Nursing Foundations · Health Assessment

Health Assessment

Subjective Datadefinition

Symptoms the patient reports, feels, or perceives; cannot be objectively measured or verified by the nurse.

in simple words: What the patient tells you — only they can feel it.

e.g. Nausea, pain, dizziness, fatigue.

Objective Datadefinition

Observable or measurable findings that can be verified by the nurse.

in simple words: What you can see, touch, or measure.

e.g. Temperature 102°F, swollen ankles, vomiting, BP 140/90 mmHg.

Signs – Objective evidence

Fever, rash, high BP
Can be confirmed by another clinician

Symptoms – Subjective experience

Pain, dizziness, fatigue
Only the patient can describe

Health Assessment · Nursing Foundations

Assessment Techniques

Four Fundamental Techniques

Physical examination uses four techniques to gather objective data. No single technique is sufficient alone. Intact senses, objectivity, and communication are required skills.

The Four Techniques

Inspection – Deliberate, purposeful, systematic observation using sight, hearing, and smell. Compare one side with the other under good lighting.
Palpation – Using hands and fingers to feel temperature, texture, turgor, tenderness, and masses.
Percussion – Tapping the body surface to evaluate size, borders, and consistency of underlying organs by the sound produced.
Auscultation – Using hearing to listen to internal body sounds such as heart, lung, and bowel sounds.

Health Assessment · Nursing Foundations

Sequence of Examination

Standard Sequence (IPPA)

InspectionLook first
PalpationFeel next
PercussionTap third
AuscultationListen last

Abdominal Exception (IAPP)

InspectionLook first
AuscultationListen before touching
PercussionTap third
PalpationFeel last

Why the Abdomen is Different

Percussion and palpation stimulate peristalsis and can artificially increase or decrease bowel sounds. Auscultation must be done before touching to capture natural, undisturbed bowel motility.

Health Assessment · Nursing Foundations

Percussion & Palpation

Percussion Sounds

Sound	Character	Location
Resonance	Low-pitched, hollow	Normal air-filled lung
Tympany	Loud, high-pitched, drum-like	Stomach, intestines
Hyperresonance	Louder, lower-pitched	Hyperinflated lungs (emphysema)
Dullness	Thud-like	Fluid or consolidation (pneumonia, effusion)

Palpation Tips

Fingertips – Fine tactile discrimination
Back of hand – Temperature
Base of fingers – Vibration
Deep palpation – 4–5 cm deep for liver, spleen, kidneys

Health Assessment · Nursing Foundations

Skin & Hydration

Skin Turgordefinition

The skin's elasticity; reflects interstitial fluid volume and is used to assess hydration status.

in simple words: Pinch a fold of skin and see how fast it returns.

e.g. Poor turgor (tenting) indicates fluid volume deficit.

Mechanism of Tenting

In dehydration, loss of interstitial fluid reduces skin elasticity, so a pinched fold tents and returns slowly. This is a classic bedside sign of dehydration.

Health Assessment · Nursing Foundations

Assessment Approaches

Comprehensive

Covers biological, psychological, cultural, spiritual, social needs
Done on first contact to establish baseline

Focused

Examines a specific problem or body system
Narrower than comprehensive

Emergency

For deteriorating patients
Life-threatening problems first

Types of Nursing Assessment

Selected based on patient condition and clinical context

Nursing Process Phases

Assessment is the first and most critical phase — all subsequent phases depend on accuracy and completeness of data. The five phases are assessment, diagnosis, planning, implementation, and evaluation.

Health Assessment · Nursing Foundations

Special Assessments

Key Assessment Tools

Braden Scale – Predicts pressure ulcer risk. Six parameters: sensory perception, moisture, activity, mobility, nutrition, friction/shear. Score ≤18 triggers prevention protocols.
Glasgow Coma Scale – Assesses level of consciousness: eye, verbal, motor responses.
Numeric Rating Scale / FACES – Validated pain assessment scales.
FLACC / CPOT – Non-verbal pain assessment for infants and intubated adults.
CIWA – Quantifies alcohol withdrawal severity; objective data.