Subjective data - Said by the client (S)
Obejective data - Observed by the nurse (O)
Assessment Techniques is as follows - Inspect-Palpation-Percussion-Auscultation
Order of Abdomen Assessment - Inspect-Auscultation-Percuss-Palapate
Inspection - *always first*
1. Take time to observe with eyes ear nose
2.Use good lighting
3.Look at color shape symmetry position
4.Observe for odors from skin breath wound
5. Develop and use nursing instincts
6.Inspection is done alone and in combination with other assessment techniuqes
Back of hand - To assess skin temperature use
Deep Palpation - 5-8cm or (2-3") deep is considered
Light Paplpation - 1cm deep is considered
Percussion - sounds produced by striking body surface
Sounds are dull resonant flat tympanic
Action is performed in the wrist
Ausculation - listening to sounds produced by the body
Bell - picks up low pitched sounds such as heart murmurs
General Survey - is an overall review or first impression a nurse has of person's well being.
Appearance - appears to be reported age
Sexual development appropriate
Alert and oriented
Facial features symmetric
No signs of acute distress
,Body Structure/mobilty - weight and height WNL BMI guidelines
Body parts equal bilaterally
Stands erect
Sits comfortably
Gait is coordinated
Walk is smooth and well balanced
Full mobility of joints
Behavior - maintains eye contact with appropriate expressions
Comfortable and cooperative
Speech clear
Clothing is correct for climate
Looks cleat and fit
Appears clean and well groomed
Comprehensive history - which includes chief complaint or reason for the visit a complete review of
systems and complete past family and social history should be obtained on the first encounter with a
patient regardless of setting and by a RN
Family Health Hx - Are completed across three generations looking specifically for patterns in genetic
issues that negatively impact quality of life
Health Hx - gives a picture of patient's current health and documentation must be completed for each visit
and or assessment
How to measure height less than 2 years of age - Obtain height by measuring the recumbent length of
children less than 2 years of age and
Children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary headboard
and a sliding vertical foot piece is ideal, but a tape measure can also be used
A) Lay the child flat against the center of the board. The head should be held against the
Headboard by the parent or an assistant and the knees held so that the hips and knees are extended. The
foot piece is moved until it is firmly against the child's heels. Read and record the measurement to the
nearest 1/8 inch.
B) A modified technique in home settings is to lay the child flat and straight where the head should be held
by the parent and the knees held so that the hips and knees are extended, mark the flat surface at the top
of the head and tip of the heels. Move child and measure the distance between the marks with a tape
measure. Read and record the measurement to the nearest 1/8 inch
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36 months
growth chart. When a standing height is obtained for a two year old, plot the finding on the 2 year to 18
year chart. After plotting measurements for children on age and gender specific growth charts, evaluate,
educate and refer according to findings.
Height children 2-3 and older - 3. Obtain a standing height on children greater than 2 to 3 years of age,
adolescents, and adults, using a portable stadiometer. The patient is to be wearing only socks or be bare
foot. Have the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees
are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The flat surface
of the stadiometer is lowered until it touches the crown of the head, compress the hair. A measuring rod
attached to a weight scale should not be used.
, Measuring weight: - 1. Balance beam or digital scales should be used to weigh patients of all ages. Spring
type
Scales are not acceptable. CDC recommends that all scales should be zero balanced and calibrated. Scales
must be checked for accuracy on an annual basis and calibrated in accordance with manufacturer's
instructions.
2. Prior to obtaining weight measurements, make sure the scale is "zeroed".
Weight infants, children, and teens and adults - 3. Weigh infants wearing only a dry diaper or light
undergarments. Weigh children after removing
Outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal
Clothing.
4. Place the patient in the middle of the scale. Read the measurement and record results
Immediately. Plot measurements on age and gender specific growth charts and evaluate
Accordingly
Measuring head circumference - Obtain measurement on children from birth to 36 months of age by
extending a non stretchable measuring tape around the broadest part of the child's head For greatest
accuracy the tape is placed 3 times with a reading taken at the right side at the left side and at the mid
forehead and the greatest circumference is plotted. The tape should be pulled adequately compress the
hair
Should be measured each visit
Chest circumference - This is measured at the nipple line
In a newborn the head circumference with be about 2 cm larger than the chest circumference AS the child
ages the chest circumference becomes larger than the head circumference
Vital Signs - generally described as the measurement of temp pulse resp and b/p give an immediate picture
of a person's current state of health and well being. Normal and abnormal ranges with management
guidelines follow for children and adults
Temperture - oral usually 98.6
Axillary 97.6 litter lower
Rectal and aural (ear) 99.6 slightly higher
Resperiations - 1. Best done immediately after taking the patient's pulse. Do not announce that you are
measuring
Respirations
2. Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or
Labored?
3. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.
