lOMoARcPSD|26582732
ASSESSMENT STRATEGIES- 246 HESI PREP
Assessment is the first stage of the nursing process. It includes the gathering of a patient’s
physiological, psychological, sociological, and spiritual status.
Objective and subjective strategies included.
Symptoms- a subjective experience reported by the patient.
Signs- an objective finding by the examiner.
Inspection-critical observation that requires good lighting. Looks at the color, shape, symmetry,
and position of body parts.
Palpation- purposeful and careful feeling with hands during the physical examination. Examines
size, consistency, texture, location, and tenderness of an organ or body part. Use the palm of
hand or fingertips to assess consistency of tissues, alignment and intactness of structures,
symmetry of body parts or movements, and transmission of sound and fine vibrations. Back of
hand assesses skin temperature.
Percussion- method of tapping on a surface to assess the underlying structure’s location, size, or
density. The sound changes as the examiner moves from one section to the next. Done with the
middle finger of the right hand tapping on the middle finger of the left hand, while the left palm
is on the body. Sounds are classified as tympanic, resonant, flat, and dull. A flat/dull sound
indicates the presence of a solid mass under the surface. A tympanic/resonant sound indicates
hollow, air-containing structures.
Auscultation- listening to the internal sounds of the body, usually using a stethoscope. Used to
examine the circulatory, respiratory, and gastrointestinal systems. High-pitched tones are best
heard with the diaphragm of the stethoscope, while low-pitched tones are best heard with the
bell of the stethoscope.
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, lOMoARcPSD|26582732
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, lOMoARcPSD|26582732
Cardiovascular system
Assess-
Pulses (peripheral and jvd) assess bilaterally and compare. Palpable pulses indicate the body
and extremities are receiving adequate perfusion. Radial, brachial, femoral, popliteal, tibial, and
dorsalis pedal pulses.
Capillary refill > 3 seconds
Auscultate heart sounds- s1, s2. Listen for intensity, rhythm, duration, and quality of sounds.
Evaluate extra heart sounds and murmurs. 5 auscultation points= aortic, pulmonic, erb’s point,
tricuspid, and mitral. Remember that the apical pulse is taken at the mitral valve.
Heart rate and rhythm- notice if pulse if increased or decreased with arrhythmias.
Blood pressure- systolic (90-120) and diastolic (60-90). Mean arterial
Pressure (map). Map = x2 diastolic + systolic /3. Example: 120/90 = map of 100. Normal range is
70-110. A map of 60 and above is necessary to adequately perfuse the kidneys, coronary
arteries, and the brain. Report anything under 60. Over 110 indicates excess pressure and
should also be addressed.
Assess for decreased level of consciousness (loc) and syncope. A patient that is alert and
responsive indicated adequate perfusion to the brain.
Urine output- equal of greater than 30 ml per hour. Less than 30 must be reported. Compare
intake vs. Output and monitor daily weight. Compare, contrast, and trend all. The kidneys are
affected early with decreased perfusion leading to a retention of fluid that puts excess strain on
the heart.
Downloaded by NELSON KIIRU ()
ASSESSMENT STRATEGIES- 246 HESI PREP
Assessment is the first stage of the nursing process. It includes the gathering of a patient’s
physiological, psychological, sociological, and spiritual status.
Objective and subjective strategies included.
Symptoms- a subjective experience reported by the patient.
Signs- an objective finding by the examiner.
Inspection-critical observation that requires good lighting. Looks at the color, shape, symmetry,
and position of body parts.
Palpation- purposeful and careful feeling with hands during the physical examination. Examines
size, consistency, texture, location, and tenderness of an organ or body part. Use the palm of
hand or fingertips to assess consistency of tissues, alignment and intactness of structures,
symmetry of body parts or movements, and transmission of sound and fine vibrations. Back of
hand assesses skin temperature.
Percussion- method of tapping on a surface to assess the underlying structure’s location, size, or
density. The sound changes as the examiner moves from one section to the next. Done with the
middle finger of the right hand tapping on the middle finger of the left hand, while the left palm
is on the body. Sounds are classified as tympanic, resonant, flat, and dull. A flat/dull sound
indicates the presence of a solid mass under the surface. A tympanic/resonant sound indicates
hollow, air-containing structures.
Auscultation- listening to the internal sounds of the body, usually using a stethoscope. Used to
examine the circulatory, respiratory, and gastrointestinal systems. High-pitched tones are best
heard with the diaphragm of the stethoscope, while low-pitched tones are best heard with the
bell of the stethoscope.
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
Cardiovascular system
Assess-
Pulses (peripheral and jvd) assess bilaterally and compare. Palpable pulses indicate the body
and extremities are receiving adequate perfusion. Radial, brachial, femoral, popliteal, tibial, and
dorsalis pedal pulses.
Capillary refill > 3 seconds
Auscultate heart sounds- s1, s2. Listen for intensity, rhythm, duration, and quality of sounds.
Evaluate extra heart sounds and murmurs. 5 auscultation points= aortic, pulmonic, erb’s point,
tricuspid, and mitral. Remember that the apical pulse is taken at the mitral valve.
Heart rate and rhythm- notice if pulse if increased or decreased with arrhythmias.
Blood pressure- systolic (90-120) and diastolic (60-90). Mean arterial
Pressure (map). Map = x2 diastolic + systolic /3. Example: 120/90 = map of 100. Normal range is
70-110. A map of 60 and above is necessary to adequately perfuse the kidneys, coronary
arteries, and the brain. Report anything under 60. Over 110 indicates excess pressure and
should also be addressed.
Assess for decreased level of consciousness (loc) and syncope. A patient that is alert and
responsive indicated adequate perfusion to the brain.
Urine output- equal of greater than 30 ml per hour. Less than 30 must be reported. Compare
intake vs. Output and monitor daily weight. Compare, contrast, and trend all. The kidneys are
affected early with decreased perfusion leading to a retention of fluid that puts excess strain on
the heart.
Downloaded by NELSON KIIRU ()
