Process:
o Use
fingertips for texture, moisture, and pulse.
o Use
the back (dorsal) of the hand to assess temperature.
o Use
the palm or ulnar surface for vibration detection.
- Example:
Checking for abdominal tenderness or lymph node swelling.
c. Percussion
- Definition:
Tapping on a body part with fingers or a small hammer to assess underlying
structures.
- Purpose:
To detect fluid, air, or solid masses under the skin, and to assess the
size, shape, and density of organs.
- Types:
o Direct
Percussion: Tapping directly on the skin.
o Indirect
Percussion: Placing one hand on the body surface and tapping it with the
fingers of the other hand.
- Sound
Types:
o Resonance:
Normal lung sounds.
o Tympany:
Hollow sounds in the stomach.
o Dullness:
Heard over dense areas like the liver or spleen.
- Example:
Percussing the chest to detect fluid accumulation in the lungs.
d. Auscultation
- Definition:
Listening to sounds within the body using a stethoscope.
- Purpose:
To assess heart, lung, and bowel sounds.
- Process:
o Ensure
a quiet environment.
o Use
the diaphragm of the stethoscope for high-pitched sounds (like heart and
breath sounds).
o Use
the bell for low-pitched sounds (like vascular bruits).
- Example:
Listening to heart sounds to detect murmurs, or to lung sounds to detect
wheezing or crackles.
2. Vital Signs Monitoring
Monitoring vital signs is
essential for assessing the patient’s physiological status. The key vital signs
are:
a. Temperature
- Normal
Range: 36.5°C to 37.5°C (97.7°F to 99.5°F)
- Methods
of Measurement:
o Oral
(under the tongue)
o Axillary
(underarm)
o Rectal
(most accurate)
o Tympanic
(ear)
o Temporal
(forehead)
- Equipment:
Thermometers (digital, mercury, infrared)
- Abnormalities:
o Hypothermia:
Temperature below normal.
o Hyperthermia/Fever:
Temperature above normal.
b. Pulse
- Normal
Range: 60-100 beats per minute (bpm) for adults.
- Sites
of Measurement:
o Radial
(wrist)
o Carotid
(neck)
o Apical
(chest)
o Brachial
(arm)
o Femoral
(groin)
o Popliteal
(knee)
o Dorsalis
pedis (foot)
- Characteristics
to Assess:
o Rate
(bpm)
o Rhythm
(regular/irregular)
o Strength
(strong, weak, bounding)
o Equality
(symmetry between both sides)
c. Respiration
- Normal
Range: 12-20 breaths per minute for adults.
- Characteristics
to Assess:
o Rate
(number of breaths per minute)
o Rhythm
(regular/irregular)
o Depth
(deep, shallow, or normal)
o Effort
(labored or unlabored breathing)
- Abnormalities:
o Tachypnea:
Rapid breathing.
o Bradypnea:
Slow breathing.
o Apnea:
No breathing.
d. Blood Pressure (BP)
- Normal
Range: 120/80 mmHg for adults.
- Methods
of Measurement:
o Manual
(using sphygmomanometer and stethoscope)
o Digital
(automated device)
- Procedure:
o Patient
should be seated with arm at heart level.
o Place
the cuff 2-3 cm above the elbow.
o Inflate
the cuff and deflate it slowly while listening for Korotkoff sounds.
- Classifications:
o Hypotension:
Low BP (<90/60 mmHg).
o Hypertension:
High BP (>140/90 mmHg).
3. Health History and Patient
Interview Techniques
A comprehensive health history is
the first step in assessing a patient’s health status. It involves collecting
subjective and objective data about the patient’s health.
a. Purpose
- To
establish a database of patient health status.
- To
identify patient’s strengths, weaknesses, and health risks.
b. Components of Health History
- Biographical
Data: Name, age, gender, occupation, and marital status.
- Chief
Complaint: Reason for seeking care.
- History
of Present Illness: Details of current symptoms.
- Past
Medical History: Previous illnesses, surgeries, hospitalizations, and
medications.
- Family
History: Identifying genetic predispositions.
- Psychosocial
History: Lifestyle, habits, and social support.
- Review
of Systems (ROS): Questions related to each body system to identify
any unreported symptoms.
c. Patient Interview Techniques
- Effective
Communication Skills: Use clear, simple language.
- Active
Listening: Pay attention to the patient’s words, tone, and nonverbal
cues.
- Open-ended
Questions: Encourage patients to give more details.
- Clarification
and Reflection: Ask for more details and repeat back what the patient
said.
- Non-Judgmental
Attitude: Avoid passing judgment on the patient’s choices or actions.
d. Interview Process
- Introduction:
Greet the patient and explain the purpose of the interview.
- Data
Collection: Use open and closed-ended questions to gather data.
- Closure:
Summarize the interview and address any patient concerns.
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