4. In adults, normal resting respiratory rate is between 14-20 breaths/minute.
5. Rapid respiration is called tachypnea.
Pulse - Count for 15 seconds multiply x4
Always cont for a full minute if the pulse is irregular
Record the rate and rhythm
Obejective data - Observed by the nurse (O)
Assessment Techniques is as follows - Inspect-Palpation-Percussion-Auscultation
Order of Abdomen Assessment - Inspect-Auscultation-Percuss-Palapate
Inspection - *always first*
1. Take time to observe with eyes ear nose
2.Use good lighting
3.Look at color shape symmetry position
4.Observe for odors from skin breath wound
5. Develop and use nursing instincts
6.Inspection is done alone and in combination with other assessment techniuqes
Back of hand - To assess skin temperature use
Deep Palpation - 5-8cm or (2-3") deep is considered
Light Paplpation - 1cm deep is considered
Percussion - sounds produced by striking body surface
Sounds are dull resonant flat tympanic
Action is performed in the wrist
Ausculation - listening to sounds produced by the body
Bell - picks up low pitched sounds such as heart murmurs
General Survey - is an overall review or first impression a nurse has of person's well being.
Appearance - appears to be reported age
Sexual development appropriate
Alert and oriented
Facial features symmetric
No signs of acute distress
,Body Structure/mobilty - weight and height WNL BMI guidelines
Body parts equal bilaterally
Stands erect
Sits comfortably
Gait is coordinated
Walk is smooth and well balanced
Full mobility of joints
Behavior - maintains eye contact with appropriate expressions
Comfortable and cooperative
Speech clear
Clothing is correct for climate
Looks cleat and fit
Appears clean and well groomed
Comprehensive history - which includes chief complaint or reason for the visit a complete review of
systems and complete past family and social history should be obtained on the first encounter with a
patient regardless of setting and by a RN
Family Health Hx - Are completed across three generations looking specifically for patterns in genetic
issues that negatively impact quality of life
Health Hx - gives a picture of patient's current health and documentation must be completed for each visit
and or assessment
How to measure height less than 2 years of age - Obtain height by measuring the recumbent length of
children less than 2 years of age and
Children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary headboard
and a sliding vertical foot piece is ideal, but a tape measure can also be used
A) Lay the child flat against the center of the board. The head should be held against the
Headboard by the parent or an assistant and the knees held so that the hips and knees are extended. The
foot piece is moved until it is firmly against the child's heels. Read and record the measurement to the
nearest 1/8 inch.
B) A modified technique in home settings is to lay the child flat and straight where the head should be held
by the parent and the knees held so that the hips and knees are extended, mark the flat surface at the top
of the head and tip of the heels. Move child and measure the distance between the marks with a tape
measure. Read and record the measurement to the nearest 1/8 inch
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36 months
growth chart. When a standing height is obtained for a two year old, plot the finding on the 2 year to 18
year chart. After plotting measurements for children on age and gender specific growth charts, evaluate,
educate and refer according to findings.
Height children 2-3 and older - 3. Obtain a standing height on children greater than 2 to 3 years of age,
adolescents, and adults, using a portable stadiometer. The patient is to be wearing only socks or be bare
foot. Have the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees
are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The flat surface
of the stadiometer is lowered until it touches the crown of the head, compress the hair. A measuring rod
attached to a weight scale should not be used.
, Measuring weight: - 1. Balance beam or digital scales should be used to weigh patients of all ages. Spring
type
Scales are not acceptable. CDC recommends that all scales should be zero balanced and calibrated. Scales
must be checked for accuracy on an annual basis and calibrated in accordance with manufacturer's
instructions.
2. Prior to obtaining weight measurements, make sure the scale is "zeroed".
Weight infants, children, and teens and adults - 3. Weigh infants wearing only a dry diaper or light
undergarments. Weigh children after removing
Outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal
Clothing.
4. Place the patient in the middle of the scale. Read the measurement and record results
Immediately. Plot measurements on age and gender specific growth charts and evaluate
Accordingly
Measuring head circumference - Obtain measurement on children from birth to 36 months of age by
extending a non stretchable measuring tape around the broadest part of the child's head For greatest
accuracy the tape is placed 3 times with a reading taken at the right side at the left side and at the mid
forehead and the greatest circumference is plotted. The tape should be pulled adequately compress the
hair
Should be measured each visit
Chest circumference - This is measured at the nipple line
In a newborn the head circumference with be about 2 cm larger than the chest circumference AS the child
ages the chest circumference becomes larger than the head circumference
Vital Signs - generally described as the measurement of temp pulse resp and b/p give an immediate picture
of a person's current state of health and well being. Normal and abnormal ranges with management
guidelines follow for children and adults
Temperture - oral usually 98.6
Axillary 97.6 litter lower
Rectal and aural (ear) 99.6 slightly higher
Resperiations - 1. Best done immediately after taking the patient's pulse. Do not announce that you are
measuring
Respirations
2. Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or
Labored?
3. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.
4. In adults, normal resting respiratory rate is between 14-20 breaths/minute.
5. Rapid respiration is called tachypnea.
Pulse - Count for 15 seconds multiply x4
Always cont for a full minute if the pulse is irregular
Record the rate and rhythm
